Background to this inspection
Updated
6 October 2021
Shirley Medical Centre provides primary medical services in 370 Wickham Road, Shirley, Croydon CR0 8BH to approximately 7600 registered patients and is one of the 49 practices in Croydon Local Area Team and part of the South West London Clinical Commissioning Group (CCG).
The clinical team at the surgery is made up of two full-time male lead GP partners, one part-time female salaried GP and one part-time female long-term locum GP, a female practice nurse and a female healthcare assistant. The non-clinical practice team consists of two team leaders and 11 administrative or reception staff members.
The practice population is in the third least deprived decile in England. The practice population of children and working age people is below the local and national averages and the practice population of older people is above the local and national averages.
The practice is registered as a partnership with the Care Quality Commission to provide the regulated activities of diagnostic and screening procedures, family planning, maternity and midwifery services, surgical procedures and treatment of disease, disorder or injury.
Updated
6 October 2021
We carried out an announced focused inspection at Shirley Medical Centre on 15 September 2021 and a remote clinical review on 14 September 2021 to follow up on breaches of regulations. Overall, the practice was rated as good.
The practice was previously inspected on 25 September 2020. Following the last inspection, requirement notices were issued in relation to summarising of patient notes, medicines management, medicines and safety alerts, coding of test results and coding of patients with long-term conditions.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Shirley Medical centre on our website at www.cqc.org.uk
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:
- Conducting staff interviews using video conferencing
- 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
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 and
- information from the provider, patients, the public and other organisations.
We rated the practice as Requires Improvement for providing safe services.
At this inspection we found the provider had made some improvements in providing safe services. In particular, the provider had made improvements to their systems and process in relation to summarising of patient notes and coding of test results of patients. However, we found new issues in relation to safeguarding, safety systems and records and medicines management.
We rated the practice as Good for providing effective services.
At this inspection we found the provider had made some improvements in providing effective services. However, outcomes for patients with long-term conditions were significantly below average, the provider had not demonstrated improved patient outcomes through quality improvement activities or clinical audits and uptake for childhood immunisations were below target.
We rated the practice as Good for providing well-led services.
We found the provider had made improvements in providing well-led services in relation to good governance and had implemented systems and process in response to the findings of our previous inspection. However, the governance arrangements in place still required improvement especially in relation to identifying, managing and mitigating risks.
We have rated this practice as Good overall, requires improvement in safe and requires improvement for population group people with long-term conditions.
The areas where the provider must make improvements are:
- Ensure that care and treatment is provided in a safe way for patients.
(Please see the specific details on action required at the end of this report).
The areas where the provider should make improvements are:
- Improve recording of DNACPR decisions.
- Improve uptake for childhood immunisations and outcomes for patients with long-term conditions.
- Demonstrate improved outcomes for patients through clinical audits or other quality improvement activities.
- Improve patient engagement through Patient Participation Group meetings.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care