Archived: Abbey Meads Surgery Also known as Great Western Hospitals NHS Foundation Trust

Updated 12 October 2022

The provider, Great Western Hospitals NHS Foundation Trust (hereafter referred to as The Trust), provides acute hospital services at the Great Western Hospital. On 28 November 2019, the Trust took over the running of Abbey Meads Surgery which is located at:

Abbey Meads Surgery

Abbey Meads Village Centre

Elstree Way

Swindon

Wiltshire

SN25 4YZ

Services are also provided from two branch sites:

Penhill Surgery

257 Penhill Drive

Swindon

Wiltshire

SN2 5HN

Crossroads Surgery

478 Cricklade Road

Swindon

Wiltshire

SN2 7BG

We visited Abbey Meads Surgery only for this inspection. Abbey Meads Surgery is based in Swindon, Wiltshire, and is one of 22 practices serving the NHS Swindon Clinical Commissioning Group (CCG) area. The practice shares a purpose-built building with a number of other health related services. Treatment and consulting rooms are not shared. The practice provides services to around 18,138 registered patients. Abbey Meads Surgery provides the following regulated activities:

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

The Trust’s Chief Executive Officer is also the Registered Manager and Nominated Individual (the person responsible for supervising the management of the carrying on of the regulated activities). The management of the practice is overseen by the trusts Deputy Divisional Director of Community and Primary Care Services and run locally by the Head of Operations and Primary Care Network Manager. The management team also consists a primary care Clinical Lead and a Primary care head of nursing.

The practice is part of a wider network of GP practices, the Trust also provides another GP practice within Swindon and together these practices have formed a Primary Care Network (PCN).

Information published by Public Health England shows that deprivation within the practice population group is in the fifth lowest decile (5 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, 92.8% White, 3.4% Asian,1.3% Black, 2.2% Mixed, and 0.3% Other.

There is a team of 9.8 full time equivalent GPs who provide cover at the three practices. The practice has a team of 5.5 full time equivalent nurses who provide nurse led clinics for long-term condition of use of both the main and the branch locations. The GPs are supported at the practice by a team of reception/administration staff. The PCN operations manager and Business support manager are at the PCN’s other practice but works between both surgeries.

Abbey Meads Surgery is open Monday/Tuesday/Friday 8am to 6.30pm. Wednesday 8am to 7.30pm and Thursday 7.30am to 6.30pm.

Crossroads Surgery is open Monday to Friday from 8am to 5.30pm.

Penhill Surgery is open Monday to Thursday from 8am to 5.30pm to patients.

The practices offer a range of appointment types including book on the day, telephone consultations and advance appointments.

Outside of these times patients are directed to contact the out-of-hours service by using the NHS 111 Number.

Updated 12 October 2022

We carried out an announced inspection at Abbey Meads Surgery on 12th September (remote) and 14th September 2022 (on-site) in response to issuing a warning notice 29a. This inspection was to assess compliance against the areas identified in the warning notice issued in May 2022 and as such was not rated. Therefore the ratings from the previous inspection remain until we return to do a rated inspection.

Safe - Requires Improvement

Effective – Good

Caring – Good

Responsive - Good

Well-led – Requires Improvement

Following our previous inspection on 6th to 9th May 2022, the practice was rated Requires Improvement overall and for all key questions except for effective, caring and responsive key questions which were rated as Good.

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

Why we carried out this inspection.

Following the issuing of a warning notice 29a on 24th May 2022, we undertook this focussed inspection to gain assurance that the practice were now compliant with the areas they were in breach of regulation.

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:

• 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

In this inspection we found that:

• The practice had made improvements in all areas identified in the warning notice and were now compliant.
• Systems were in place to ensure consistent clinical coding and summarising.
• Emergency medicines were stored in a secure location.
• Keypads had been utilised to ensure patients and visitors to the practice could not enter non-patient areas.
• A system of routine audit had been put into place to ensure appropriate coding of patients with pre-diabetes.
• A system to review historical alerts had been put into place with routine audit, However, at the time of the inspection review was still in progress.

The areas where the provider should make improvements are:

• Continue to audit and review historically missed alerts.

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