The Swan Practice

Updated 30 January 2020

The Swan Practice is a multi-site GP practice located in Buckingham and Steeple Claydon in Buckinghamshire. The practice was formed following several changes in the health community in North Buckinghamshire, specifically two mergers – one in 2014 followed by a further merge in 2016. The practice has approximately 30,500 patients and is one of the practices within Buckinghamshire Clinical Commissioning Group (CCG).

Clinical services are provided from three sites:

• North End Surgery, High Street, Buckingham, Buckinghamshire MK18 1NU
• Verney Close Surgery, Verney Close, Buckingham, Buckinghamshire MK18 1JP
• Steeple Claydon Surgery, 2 Vicarage Lane, Steeple Claydon, Buckinghamshire MK18 2PR

Management, administration and support services are provided from:

• Masonic House, High Street, Buckingham, Buckinghamshire MK18 1NU.

The practice website is:

We visited three of the four sites as part of this inspection – North End Surgery (referred to as the main site), Verney Close Surgery and Masonic House. Our visit to Verney Close Surgery included a review of the in-house dispensary.

There are 11 GP partners, nine salaried GPs, a Physician Associate, a clinical pharmacist, three paramedics and a First Contact Physiotherapist at the practice. The nursing team consists of a lead nurse manager, two advanced nurse practitioners, five practice nurses, five health care assistants and a phlebotomist with a mix of skills and experience. One of the GPs is the designated dispensary lead and the combined dispensary team consists of one pharmacy technician and 13 dispensers.

The business manager, five other senior departmental managers and a team of reception and administrative staff undertake the day to day management and running of the practice.

According to national data there are high levels of affluence and minimal deprivation in Buckinghamshire, specifically the towns, villages and hamlets within the practice catchment areas. The practice population has a higher proportion of patients with a long-standing health condition compared to the local and national averages. The age profile of the practice population is mixed – this is a result of providing GP services to three local prep/boarding schools (approximately 750 patients) and the local independent university (approximately 2,500 patients). There is also a proportion of patients in four local care homes (approximately 140 registered patients).

All three sites have core opening hours from 8am to 6.30pm Monday to Friday to enable patients to contact the practice. Extended hours appointments were available with either a GP, nurse or paramedic on Monday evenings until 8pm and Saturday between 8am and 1pm. Patients at the practice could access improved access appointments at any of the seven practices across North Buckinghamshire. These improved access appointments were booked via the patient’s registered practice and offered a variety of appointments including up until 8pm Monday to Friday, selected hours on Saturdays and 9am until 1pm on Sunday and Bank Holidays.

All three dispensaries have core opening hours between 8am and 6pm every weekday.

The practice is registered by the Care Quality Commission (CQC) to carry out the following regulated activities: Maternity and midwifery services, Family planning, Treatment of disease, disorder or injury and Diagnostic and screening procedures.

Updated 30 January 2020

We carried out an announced focused inspection at The Swan Practice, a multi-site GP practice in North Buckinghamshire on 12 December 2019 as part of our inspection programme.

We carried out an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions:

• Are services safe?
• Are services effective?
• Are services well-led?

Following assurance received from our review of information we carried forward the ratings for the following key questions from the previous inspection in October 2015:

• Are services caring?
• Are services responsive?

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

• Information from the provider, patients, the public and other organisations.

We have rated this practice as good overall. We rated the practice as good for providing safe, effective and well-led services and for the following population groups: older people; people with long term conditions, families children and young people; working age people (including those recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental health (including dementia).

We found that:

• It was evident the practice had gone through a period of transition. This included two mergers in the last five years, a significant increase in the patient population and changes within the GP partnership and the management team.

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.

• Patients received effective care and treatment that met their needs.

• The way the practice was led and managed promoted the delivery of high-quality, person-centred care.

• Personal development and learning were actively promoted and a wide range of learning opportunities were provided for staff of all grades and disciplines.

• Patient and stakeholder feedback was consistently positive and the practice took account of feedback in the way services were provided.

• When changes were made to the way the service was provided the practice managed these in a sensitive and controlled manner. The views of staff and patients were sought and acted upon when changes were proposed and carried out.

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

• Continue to review clinical outcomes and interventions for patients diagnosed with long term conditions and mental health problems where national indicators identify below average performance.

We identified two areas of outstanding practice:

• Feedback from external stakeholders was overwhelmingly positive. This included feedback from local care and nursing homes, schools and the university which accessed GP services from the practice. We spoke with representatives from each of the stakeholders, they all highlighted examples of coordinated effective care. This included examples when the practice GPs had supported staff to achieve additional clinical qualifications, including mentorship support to gain prescribing qualifications. The practice also supported the schools in providing resources (where appropriate) for the Personal, Social, Health and Economic (PSHE) lessons. PSHE is a school curriculum subject which focuses on developing the knowledge, skills and attributes to keep children and young people healthy and safe and to prepare them for life and work.

• There was strong collaboration, team-working and support across all teams, all functions, all sites with a strong emphasis on the safety and well-being of staff. We saw many examples of positive changes to promote staff well-being, this included a review of flexible working, remote home working (where appropriate), team building exercises, an annual well-being day with an aligning budget, promotion of exercise and physical activity, relocation of some members of staff to remove isolation and creation of teams, reconfigured coffee breaks and adoption of the British Medical Association’s (BMA) safe working and workload principles. We also saw the five-year business plan for 2018-2023 included staff wellbeing and employee welfare as a theme through every component.

Details of our findings and the evidence supporting the change in rating are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Updated 26 November 2015

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

GPs and nursing staff had the knowledge, skills and competency to respond to the needs of patients with long term conditions such as diabetes and asthma. Longer appointments and home visits were available when needed. All of these patients were offered a structured annual review to check that their health and medication needs were being met. For those people with the most complex needs, the GPs worked with relevant health and social care professionals to deliver a multidisciplinary package of care. Patients with end of life care needs and their families were well supported by the practice.

Updated 26 November 2015

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.

Records showed the GPs proactively sought and promoted improvement in immunisation management and this was evident in the immunisation data as the practice were similar to both local and national averages for childhood immunisations. Childhood immunisation rates for the vaccinations given in 2014/15 to under two year olds ranged from 96% to 100% and five year olds from 86% to 95%. These were in line with the CCG and national averages.

Children who did not attend for their immunisations were followed up by the practice and discussed with the health visitor if they were considered at risk.

Every month (the second Friday of each calendar month) the practice held a Multidisciplinary Team Meeting to discuss matters relating to children, young people and their families. The practice invited GPs, Practice Nurses, Health Visitors, School Nurses and Midwives to attend these meetings and discuss and action any child protection concerns.

We saw the practice supports and accommodates a twice weekly sexual health outreach service. This serves the population of Buckingham and the surrounding villages and reduces the requirement to attend sexual health clinics in Aylesbury (38 mile round trip) and Milton Keynes (26 mile round trip).

Updated 26 November 2015

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

The practice provided person centred care to meet the needs of the older patients in its population and had a range of enhanced services, for example in dementia, end of life care and reducing admissions to hospital. Unplanned hospital admissions and re-admissions for this group were regularly reviewed and improvements made.

Every month (the first Friday of each calendar month) the practice held a Multidisciplinary Team Meeting to discuss matters relating to older people, chronic disease and terminal care. The practice invited GPs, District Nurses, Practice Nurses and members from the Palliative Care team to co-ordinate care in a multi-agency fashion, ensuring patients received the highest level of holistic care possible.

It was responsive to the needs of older people, and offered home visits and rapid access appointments for those with enhanced needs. The practice identified if patients were also carers; information about support groups was available in the waiting room.

Nationally reported data showed that outcomes for patients were good for conditions commonly found in older people, for example, data showed the percentage of patients aged 75 or over with a fragility fracture that are currently treated with an appropriate bone-sparing agent was 100%. This was 32.6% higher than the national average.

The practice provided medical care to four local care homes with a lead GP designated to each of the four homes. The designated GPs held regular sessions at the homes to review patients with non-urgent health problems; this time was also used to proactively identify and manage any emerging health issues and undertake medication reviews. The practice were aware of lone elderly patients who were vulnerable, and without request would make regular home visits to check on their welfare. A GP also carried out home visits to older patients presenting with more urgent health needs and the practice provided GP services to the community hospital; completing ward rounds five times each week.

Updated 26 November 2015

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.

There was a range of appointments between 8am and 6pm Monday to Friday with earlier appointments available from 7.15am three days a week. The practice was open on alternate Saturday mornings, specifically for patients not able to attend outside normal working hours with no restrictions to other patients.

Phlebotomy services were available at the practice which meant patients did not have to attend the hospital for blood tests.

We saw proactive online services as well as a full range of health promotion and screening that reflected the needs for this age group.

The practice provides GP services to approximately 1800 students (approximately 50% are foreign students with no prior knowledge of GP services within England) at a local university. Key members of staff including a GP who is the dedicated GP for the university attend the four yearly intakes of new students to commence the practice registration process. One of the GPs is the dedicated GP for providing students with GP services and runs a term time daily clinic at the university campus. We saw how the practice showed how they catered for short term requests for appointments especially around exam and result times.

Updated 26 November 2015

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

The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia. It carried out advance care planning including regular face-to-face reviews for these patients. For example:

• 88% of patients diagnosed with dementia had their care reviewed in a face-to-face review; this higher than the local CCG average and national average.

• 96.8% of patients with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive, agreed care plan documented in the record; this was higher than the local CCG average (92.8%) and the national average (85.9%).

Patients experiencing poor mental health were told about how to access various support groups and voluntary organisations including MIND and SANE. These are two national organisations that offer support and advice to people experiencing poor mental health and their families. The practice worked also worked with a local mental health charity called Bucks Mind which includes a local befriending scheme and activity group within the local community.

Updated 26 November 2015

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. It offered longer appointments and carried out annual health reviews for people with a learning disability. These reviews were often pre-booked on a Saturday morning at the practice which is a known quiet time within the practice.

The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people. It had told vulnerable patients 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.