Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Shiregreen Medical Centre on 3 August 2016. The overall rating for the practice was good with requires improvement for the ‘safe’ domain. The full comprehensive report on the 3 August 2016 inspection can be found by selecting the ‘all reports’ link for Shiregreen Medical Centre on our website at www.cqc.org.uk.

This inspection was a focused desktop inspection and carried out on Wednesday 29 March.  This was to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 3 August 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

• We saw evidence that the practice had carried out risk assessments for fire safety, legionella and health and safety at the main and the branch surgery.

• The practice had updated their recruitment process to include structured interview questions.

• We saw evidence that staff appraisals had been documented.

  The provider had documented staff appraisals.

• The practice had updated their complaints process to include the Parliamentary Health Service Ombudsman details.
• Arrangements were being considered to improve and maintain patient confidentiality in the reception area.

• We saw logged evidence that

  The oxygen and the defibrillator had been checked regularly.

• An annual infection prevention and control audit had been carried out at the branch surgery.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Shiregreen Medical Centre on 3 August 2016. Overall the practice is rated as good.

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

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services was available and easy to understand.
• Patients 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.
• Staff felt supported by management and the practice sought feedback from patients, which it acted on.
• The provider was aware of and complied with the requirements of the duty of candour.
• Staff understood their responsibilities to raise concerns, and to report incidents and near misses, however, this needed a more systematic approach.

The areas where the provider must make improvements are:

• Fire assessments, Legionella and Health and Safety risk assessments must be carried out at both the main and branch surgery.

• The practice must ensure their recruitment process includes structured interview questions and all staff appraisals should be documented.

• The practice must ensure that their complaints process is robust and is fit for purpose and contains an analysis of trends.

The area where the provider should make improvements are:

• The practice should consider their complaints process to ensure that it is fit for purpose.

• New arrangements for maintaining patient confidentiality should be considered in the reception area.

• Oxygen and the defibrillator should be checked and logged regularly.

• An annual infection prevention and control audit should be undertaken at the branch surgery.

Professor Steve Field (C

CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

This practice is rated requires improvement overall. (Previous rating 29 March 2017 – Good)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We carried out an announced comprehensive inspection at Shiregreen Medical Centre on 20 November 2018 as part of our inspection programme.

At this inspection we found:

• There were gaps in the practice’s governance arrangements resulting in risk management processes not being comprehensive. For example, there was insufficient oversight to ensure mitigating actions identified on safety risk assessments had been completed.
• The practice had systems to identify and investigate safety incidents so that they were less likely to happen again. When incidents did happen, the practice learned from them and improved their processes.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• The appointment system had been changed in recent months. Patient feedback was mostly positive, though there were some mixed comments about being able to access an appointment.
• Staff told us they felt respected, supported and valued. They told us they worked well as a team and were proud to work in the practice.

The areas where the provider must make improvements as they are in breach of regulations are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Review the process to check and record medicines prescribed to patients with poor mental health are being ordered by patients.

• Take action to ensure all recruitment checks are documented.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice