Newbury Green Medical Practice

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that the service’s leadership, management and governance assured high-quality, person-centred care and promoted an open and fair culture. At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality, human rights, diversity, inclusion and engagement. Staff and leaders understood the challenges and the needs of people and their communities.

A mission statement was in place and included within practice literature. Staff described the culture as being focused on patients, and leaders were reported to be approachable. Weekly whole-practice and clinical meetings were held to discuss service issues, learning, audits, significant events and quality improvement work.

The practice demonstrated a culture of continuous improvement, with staff actively involved in developing clinical protocols, reviewing performance data and identifying opportunities to improve patient outcomes.

All staff had contributed to the development of the service’s vision and strategy, which was kept under review. Leaders monitored and reviewed progress against the delivery of their strategy. The service was aware of local challenges which affected their service, such as the recent increase in the local population and worked with partner agencies to address these challenges. Staff and leaders actively promoted equality and diversity and worked to identify the causes of any workforce inequalities. They demonstrated a positive and compassionate listening culture that focused on learning and development.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

All staff we spoke with were clear on their individual roles and responsibilities. Leaders proactively supported staff and regularly met with them to complete appraisals and performance reviews. The provider had established governance processes in relation to the quality statements we reviewed during this assessment, which were appropriate for their service. Staff could access all required policies and procedures, which were kept up to date and reflected latest guidance. Leaders held regular meetings with staff, during which they discussed emerging risks and potential improvements to the service. Leaders clearly recorded any actions that arose from these meetings and shared these with staff. Staff took confidentiality and information security seriously, which included verifying people’s identity during remote consultations. Staff submitted data and notifications to external agencies as required.

However, some governance concerns were identified. Leaders did not always have access to key landlord-held compliance documentation, including fire safety and legionella records and a reasonable adjustment risk assessment had not been completed. The effectiveness of prescription stationery monitoring was limited, with weaknesses identified in record keeping. There were also concerns regarding the management of a significant incident involving a prescribing error, where Duty of Candour requirements had not been fully met and a statutory CQC notification had not been submitted.

Following the assessment, the provider implemented strengthened controls for the management of prescription stationery, including the introduction of a Prescription Sign-Out Policy and an updated prescription tracking system. Untracked blank prescription forms had been removed from clinical rooms and printers and were being stored securely in accordance with revised procedures.

The provider also demonstrated actions taken in response to the prescribing incident discussed during the assessment. A statutory notification had been submitted to CQC, and evidence was provided that Duty of Candour requirements had been met through written communication with the patient. In addition, the Significant Events Policy had been updated to include guidance regarding incidents that require notification to CQC.

The provider confirmed that its business continuity plan would be reviewed to ensure references to prescription stationery remained accurate and reflected current arrangements.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.