Newbury Street 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 people were protected from abuse and avoidable harm. We also looked at how the practice investigated, listened and learned from safety events to continually identify and embed good practices. Furthermore, we looked for evidence to see if the practices approach to medicines reflected current and relevant best practice and professional guidance.

At our last inspection, we rated this key question as requires improvement. At this inspection, we saw improvements had been made and sustained and the rating for the provision of safe services is now good.

The breach of regulations (Regulation 12: Safe care and treatment) has now been closed.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice had an improved, proactive and positive culture of safety, based on openness and honesty.

Throughout this inspection, we found learning from the previous inspections had been applied and completed, this included the completion of the required action plan. This impacted our overall findings during the inspection. Staff told us they felt supported to raise concerns and highlighted leaders had embedded clear incident reporting processes. This was supported by regular training, improved communication and a designated GP partner who led on incident reporting.

Representatives from the patient participation group (PPG) commented the leaders took concerns seriously and proactively made improvements to the practice.

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

All staff we received feedback from were able to share examples of significant events, incidents and complaints including actions taken in response. This demonstrated the learning culture within the practice had improved and was now embedded.

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.

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

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

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

The practice made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Following the findings of the previous inspections, new clinical governance processes and supporting policies had been embedded to strengthen clinical governance and oversight of how medicines were managed within the practice. We saw the new processes and policies provided an effective system to ensure patients received appropriate monitoring, assessment and interventions related to their clinical needs.

The practice had introduced and then refined a new multi-disciplinary team, referred to as the Safety and Quality Assurance Team (SQuAT) to improve medicine optimisation. The SQuAT met monthly and ran regular reports to identify risk areas, assess those patients identified and if required recall the patient or document and mitigate any potential risks.

To ensure a clear and consistent message was shared, the practice had introduced a new cascade of information, updates and learning to ensure all practice staff were aware of SQuAT findings and actions.

SQuAT performance was regularly reviewed, and the practice had begun benchmarking their clinical performance against local and national performance. From the data provided, we saw the practice was performing better in several different datasets.

Leaders and staff told us they thought the new processes had improved clinical safety within the practice.

As part of our inspection, a series of patient clinical record searches were undertaken by a CQC GP specialist advisor. This included a review of the management of patients on medicines that required monitoring. We found patients had received monitoring in line with guidance, leaders told us this achievement was not only a SQuAT achievement but a practice wide achievement.

As part of this inspection, we also reviewed 6 additional national prescribing data sets and saw the practices prescribing achievements were comparable to local and national averages with no variation. This included hypnotic (medicines used for the treatment of insomnia) and opioid (medicines to treat pain) prescribing.