The Care Quality Commission
  • Doctor
  • GP practice

Newbury Street Practice

Overall: Requires improvement read more about inspection ratings

The Health Centre, Mably Way, Wantage, Oxfordshire, OX12 9BN (01235) 639521

Provided and run by:
Newbury Street Practice

All Inspections

15 June 2023

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Newbury Street Surgery in September 2022. The overall rating for the practice was inadequate, specifically inadequate for the provision of safe and effective services, requires improvement for well led and good for caring and responsive services. We used our enforcement powers to take action against the breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 including issuing 3 Requirement Notices. We placed the practice in special measures to enable the practice to improve.

We carried out an announced focused inspection in June 2023 to determine if the breaches of regulations had been addressed following the inspection in September 2022. Whilst improvements had been made in relation to the safe provision of service, there were still issues which constituted a new and continued breach of regulations.

Following this inspection, we have provided a new overall rating of Requires Improvement and the key questions have been rated as:

Safe - requires improvement

Effective - good

Caring - good

Responsive - good

Well-led – requires improvement

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Newbury Street Practice on our website at www.cqc.org.uk.

Why we carried out this inspection

We carried out this inspection to follow up concerns and breaches of regulation from a previous inspection. This was a focused inspection which included the key questions safe, effective, well led and responsive.

How we carried out the inspection/review

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included :

  • Conducting staff interviews using video conferencing.
  • Completing remote clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A short site visit.
  • Speaking to members of the patient participation group.

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We found that:

  • The practice had continued to make improvements since our previous inspection in September 2022.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • The practice did not have a process in place to ensure all staff had received the appropriate vaccinations to keep themselves and patients safe.
  • The practice had reviewed their appointment booking system and implemented a hybrid system and hoped would lead to an increase in availability.
  • There was an improved system to seek feedback from patients and staff.
  • Staff helped patients to live healthier lives.
  • The system for managing and acting on significant events and complaints was not always effective.
  • All staff training were completed in line with providers policy.
  • Leaders were approachable and supportive.

We found a breach of regulations. The provider must:

  • Ensure care and treatment is provided is a safe way to patients

The provider should:

  • Continue to monitor and improve the uptake of cervical screening to meet the national target of 80%.
  • Establish an effective system of recoding, reviewing and responding to complaints and significant events.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

20 September 2022

During a routine inspection

We carried out an announced focused inspection at Newbury Street Practice on 20 September 2022. Overall, the provider is rated as inadequate.

We rated the following key questions as:

Safe - Inadequate

Effective - Inadequate

Caring - Good (rating carried forward from previous 2016 inspection)

Responsive - Good (rating carried forward from previous 2016 inspection)

Well-led - Requires improvement

Following our previous inspection in October 2016 the provider was rated good for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Newbury Street Practice on our website at www.cqc.org.uk

Why we carried out this inspection

We undertook this inspection as part of a random selection of services rated Good and Outstanding to test the reliability of our new monitoring approach.

This was a focused inspection which included the key questions safe, effective and well-led and specific questions from responsive to find out whether patients could access services effectively and in a timely manner.

How we carried out the inspection:

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing facilities.
  • Completing clinical searches on the provider’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A short site visit.

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this provider inadequate for providing safe services because:

  • Safe recruitment checks were not always carried out in line with provider policies.
  • Staff immunisations were not monitored.
  • Infection Prevention and Control audits were not carried out fully or acted upon.
  • Infection Prevention and Control routine tasks were not completed in line with provider policies.
  • There was no clear timeline for when the backlog in summarising patient records will be completed.
  • There were gaps in the process for monitoring repeat medicines and structured medicines reviews.
  • The system for managing and acting on Medicines and Healthcare products Regulatory Agency (MHRA) safety alerts was not always effective.

We have rated this provider inadequate for providing effective services. This is because:

  • Patients were not always regularly reviewed and updated in line with current guidance.
  • The provider was not able to demonstrate they always obtained and recorded consent or carried out assessments on a patient’s capacity to consent.

We have rated this provider requires improvement for providing well-led services. This is because:

  • The overall governance structures in place were not always effective.
  • The process for managing risks needed to be strengthened.
  • The provider did not have systems in place to continue to deliver services, respond to risk and meet patients’ needs during the pandemic.

We also found that:

  • Staff dealt with patients with kindness and respect.
  • The provider had a strong focus on person centred care and preferred all patients to see their usual GP for continuity of care.
  • There was a programme of quality improvement initiatives and a culture of continuous learning.
  • The provider adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
  • The provider recognised the importance of their Patient Participation Group and acted on suggestions.
  • Leaders were approachable.
  • Staff were supported to develop and progress within the provider if they wanted to.
  • The provider was involved in some innovative projects and pilot schemes. For example, the provider website had a ‘lifestyle medicine’ section made up of short videos advising patients on how to make better lifestyle choices.
  • The provider had worked with a local secondary school to look at the needs of young people and improve their access to services at the provider.

We found three breaches of regulations. The provider must:

  • Ensure care and treatment is provided is a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure where appropriate, persons employed are registered with the relevant professional body.

In addition, the provider should:

  • Improve the staff awareness of the Freedom to Speak Up Guardian.
  • Improve the recording and sharing of information following a significant event.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

12 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Newbury Street Practice on 12 October 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. GPs and practice nurses had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice had maintained effective delivery of services during an unprecedented increase of 3,800 patients in early 2016. Staffing resources had been increased and service delivery systems amended to manage the sharp increase in regietered patient numbers.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • The practice had a system in place to ensure immunisations for patients were given in a timely manner and appropriately. The system enhanced advice already available about national immunisation programmes.
  • The practice used a range of innovative and comprehensive treatment prompts that covered a wide range of diseases and health problems. These enhanced nationally available treatment protocols and offered patients advice on self management of their health conditions.

  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on. However, the practice had not sought patient feedback on several aspects of the care delivered since publication of the national patient survey in July 2016. Patient feedback relating to the availability of appointments had been acted upon with a revised appointment system introduced.

The areas where the provider should make improvement are:

  • Ensure arrangements are made to secure the clinical waste bin to reduce the risk of this being moved or tampered with.

  • Ensure the practice maintains a training schedule with a view to ensure the training needs of staff is monitored through practice meetings.

  • Review service provision in response to patient feedback. Patients had rated the practice lower than others for several aspects of the care and treatment received from GPs.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

30 December 2013

During a routine inspection

During our visit to Newbury Street Practice we met with one of the GP partners and with the practice manager. We spoke with seven patients, a member of the patient participation group and with five members of staff.

Patients were offered appointment options and various means to book their appointments. A patient we spoke with said "getting appointments here is brilliant. I rang at 8 am this morning and was seen by 10".

Patients received care and treatment that took account of their safety. One patient said "I've got a few allergies and they [the doctor] always makes a thorough check before prescribing me any medicines".

The risk of infection was reduced because current guidance was followed. One of the patients we spoke with described the premises as "spotless".

Staff received training and support appropriate to their roles and responsibilities. We saw that there was a system in place for annual review of clinical competencies of practice nurses and care support staff.

The practice had a system in place to seek and act upon patients views. There was an active Patient Participation Group and annual patient satisfaction surveys were undertaken.