Newbury Green Medical Practice

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that staff protected people from avoidable harm and made sure care was delivered from environments that were clean and well maintained. At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service had contracts to ensure the premises was maintained. Staff and leaders completed health and safety risk assessments and undertook audits to ensure they had identified and addressed all risks. The service had a business continuity plan which was regularly reviewed and outlined how the service should continue to operate in the event of a disruption.

The practice had systems and processes in place to support a safe environment for patients and staff. The premises were accessible, with consultation rooms located on the ground floor allowing access for patients with mobility needs. However, a reasonable adjustment risk assessment had not been completed. Emergency medicines, oxygen and the defibrillator were checked monthly, with medicines and equipment found to be in date.

Fire risk assessments had been completed, with identified actions addressed, and trained fire marshals were in place. We saw evidence of regular fire alarm testing and evacuation drills. However, there were some gaps in oversight of landlord-managed safety documentation, including limited access to fire safety records and legionella certificates.

Following the assessment, the provider submitted a completed Reasonable Adjustments Risk Assessment, providing assurance that the needs of patients requiring reasonable adjustments had been formally considered. The provider also supplied an updated Health and Safety Risk Assessment and Fire Safety Policy.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

We reviewed a number of staff files and found that most staff had completed their mandatory training. However, we identified that some staff had low levels of compliance. For example, one staff member was at 38%. We also identified that locum staff did not always provide training certificates for mandatory training including basic life support.

Recruitment records demonstrated that some required pre-employment checks had been completed, including references, DBS checks and identity verification for certain staff members. However, there were gaps in assurance for both permanent and locum staff. These included missing DBS documentation, incomplete identity checks, references that could not be evidenced, and a lack of documented risk assessments where recruitment checks were incomplete.

Following the assessment, the provider implemented improvements to recruitment governance and staff record management. An electronic HR system had been established to supplement existing records, and staff had been asked to provide updated identification and right-to-work documentation. DBS records had been reviewed and uploaded to staff files, and recruitment risk assessments had been completed where appropriate.

The provider updated its locum recruitment checklist, sought outstanding documentation from existing locum staff and confirmed that risk assessments would be completed where information remained unavailable.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service had cleaning schedules available, which outlined how staff should clean the building and its equipment. The service demonstrated how these were monitored for completion to maintain oversight of cleaning arrangements. During our onsite visit, the service's premises and a sample of equipment reviewed was noted to be visibly clean.

The service’s infection prevention and control lead conducted regular risk assessments and audits to ensure compliance and took action where necessary to mitigate any identified risks, with the most recent audit in December 2025 achieving 100% compliance. An action plan was available and monitored following audits. Staff had completed relevant training in infection prevention and control.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences in line with national guidance. The practice delivers good medicines optimisation by mostly embedding robust, proactive safety reviews that ensure people receive evidence-based, clinically effective, and safe prescribing.

Medicines were stored, prescribed, administered and monitored safely, in line with current best practice. This included emergency medicines, controlled drugs, medical gases and vaccines.

Our review of clinical records, prescribing data and medicines governance processes provided assurance that medicines were managed effectively. Staff received regular training and competency assessments in medicines optimisation. People were actively involved in decisions about their medicines through regular reviews and were provided information to help them understand how to manage their medicines safely.

Clinical searches undertaken by a CQC clinician showed that people received appropriate monitoring in line with national guidance and effective systems were in place to manage and respond to safety alerts and medicine recalls. Prescribing data reviewed as part of our assessment demonstrated appropriate antimicrobial stewardship, as the number of antimicrobials issued by the provider was lower than local and national averages.

Clinical oversight was provided through annual audits, peer review, case discussions and clinical meetings. Staff were supported to develop their competencies through protected learning time, external training opportunities and targeted supervision where required.

Systems were in place to identify patients who were overdue structured medication reviews, with reviews undertaken by the pharmacy team and through routine chronic disease management processes. The practice also had processes to identify early requests for medicines and potential overuse, with patients offered further review where concerns were identified.