The Care Quality Commission
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Archived: Botley Medical Centre

Overall: Good read more about inspection ratings

Elms Road, Botley, Oxford, OX2 9JS (01865) 248719

Provided and run by:
Botley Medical Centre

All Inspections

28 September 2022

During a routine inspection

We carried out an announced comprehensive inspection at Botley Medical Centre on 27 and 28 September. Overall, the practice is rated as good and requires improvement for providing effective services.

Safe - Good

Effective - Requires Improvement

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection in December 2021 the practice was rated requires improvement overall and for three key questions. At this inspection we identified continued improvements in the provision of services.

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

Why we carried out this inspection

We carried out this inspection to follow up breaches of regulation from a previous inspection in line with our inspection priorities.

How we carried out the inspection.

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 facilities.
  • Completing 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.

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 provided care in a way that kept patients safe and protected them from avoidable harm.
  • There were improved systems to provide ongoing care for patients with long-term conditions. However, some patients did not always receive follow-up care regarding their conditions.
  • There were improved systems for monitoring the care provided to patients. Areas for audit were being identified and used to drive improvements.
  • Staff received training and appraisals. Supervision arrangements were not always appropriate.
  • There were significant improvements to governance systems.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Access to services had improved although patients continued to report difficulty in accessing appointments at times.
  • Patients could access care and treatment in a timely way.
  • Staff reported a supportive and inclusive culture. A new practice manager was employed in May 2022 and staff and patients reported improvements in engagement and services since this time.

We found one breach of regulations. The provider must:

  • Ensure appropriate and timely care planning takes place to ensure the health, safety and welfare of patients, including where responsibility for the care and treatment is shared with other services.

In addition the provider should:

  • Continue to review and identify means of improving patient access to services.
  • Review the supervision arrangements for staff who require formal supervision in line with national guidance.

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 Hospitals and Interim Chief Inspector of Primary Medical Services

8 December 2021

During a routine inspection

We carried out an announced comprehensive follow up inspection at Botley Medical Centre on 7 and 8 December 2021 to identify if improvements had been made following our previous inspection in April 2021 which led to urgent enforcement action. This inspection was to determine whether the highest risk concerns identified in April 2021 had been acted on and mitigated. We have provided a new rating for the location:

Safe - Good

Effective – Requires Improvement

Caring - Good

Responsive - Requires Improvement

Well-led - Requires Improvement

Following our previous inspection in April 2021, the practice was rated Inadequate overall. Specifically, inadequate for the provision of safe and well led services, and requires improvement for the provision of effective services.

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

Why we carried out this inspection

This comprehensive inspection was undertaken remotely and onsite. Our key areas of focus were:

  • Inspecting all key questions
  • Identifying if improvements had been made to services and the quality of clinical care
  • Gaining the views of patients and stakeholders
  • Gathering and analysing evidence from the provider

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
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short site visit
  • Requesting patients to send us feedback about their experiences

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 practice as Requires Improvement overall

We found that:

  • There was significant improvement to the monitoring of patient safety, specifically the prescribing of high risk medicines.
  • There was improvement in the effectiveness of patient care and treatment, but some care was not meeting required standards in line with national guidance. Specifically updating care plans for patients with mental health conditions and ensuring advanced clinical decisions are reviewed annually.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
  • Patient access to communication channels and care had been identified as an area requiring improvement, but there were sometimes barriers for patients in accessing services when they required.
  • There were improved monitoring processes for dealing with daily tasks such as patient correspondence and adjustments were made when workflow increased to reduce backlogs.
  • There was limited independent quality improvement on the part of the practice and leaders did not have sufficient audit and monitoring processes to ensure they identified areas for improvement.
  • There was a significant improvement in culture reported by staff.

We found one breach of regulation. The provider must:

  • Ensure adequate governance and monitoring processes are operated to assess, monitor and improve the quality and safety of the services provided.

Following our inspection in April 2021 we placed Botley Medical Centre into special measures. As a result of the improvements made and the findings of this inspection we have decided to remove the practice from special measures.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

13 August 2021

During an inspection looking at part of the service

We carried out an announced focused follow up inspection at Botley Medical Centre on 13 August 2021 to identify if improvements had been made following our previous inspection in April 2021 which led to urgent enforcement action. This inspection was to determine whether the highest risk concerns identified in April 2021 had been acted on and mitigated. We did not provide a rating as a result of this inspection.

We previously inspected Botley Medical Centre in April 2021 and rated them Inadequate. We issued urgent conditions on the practice’s registration, requiring them to make urgent improvements.

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

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 virtually including remote clinical searches on the clinical record system. This was with consent from the provider and in line with all data protection and information governance requirements.

The inspection included:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider

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:

  • Improvements had been made to the monitoring of patients on high risk medications.
  • The management of correspondence and clinical tasks was appropriate from the evidence we gathered.
  • The monitoring of staff training had improved.
  • There was a process for staff to receive role specific inductions.

This inspection focused on the key areas of service provision listed above. We will undertake a comprehensive inspection to determine whether the location can be removed from special measures and consider a new rating within six months of the publication of the last inspection report.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

7 April 2021

During a routine inspection

We carried out an announced inspection at Botley Medical Centre on 7 April 2021 to identify if improvements had been made following our previous inspection and due to risks highlighted to CQC. These included concerns reported about leadership and governance within the practice. Overall, the practice is rated as Inadequate. This is rating is based on significant concerns we have identified regarding patient care and governance arrangements during the inspection.

Ratings:

Safe - Inadequate

Effective - Requires improvement

Well-led - Inadequate

We previously inspected Botley Medical Centre in October 2019 and rated the practice requires improvement. We issued requirement notices to the practice and requested an action plan for improvements.

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

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
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • 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 practice as Inadequate overall and Requires Improvement for all population groups.

We found that:

  • The practice did not always provide care in a way that kept patients safe and protected them from avoidable harm. There was a lack of monitoring for patients prescribed medicines and lack of action following reviews and tests.
  • There were omissions in the recording and monitoring of patient care. Patients did not always have an accurate record of their care requirements on the patient record system.
  • There was a lack of coherent governance structures to ensure quality improvements were made where required and that risks to patients were identified and acted on.
  • During the pandemic there had been challenges caused by staff absences and staff leaving the practice.
  • Training was not monitored or always undertaken by staff to ensure they had the skills and knowledge to work with patients.
  • There were systems to identify risks to patients who called the practice requesting services. However, these were not always communicated to staff appropriately.
  • The practice was involved in the national programme of vaccinating the population against Covid-19.
  • The premises and equipment were well maintained.

We found two breaches of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way for service users
  • Establish and effectively operate systems or processes to ensure compliance with the requirements of relevant legislation and regulations

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 population group, 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.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

17/10/2019

During a routine inspection

We carried out an announced follow up comprehensive inspection at Botley Medical Centre on Thursday 17 October 2019. This inspection was undertaken to check whether the practice had taken the action they told us they would take, from action plans submitted, to meet the regulation we found had been breached during our last two day inspection on 26 March 2019 and 2 April 2019.

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 continued to rate this practice as requires improvement overall. It is rated good for all population groups.

This rating arises because t he key questions at this inspection are rated as follows:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We found that:

  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • Some improvements had been achieved in operating safe recruitment processes, responding to safety alerts and addressing patient feedback.

We rated the practice as requires improvement for providing safe services because:

  • The practice did not always provide care in a way that kept patients safe and protected them from avoidable harm. The processes in place to manage prescribing of high risk medicines were not operated effectively or consistently.

We rated the practice as requires improvement for providing well-led services because:

  • The practice continued to fail to have clear and effective processes for managing risks, issues and performance. The processes in place to identify, assess and mitigate risks to patient safety were not always operated effectively.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Evaluate the work underway to improve uptake of cancer screening programmes to identify whether there is an increase in uptake.

(Please see the specific details on action required at the end of this report).

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

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

26/03/2019

During a routine inspection

We carried out an announced comprehensive inspection at Botley Medical Centre on 26 March and 2 April 2019 as part of our inspection programme. We first inspected this practice under our new methodology in September 2015 and it was rated as requires improvement. Two further inspections were undertaken in May 2016 and February 2017 before the practice achieved a rating of Good.

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 practice as requires improvement overall.

We rated the practice as requires improvement for providing safe services because:

  • The practice did not have clear systems and processes to keep patients safe.
  • The practice did not have appropriate systems in place for the safe management of medicines for use in an emergency.
  • The practice did not carry out all necessary pre-recruitment checks to ensure staff employed were fit and proper persons.
  • The system used to respond to safety alerts was not operated consistently.

We rated the practice as requires improvement for providing caring services because:

  • Patient feedback from the national survey and other sources was below average and the practice did not have a clear plan to address this feedback.

We rated the practice as requires improvement for providing well-led services because:

  • The management of records, procedures and policies required for the day-to-day management of the service was disorganised.
  • Systems to identify, assess and manage risk were not operated effectively.
  • Governance processes in place did not always support the clinical delivery of high quality and sustainable care and treatment.

We found some areas of good practice and rated provision of effective and responsive services as good. For example:

  • Appointment systems were flexible and offered a range of appointment options.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • There was an audit programme focused on quality improvement.

The areas where the provider must make improvements are:

  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

We also found areas of provision of service where the provider had not breached regulations but required improvement. Therefore, the provider should:

  • Continue to encourage uptake of cervical screening to achieve the national target of 80%.
  • Improve uptake of health checks for patients diagnosed with a learning disability.
  • Review performance against national targets for care of patients with long term medical conditions with a view to improve outcomes.
  • Develop a strategy to address below average patient feedback about the care received from the practice.

(Please see the specific details on action required at the end of this report).

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

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

6 February 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Botley Medical Centre on 23 September 2015. The overall rating for the practice was requires improvement. The full comprehensive report on the September 2015 inspection can be found by selecting the ‘all reports’ link for Botley Medical Centre on our website at www.cqc.org.uk.

Following this we carried out an announced focused follow up inspection at Botley Medical Centre on 12 May 2016 where we found that the practice was requires improvement in one of the ‘Well-led’ domain.

This inspection was a desk-based review carried out on 6 February 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 12 May 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as Good.

Our key findings were as follows:

  • Building and safety issues were monitored using an annual risk assessment which was reviewed every six months
  • Installation safety certificates had been renewed before their expiry date
  • A new medicine fridge temperature log meant that any concerns regarding fridge temperatures were investigated and dealt with immediately

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

12 May 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

Our previous inspection in September 2015 found breaches of regulations relating to the safe and well-led delivery of services. The practice was rated good for providing effective and responsive services. The population groups were rated as requires improvement for the patients registered at the practice.

We carried out an announced focussed follow up inspection at Botley Medical Centre on 12 May 2016 to check the practice was meeting regulations. For this reason we have only rated the location for the key questions to which these relate. This report should be read in conjunction with the full inspection report of 23 September 2015.

During this inspection on 12 May 2016, we found the practice had made some improvements since our last inspection, but further improvements were required. The practice is rated as safe for providing safe services and requires improvement for the being well-led.

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

  • The practice had improved engagement and communication across different staff group through the introduction of weekly all-team meetings with break-out times for separate teams, and all staff could add to the agenda. The practice had arranged its first team away day for June 2016.

  • The practice now ensured that patient consent for treatment such as minor surgery was appropriately asked for and clearly documented on all patient records.

  • The practice had reviewed and followed its chaperone policy to ensure that only DBS checked, risk assessed and trained members of clinical staff and the practice manager undertook chaperone duties.

  • All staff had completed Mental Capacity Act 2005 training. The practice had purchased new training software and advised all staff to undertake appropriate training relevant to their role.

The areas where the provider must make improvements are:

  • Ensure to review and monitor building safety issues, carry out relevant health and safety assessments, and ensure installation safety certificates are renewed before their expiry date.

  • Ensure that any concerns regarding medicine fridge temperatures are dealt with immediately according to cold chain policy.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

23 September 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Botley Medical Centre on 23 September 2015. Overall the practice is rated as requires improvement.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed, with the exception of those relating to staff undertaking chaperone duties.
  • Data showed patient outcomes were at or above average for the locality. Audits had been carried out, and were seen to be driving improvement in performance to improve patient outcomes.
  • Patients said they were treated with compassion, dignity and respect.
  • Information about services and how to complain was available and easy to understand.
  • Urgent appointments were usually available on the day they were requested. However patients said that they sometimes had to wait a long time for non-urgent appointments.
  • Patients’ consent to care and treatment was not always sought in line with legislation and guidance.
  • The practice had not proactively sought feedback from staff.

The areas where the provider must make improvements are:

  • Improve the engagement and communication with staff in the practice across different staff groups.

In addition the provider should:

  • Ensure that the training matrices reflect the requirements of the different roles within the practice and are accurately maintained.
  • Ensure consent is appropriately asked for and documented on all patient records.
  • Ensure recruitment arrangements include all necessary employment checks for all staff. Where staff perform chaperone duties, the practice must risk assess whether a criminal record check through the Disclosure and Barring Service check is required.
  • Ensure that training for the Mental Capacity Act 2005 is included in training at the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

13 February 2014

During an inspection looking at part of the service

We carried out this visit because at our previous visit on 16 September 2013 we found some issues relating to staff awareness of how to spot and report possible signs of abuse of patients and availability of some records relating to staff and the management of the service. For example, records relating to safety checks of the building and equipment could not be located. We asked the provider to take action to address these issues.

The provider had told us, by sending us an action plan, they they were taking action to carry out the improvements needed. This visit was carried out to check that the provider had fulfilled the actions they told us they would take.

The provider had taken action to train staff to spot and report possible abuse of patients. The staff we spoke with were knowledgeable about the various types of abuse they might encounter during their duties. Staff knew how and where to report concerns regarding possible abuse of patients.

The practice provided us with records relating to staff and management of the service that were in good order. We saw that these records could be located when required.

We met with the practice manager and spoke with three members of staff during our visit. We did not speak with patients because it was not appropriate to do so.

16 September 2013

During a routine inspection

On the day of our visit to Botley Medical Centre we met with the office manager and one of the GP partners. We spoke with seven patients and with four members of practice staff.

Patients told us they were treated with dignity and respect. One patient said "I feel safe with the GP's and nurses who always treat me with dignity and respect'. We saw patients called personally by GP's and nurses when it was time for their appointment.

Patients were happy with the care and treatment they received. One patient said 'I have been with this practice for a long time and the service is excellent'.

Patients were not fully protected from the risk of abuse because staff had not been trained to identify and report signs of abuse and neglect.

Patients were protected from the risk and spread of infection because appropriate guidance had been followed.

Staff felt supported in their roles. A member of staff we spoke with said the GP's were "very kind and helpful. They don't mind you bothering them". Staff received training and support appropriate to their roles.

Patient views were sought and their responses were acted upon. The practice had conducted two satisfaction surveys. When patients commented that car park provision was poor, improvements were made.

Some records required to manage the service safely and effectively were not kept or could not be located promptly.