Green Meadows Surgery

Updated 4 September 2023

Green Meadows Surgery is a single site GP practice located in Berkshire at:

Brook House

Heatherwood Hospital

Brook Avenue

Ascot

Berkshire

SL5 7GB

The provider is registered with CQC to deliver the following Regulated Activities:

• Diagnostic and screening procedures
• Family planning
• Maternity and midwifery services
• Surgical procedures
• Treatment of disease, disorder or injury

The practice is situated within the Frimley Integrated Care System (ICS) and delivers General Medical Services (GMS) to a patient population of approximately 9,400 patients. This is part of a contract held with NHS England.

The practice is part of a wider network of GP practices called a Primary Care Network (PCN which includes 4 GP practices and is called the Ascot PCN.

Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the highest decile (10 of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is approximately 90% White, 5% Asian, 1% Black, 2.5% Mixed, and the remainder of the patient population identified themselves as other ethnicity.

The age distribution of the practice differed from the local and national averages because more patients were over the age of 50 compared to local and national averages.

The practice consisted of 3 GP partners and 3 salaried GPs which equated to a GP workforce of 4 full-time GPs. The clinical team also included 1 practice nurse, 1 healthcare assistant and 1 practice paramedic. An advanced nurse practitioner was recruited and due to start at the practice following our inspection. The administration team comprised 12 members of part-time staff which covered reception and administration roles. The practice manager was supported by an assistant manager, an office manager and a clinical manager.

The practice is open between 8.00am and 6.30pm Monday to Friday and appointments were available between 8.30am and 5.30pm every day. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Extended access is provided locally by the GP Federation, Berkshire Primary Care, where late evening and weekend appointments are available between 6.30pm and 8.00pm Monday to Friday and 8.00am and 2.00pm on Saturdays. Out of hours services are provided by NHS 111.

Updated 4 September 2023

We carried out an announced comprehensive at Green Meadows Surgery on 6 July 2023. Overall, the practice is rated as good.

We rated the key questions as follows:

Safe - good

Effective - good

Caring - good

Responsive – requires improvement

Well-led - good

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

Why we carried out this inspection

We carried out this inspection because our inspection priorities include services that have been registered with the Care Quality Commission (CQC) for over 12 months without being inspected. Green Meadows Surgery moved to new premises on 17 November 2021 and because of this move, the service was eligible for inspection.

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 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.
• 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 Good overall. We rated the practice Good for providing safe, effective, caring, and well-led services. However, we rated the practice Requires improvement for providing responsive services. We found:

• Systems and processes to keep people safe and safeguarded from abuse and avoidable harm existed and operated effectively.
• When things went wrong, the practice reviewed what had happened, made changes where necessary and shared learning with staff.
• There was a system to manage the stock of emergency medicines and equipment and we found this monitored regularly to ensure equipment and medicines were available.
• Staff had the appropriate knowledge, skills and training to carry out their roles confidently.
• The practice worked effectively with system partners to ensure information was shared appropriately, including where referrals to other services were required.
• The practice treated patients with compassion, respect and kindness and ensured patients were involved in decisions about their care.
• The practice listened to feedback from patients and used it to improve the quality and delivery of services.
• Patient feedback was not always positive about the experiences of accessing care and treatment and patients reported they could not always access care in a timely manner.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
• Leadership and management had effective systems and processes which gave them oversight of performance and risks within the practice. Where improvements or risks were identified, action was taken.
• The leadership and management were visible and approachable, and staff were confident to raise concerns.

Whilst we found no breaches of regulations, the provider should:

• Continue to monitor the systems to improve patient access and consider further opportunities to improve patients’ experiences when accessing care and treatment.
• Improve the accuracy of information in patients’ clinical records. Specifically the coding of medication reviews.
• Continue to improve the uptake of cervical screening appointments.

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