Archived: Green Meadows Partnership

Updated 31 March 2016

Green Meadows Partnership has been a family practice since the 1930s and is situated in Ascot, Berkshire. Green Meadows Partnership is one of 15 practices within Bracknell and Ascot Clinical Commissioning Group (CCG). There are approximately 10,000 registered patients. The practice comprises of two buildings, one of which is a purpose built surgery and the other a converted suburban house known as Knightswood.

All services are provided from:

• Green Meadows Partnership, Winkfield Road, Ascot, Berkshire SL5 7LS

There are six GPs (two male and four female) at the practice comprising of four partners and two salaried GPs. The all-female nursing team consists of five practice nurses with a mix of skills and experience.

A practice manager, two assistant practice managers and a team of 15 administrative staff undertake the day to day management and running of the practice. The practice has a General Medical Services (GMS) contract.

The practice is a training practice for GP Registrars. GP Registrars are qualified doctors who undertake additional training to gain experience and higher qualifications in general practice and family medicine. No GP Registrars have been working at the practice whilst the practice has been in special measures.

The practice is open between 8am and 6:30pm Monday to Friday. An extended hours services, aimed at patients who may have difficult attending the surgery for planned care appointments during normal opening hours was available, this service provides pre-bookable, planned GP and nurse appointments in the evening Monday to Friday (6:30pm-8pm) and Saturdays (8am-1:30pm) at a central Bracknell location.

The practice population has a proportion of patients in three local care homes (119 registered patients) and one local independent boarding school for girls (98 registered patients).With 1.17% of patients in a residential or nursing home (higher than the national average), the practice holds twice weekly clinics at three local care homes.

The practice population has a higher proportion of patients aged 45-85 compared to the national average. There is minimal deprivation according to national data. The prevalence of patients with health-related problems in daily life is 34% compared to the national average of 49%.

Over the previous two years the practice has seen a significant amount of change, several different practice managers, GP partners leaving, instability and a lack of clear leadership and management.

The practice opted out of providing the out-of-hours service. This service is provided by the out-of-hours service accessed via the NHS 111 service. Advice on how to access the out-of-hours service is clearly displayed on the practice website and over the telephone when the surgery is closed.

The practice was first inspected in February 2014 and we identified breaches in the regulations relating to safeguarding, cleanliness and infection control and assessing and monitoring the quality of service provision. We undertook a follow up inspection in September 2014 to review the previous breaches in regulations. We found the provider had not acted upon the information provided to them in February 2014 and further breaches were found in relation to cleanliness and infection control and assessing and monitoring the quality of service provision.

Following a comprehensive inspection in June 2015, the practice was given an overall inadequate rating and a decision was made to place the practice in special measures.

The practice was rated inadequate in the safe and well-led domains, requires improvement in the effective and responsive domains and good in the caring domain. In addition, all six population groups were rated as inadequate.

This inspection was carried to consider if all regulatory breaches identified in the June 2015 inspection had been addressed and to consider whether sufficient improvements had been made.

Updated 31 March 2016

Letter from the Chief Inspector of General Practice

Following a comprehensive inspection of Green Meadows Partnership, Ascot, Berkshire in June 2015, the practice was given an overall inadequate rating and a decision was made to place the practice in special measures.

The practice was rated inadequate in the safe and well-led domains, requires improvement in the effective and responsive domains and good in the caring domain. In addition, all six population groups were rated as inadequate.

This provider had been inspected thrice before in February 2014, September 2014 and June 2015. On all three previous inspections we found that the practice was not meeting all the essential standards of quality and safety.

When the practice was inspected in February 2014 we identified breaches in the regulations relating to safeguarding, cleanliness and infection control and assessing and monitoring the quality of service provision.

We undertook a follow up inspection in September 2014 to review the previous breaches in regulations. We found the provider had not acted upon the information provided to them in February 2014 and further breaches were found in relation to cleanliness and infection control and assessing and monitoring the quality of service provision.

Following a comprehensive inspection in June 2015, the practice was given an overall inadequate rating and a decision was made to place the practice in special measures

We carried out an announced comprehensive inspection at Green Meadows Partnership on 11 February 2016, to consider whether sufficient improvements had been made. The provider had addressed the concerns we had at the previous three inspections (February 2014, September 2014 and June 2015). Overall the practice is rated as good at this inspection.

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

• The practice had a clear vision that had improvement of service quality and safety as its top priority. The practice fully embraced the need to change, high standards were promoted and there was good evidence of team working.

• 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, this included recruitment checks and completed actions following infection control concerns we identified at the June 2015 inspection.

• Feedback from patients about their care was consistently and strongly positive. However, not all patients were satisfied with telephone access to the practice.

• Nationally reported Quality and Outcomes Framework (QOF) data, for 2014/15, showed the practice had performed below the local Clinical Commissioning Group and national averages in obtaining points available to them for providing recommended care and treatment to patients. The practice maintained a comprehensive understanding of the performance and we saw areas of low performance specifically diabetes and mental health indicators had been reviewed and action plans implemented.

• Staff were consistent in supporting patients to live healthier lives through a targeted and proactive approach to health promotion.

• We found there was good staff morale in the practice, with high levels of team spirit and motivation. There was a strong learning culture evident in the practice. This came across clearly through discussions with staff members.

• It was evident the practice had gone through a period of transition including the implementation of a new management team. There was now a clear leadership structure and staff felt supported by management.

However, there were areas where the practice needs to make improvements. Importantly the provider should:

• Improve patient outcomes through the measures of the Quality and Outcomes Framework. (QOF, is a system intended to improve the quality of general practice and reward good practice). Specfically, diabetes and mental health (including dementia) outcomes.

• Continue to review and improve how telephone calls are handled by the practice to ensure patients are able to contact the practice without difficulty.

I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Updated 31 March 2016

The practice is rated as good for the care of people with long-term conditions.

• The GPs and nursing team had the knowledge, skills and competency to respond to the needs of patients with long term conditions such as diabetes and COPD (Chronic obstructive pulmonary disease is the name for a collection of lung diseases including chronic bronchitis, emphysema and chronic obstructive airways disease).

• Longer appointments and home visits were available when needed.

• Patients at risk of hospital admission were identified as a priority.

• The practice actively screened patients for various long-term conditions during a new patient check and other health reviews. There was a high prevalence of diabetes within the patient population; this was a result of pro-active case finding for undiagnosed patients. The practice followed up patients with borderline results and test patients with potential symptoms for example, non healing wounds and blurred vision. This proactive approach has resulted in an increased number of diabetic patients, for example, there had been 10 new diagnoses of diabetes in January 2016.

• Outcomes for patients who use services were consistently very good. Nationally reported Quality and Outcomes Framework (QOF) data, for 2014/15, showed the practice had performed well in the management of long-term conditions with the exception of diabetes. This may be a result of the high prevalence and rapidly increasing number of diabetic patients.  For example: QOF performance for diabetes related indicators was 85%; lower when compared to the CCG average (95%) and the national average (89%).

Updated 31 March 2016

The practice is rated as good for the care of families, children and young people.

• There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk. For example, children and young people who had a high number of A&E attendances.

• There was a designated staff member who arranged and scheduled immunisations. This was evident as immunisation rates were higher when compared to the CCG and national averages.

• 73% of patients diagnosed with asthma, on the register, had an asthma review in the last 12 months. This was lower when compared to the national average, 75%.

• Patients told us that children and young patients were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.

• The practice’s uptake for the cervical screening programme was 91%, which was significantly higher when compared to the CCG average (78%) and the national average (82%).

• Appointments were available outside of school hours and the premises were suitable for children and babies.

• We saw positive examples of joint working with midwives and health visitors.

Updated 31 March 2016

The practice is rated as good for the care of older people.

• The practice offered proactive, personalised care to meet the needs of the older patients in its population.

• The practice was responsive to the needs of older patients. Longer appointments, home visits and urgent appointments were available for those with enhanced needs.

• The practice systematically identified older patients and coordinated the multi-disciplinary team (MDT) for the planning and delivery of palliative care for patients approaching the end of life. The practice was aware of the gold standards framework for end of life care and knew how many patients they had who were receiving palliative care including a palliative care register.

• We saw unplanned hospital admissions and re-admissions for the over 75’s were regularly reviewed and improvements made.

• Nationally reported data showed that outcomes for patients for conditions commonly found in older people were higher than national averages. For example, 100% of patients aged 50 or over (and who have not attained the age of 75) with a fragility fracture and confirmed diagnosis of osteoporosis, were currently treated with an appropriate bone-sparing agent. This is higher when compared to the local Clinical Commissioning Group (CCG) average (92%) and national average (92%).

Updated 31 March 2016

The practice is rated as good for the care of working-age people (including those recently retired and students).

• The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.

• Following the June 2015 inspection, we saw the practice had relaunched a website including updated information on practice opening hours and services available. The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group.

• The practice provided a full travel vaccine service (excluding yellow fever).

Updated 31 March 2016

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia).

• 76% of patients experiencing poor mental health had a comprehensive, agreed care plan documented in their medical record, which was lower when compared to the local CCG average (92%) and national average (88%).

• 78% of patients diagnosed with dementia whose care has been reviewed in a face-to-face review. This was lower when compared to the local CCG average (83%) and national average (84%).

• We saw detailed assurance that this level of performance was being addressed. Actions included specific meetings, patient recalls and medicines reviews. In addition, one of the nurses has been allocated protected time to start reviewing patient lists andhas dedicated clinics and telephone time to address any areas of lower performance.

• The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia.

• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.

• The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.

Updated 31 March 2016

The practice is rated as good for the care of whose circumstances may make them vulnerable.

• The practice offered longer appointments for patients with a learning disability. It had carried out annual health checks for patients with a learning disability and there was evidence that these had been followed up.

• The practice regularly worked with multi-disciplinary teams in the case management of vulnerable patients.

• It had told vulnerable patients about how to access various support groups and voluntary organisations.

• Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.