18 August 2017
The Greenhouse Practice provides primary medical services to approximately 1,000 patients in the London Borough of Hackney and is one of 36 member practices in the NHS Hackney Clinical Commissioning Group (CCG). It is a specialist service providing GP services to street homeless people or those in temporary or hostel accommodation in the borough of Hackney. Forty percent of the practice population are rough sleepers whilst 60% live in hostels or other temporary accommodation. The practice does not register patients aged under 16 years.
The practice population is in the most deprived decile in England. Ninety-six percent of patients have at least one long-standing condition whilst 75% have three or more long standing conditions. Approximately 75% of the practice population is male and 25% are female. There are no patients aged over 75 years registered at the practice. The practice has surveyed the ethnicity of the practice population and has determined that 53% of patients identified as having white ethnicity, with significant population groups of British and Eastern European origin, 7% Caribbean, 10% as other black background 30% as having mixed or other ethnicity.
The practice operates from a purpose built property with all patient facilities being wheelchair accessible. There are offices for administrative and management staff on the ground and lower ground floors.
The practice operates under a caretaker contract with the NHS. This was awarded in April 2016 and is currently scheduled to end in 2018.
The practice team at the surgery is made up of one part-time male clinical lead GP, and two part time male GPs who provide a combined total of nine GP sessions. There is a part-time locum practice nurse nursing a part-time substance misuse clinician, and a healthcare assistant (HCA) who also undertakes reception duties. In addition, there are six further administrative staff including a full-time practice manager and a director of operations who also fulfils this role for other practices managed by the provider.
The practice is registered to provide the regulated activities of maternity and midwifery services, diagnostic and screening procedures, family planning and treatment of disease, disorder or injury.
Appointments with GPs are available every weekday morning between 8:30am and 11:50am, every afternoon between 2pm and 6:20pm. In addition to pre-bookable appointments that can be booked up to four weeks in advance, urgent appointments are also available for patients that need them. The practice did not have a limit on how many walk-in appointments were offered in a day.
The practice has opted not to provide out of hours services (OOH) to patients and these were provided on the practice’s behalf by City & Hackney Urgent Healthcare Social Enterprise (CHUSE). The details of the how to access the OOH service are communicated in a recorded message accessed by calling the practice when it is closed and details can also be found on the practice website.
Patients can book appointments in person, on-line or by telephone. Patients can access a range of appointments with the GPs and nurses. Face to face appointments are available on the day and are also bookable up to four weeks in advance. Telephone consultations are offered where advice and prescriptions, if appropriate, can be issued and a telephone triage system is in operation where a patient’s condition is assessed and clinical advice given. Home visits are offered to patients whose condition means they cannot visit the practice.
The practice hosts a wide range of services including clinics for diabetes, respiratory conditions and psychological support. The practice also provides health promotion services including a flu vaccination programme and cervical screening.
The Greenhouse Practice has not previously been inspected by CQC.
18 August 2017
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at The Greenhouse Practice on 15 June 2017. Overall the practice is rated as outstanding.
Our key findings across all the areas we inspected were as follows:
- There was a strong, open and embedded culture at the practice in respect of patient safety and the practice used every opportunity to learn from incidents. We observed a genuine open culture in which all safety concerns raised by staff were highly valued and integral to learning and improvement. All staff were encouraged to participate in learning and to improve safety as much as possible. We saw evidence that incidents were shared externally to enhance learning on a wider basis.
- Comprehensive systems were in place to keep people safe, which took account of current best practice. For example, there was an effective system in place to review patients on high risk medicines which included a nominated lead, an alert on the clinical system, a recall system and regular patient audits to ensure prescribing was in line with safe and best practice.
- 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.
- There was evidence of quality improvement including clinical audit. We saw that the practice had put in place a comprehensive audit programme which was driven by the needs of the practice population in order to improve patient outcomes. There had been 11 clinical audits commenced in the last two years, four of these were completed audits where the improvements made were implemented and monitored.
- Feedback from patients about their care was consistently positive. Data from the national GP patient survey showed patients rated the practice higher than others for almost all aspects of care. 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 good facilities and was well equipped to treat patients and meet their needs.
- The practice worked closely with co-located housing officers and homelessness case workers to support patients transitioning into more secure accommodation.
- The practice worked with other care providers to reduce inequality and improve access to secondary and specialised care.
- Leaders had an inspiring shared purpose and a clear vision which had reducing inequality and access to high quality, safe care as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff and the Patient Association. There was a high level of constructive engagement with staff and a high level of staff satisfaction.
- 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 improvements:
- Continue to monitor practice performance in relation to outcomes for patients with long term conditions.
- Review and improve how patients with caring responsibilities are identified and recorded on the clinical system to ensure that information, advice and support is made available to them.
- The practice should review arrangements in place to ensure a patient has access to a female GP if this is requested.
We saw several areas of outstanding practice:
- The practice did not place a limit on the number of walk-in appointments available on any day so that patients who found it difficult to book appointments in advance or who struggled to adhere to scheduled appointments, could access GP services in a way that suited them.
- A specialist substance and alcohol misuse clinician at the practice offered and delivered alcohol and substance reduction programmes. The substance misuse clinician and the lead GP had a meeting before every clinical session and would discuss the care plan for each patient with an appointment. Patients attending this clinic who had not recently seen a GP were encouraged to see the doctor and would be accommodated on the same day where possible. This meant that GPs were able to undertake opportunistic health and medicine reviews.
- The practice had reviewed the practice list within the previous year and had identified an increasing number of Polish and Vietnamese speaking patients registering. The practice had arranged for a Vietnamese speaking interpreter from a local hospital to attend the practice weekly and had employed its own Polish speaking translator who also attended the practice one day per week. Patients we spoke with told us this had significantly improved their access to health services.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
18 August 2017
The practice is rated as good for providing effective and caring services and outstanding for providing safe, responsive and well led services. The practice is rated as outstanding 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.
- The percentage of patients on the diabetes register, whose last measured total cholesterol (measured within the preceding 12 months) was 5 mmol/l or less was 80% (CCG average 85%, national average 80%) whilst 95% had a record of a foot examination and risk classification (CCG average 92%, national average 88%).
- 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.
- There were emergency processes for patients with long-term conditions who experienced a sudden deterioration in health.
- All these patients 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. 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.
18 August 2017
The practice is rated as good for providing effective and caring services and outstanding for providing safe, responsive and well led services. The practice is rated as outstanding for the care of families, children and young people.
- The practice did not register patients aged under 16 years and there were a very small number of patients aged under 18 years of age registered with the practice. However, some patients at the practice had young family members who were cared for by other people and we noted that the practice demonstrated an awareness of the needs of families, children and young people.
- The practice had emergency processes for acutely ill young people and for acute pregnancy complications.
- Patients told us, on the day of inspection, that young people were treated in an age-appropriate way and were recognised as individuals.
- The practice’s uptake for the cervical screening programme was 77%, which was comparable with the CCG average of 79% and the national average of 81%.
18 August 2017
There were no patients over the age of 75 registered with the practice, so we did not rate this aspect. It must be noted, however, that the practice demonstrated an awareness of the needs of patients over the age of 75.
18 August 2017
The practice is rated as good for providing effective and caring services and outstanding for providing safe, responsive and well led services. The practice is rated as outstanding for the care of working age people (including those recently retired and students).
- The needs of these populations had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care, for example, by offering unlimited walk-in appointments each weekday.
- 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. Many of the practice population could only access the practice website using mobile telephones so it had been designed to optimal when viewed on mobile devices.
- The practice provided a room for weekly clinics run by a social justice charity that advised patients about education, housing and legal advice.
18 August 2017
The practice is rated as good for providing effective and caring services and outstanding for providing safe, responsive and well led services. The practice is rated as outstanding for the care of people experiencing poor mental health (including people with dementia).
- The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses whose alcohol consumption has been recorded in the preceding 12 months was 94% compared to the CCG average of 91% and national average of 89%. The practice had a system for monitoring repeat prescribing for patients receiving medicines for mental health needs.
- The percentage of eligible women with schizophrenia, bipolar affective disorder and other psychoses who had had a cervical screening test in the preceding 5 years was 94% (17 of 18 patients).
- The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those living with dementia.
- 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.
- Staff interviewed had a good understanding of how to support patients with mental health needs and dementia.
18 August 2017
The practice is rated as good for providing effective and caring services and outstanding for providing safe, responsive and well led services. The practice is rated as outstanding for the care of people whose circumstances may make them vulnerable.
- The practice’ computer system would alert staff to all of the outstanding care needs of patients who visiting the practice. This helped clinicians provide more effective care for patients who preferred to attend the practice infrequently.
- A protocol had been put in place through which reception staff would check latest contact details with patients at every point of contact. This meant that the practice was able use an appointment text reminder service effectively.
- The practice had worked closely with the local palliative care team as well as local hospices to develop a strategy to support patients who were approaching the end of their lives. This support included helping patients to consider where they might prefer to die and whether they would like assistance with tracing or contacting family members. 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.
- Staff displayed patience and compassion when speaking with patients who were distressed. Reception staff knew that if patients wanted to discuss sensitive issues they could offer them a private room to discuss their needs.
- The practice was aware that the nature of their population group meant that patients often had complex family backgrounds which could add to the distress experienced during times of bereavement. Staff were sensitive to this and would consider how to react to each bereavement on an individual basis. For instance, the practice told us they would try to find specialist support for patients who were estranged from their families or who needed emergency funding to attend a funeral.