Causeway Green Surgery

Updated 26 October 2017

Causeway Green Surgery provides NHS services to the local community in Oldbury, West Midlands. The practice has an approximate patient population of 2300 and is part of the NHS Sandwell and West Birmingham Clinical Commissioning Group (CCG). CCGs are groups of general practices that work together to plan and design local health services in England. They do this by 'commissioning' or buying health and care services.

Causeway Green Surgery is registered with the Care Quality Commission (CQC) to provide primary medical services. The current provider registered with the CQC in October 2016. The practice has a general medical service (GMS) contract with NHS England. Under the GMS contract the practice is required to provide essential services to patients who are ill and includes chronic disease management and end of life care.

Based on data available from Public Health England, the levels of deprivation (deprivation covers a broad range of issues and refers to unmet needs caused by a lack of resources of all kinds, not just financial) in the area served by Causeway Green Surgery are below the national average, ranked at three out of 10, with 10 being the least deprived.

The practice staffing comprises of one lead GP (male), two regular locum GPs (one male and one female), a practice nurse and a healthcare assistant. The GP, business manager and the practice manager form the practice management team and were supported by a team of administration and reception staff.

The practice is open between 8am to 6.30pm Monday to Friday. The practice is part of hub working arrangement (organised by the CCG) and patients could access care between 6.30pm and 8pm. Saturday (9am to 12pm) and Sunday (10am to 2pm) access was also available.

The practice has opted out of providing out-of-hours services to their own patients. This service is provided by the external out of hours service provider.

Updated 26 October 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Causeway Green Surgery on 27 September 2017. 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 a system in place for reporting and recording significant events.
• The practice had clearly defined and embedded systems to minimise risks to patient safety.

• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• Results from the national GP patient survey was in line with local and national averages and showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment. The practice was aware of lower scores and was exploring ways to improve.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• The practice had adjusted its premises as far as practicable to enable access to those who had difficulties with their mobility.
• 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.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider should make improvement are:

• Consider how patients with hearing impairments could be better supported.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 26 October 2017

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

• Nursing staff had lead roles in long-term disease management and patients at risk of hospital admission were identified as a priority. Management staff took on the lead role to co-ordinate and review achievement of targets.
• The percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) was 150/90 mmHg or less was 96%. This was above the local CCG average of 91% and the national average of 91%.
• The percentage of patients newly diagnosed with diabetes, on the register, in the preceding 12 months who had a record of being referred to a structured education programme within 9 months after entry on to the diabetes register was 100%. This was above the local CCG average of 90% and the national average of 92%. The exception reporting was 0%.
• The practice followed up on patients with long-term conditions discharged from hospital and ensured that their care plans were updated to reflect any additional needs.
• Longer appointments and home visits were available when needed.
• For convenience the practice offered a range of services in-house to support the diagnosis and monitoring of patients with long term conditions such electrocardiographs (ECGs), at the practice.
• All patients with a long term condition had a named GP and there was a system to recall patients for a structured annual review to check their health and medicines needs were being met. We saw that a process was put in place to review the recall processes regularly to minimise the risk of any missed reviews.
• For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.
• Relevant patients were also signposted to patient groups and supported to access a support network.

Updated 26 October 2017

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

• The documents we reviewed showed the practice had systems 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 accident and emergency (A&E) attendances.
• The practice held bi-monthly meetings with health visitors and Safeguarding Team (Children & Adults). There were registers in place and patients on this register were discussed.
• Immunisation rates were relatively high for all standard childhood immunisations.
• The practice provided support for premature babies and their families following discharge from hospital. The practice held baby clinics and weekly child health surveillance clinics.
• Appointments were available outside of school hours and the premises were suitable for children and babies. The practice had made reasonable adjustments following an access audit.

Updated 26 October 2017

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

• Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns.
• The practice offered proactive, personalised care to meet the needs of the older patients in its population. For example, the practice had identified approximately147 elderly patients of which 123 had their elderly assessments completed. Care plans were discussed with patients and where appropriate, their carer’s and included aims and objectives.

• The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs. The practice had seven patients who were housebound and it had had carried out home visits to all patients as required.

• The practice identified at an early stage older patients who may need palliative care as they were approaching the end of life and referred them to the CCGs palliative care hub.
• The practice followed up on older patients discharged from hospital and ensured that their care plans were updated to reflect any extra needs.
• Access to services, including flexible appointment times and same day telephone consultation were available for this age group.

Updated 26 October 2017

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.
• Patients could access appointments and services in a way and at a time that suited them. Appointments could be booked over the telephone, face to face and online. The practice was part of a hub working arrangement (CCG initiative) and patients could access appointments after working hours Monday to Friday between 6.30pm and 8pm. Weekend access was also available.
• There was a text messaging reminder in place to ensure patients attended their appointment.
• The practice was proactive in offering online services as well as a full range of health promotion and screening that reflected the needs for this age group.

Updated 26 October 2017

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

• The practice carried out advance care planning for patients living with dementia.
• 100% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months. This was above the local CCG average of 84% and the national average of 84%. The exception reporting was 14% which was above the local CCG and national average of 7%.
• The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who had a comprehensive care plan documented in the record, in the preceding 12 months was 100%. This was above the local CCG average of 91% and the national average of 89%. The exception reporting at 6% was below the local CCG average of 15% and the national average of 13%.
• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those living with dementia.
• Patients at risk of dementia were identified and offered an assessment.
• The practice had information available for patients experiencing poor mental health about how they could access various support groups and voluntary organisations.
• The practice had a system to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.

Updated 26 October 2017

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

• The practice held a register of patients living in vulnerable circumstances including those with a learning disability.
• End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.
• The practice offered longer appointments for patients with a learning disability.
• The practice regularly worked with other health care professionals in the case management of vulnerable patients.
• The practice had information available for vulnerable patients about how to access various support groups and voluntary organisations.
• Staff interviewed knew how to recognise signs of abuse in children, young people and adults whose circumstances may make them vulnerable. They 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.