The Care Quality Commission
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  • GP practice

Shirley Medical Centre

Overall: Good read more about inspection ratings

370 Wickham Road, Shirley, Croydon, Surrey, CR0 8BH (020) 8777 2066

Provided and run by:
Shirley Medical Centre

All Inspections

15 September 2021

During an inspection looking at part of the service

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

21 Sep 2020 to 25 Sep 2020

During an inspection looking at part of the service

We carried out a remote regulatory review (21 September 2020) and a focused onsite inspection (25 September 2020) of Shirley Medical Centre following our review of the information available to us.

The provider was rated overall as good during our last inspection in January 2019.

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.

This is an unrated inspection to follow-up on concerns.

We found that:

  • The systems and processes in place to keep patients safe required improvement. For example, the practice did not have a robust system in place for monitoring patients on high-risk medicines.
  • The provider knew the challenges they were facing and had plans to address them.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Ensure that effective systems and processes are in place to ensure good governance in accordance to fundamental standards of care.

(Please see the specific details on action required at the end of this report).

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

23 Jan 2019

During a routine inspection

We carried out an announced comprehensive inspection at Shirley Medical Centre on 23 January 2019 to follow up on breaches of regulations.

At the last inspection in January 2018 we rated the practice as requires improvement overall because:

  • Systems to ensure safety were not operating effectively. For example, assessments of fire safety, emergency lighting and legionella had identified actions that had not been acted upon and there was no system in place to ensure blood tests were reviewed before prescribing high risk medicines.
  • Staff recruitment and training records were incomplete.
  • The practice did not achieve the national targets for uptake of cervical screening and childhood immunisations.
  • The practice had not signed up to provide NHS health checks and learning disability health checks.

At this inspection, we found that the provider had satisfactorily addressed these areas.

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 have rated this practice as good overall and good for all population groups.

We found that:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. 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.
  • Patients found the appointment system easy to use and reported they were able to access care when they needed it.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

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

  • Review practice procedures for completing health checks for patients with learning disability.
  • Review practice procedures regarding issuing of repeat prescriptions.

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

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

16 January 2018

During a routine inspection

Letter from the Chief Inspector of General Practice

This practice is rated as Requires improvement overall. (Previous inspection October 2015 – Good)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Requires improvement

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Requires improvement

People with long-term conditions – Good

Families, children and young people – Requires improvement

Working age people (including those recently retired and students – Requires improvement

People whose circumstances may make them vulnerable – Requires improvement

People experiencing poor mental health (including people with dementia) - Requires improvement

We carried out an announced comprehensive inspection at Shirley Medical Centre on 16 January 2018, as part of our routine inspection programme.

At this inspection we found:

  • A number of systems to ensure safety were not operating effectively. For example, assessments of fire safety, emergency lighting and legionella had identified actions that had not all been acted upon and there was no system to ensure that recent blood test results were reviewed before prescribing high risk medicines.
  • Staff recruitment and training records were incomplete.
  • The practice did not achieve the national targets for uptake of cervical screening or childhood immunisations. NHS health checks were not provided and patients with a learning difficulty did not receive an annual review because the practice had not signed up to the local enhanced service scheme.
  • The practice performed in line with average on most indicators of the Quality Outcome Framework (QOF) QOF is a system intended to improve the quality of general practice and reward good practice.
  • There was evidence of learning and improvement when things went wrong, but the system for this was not clear or consistent.
  • Patients found the appointment system generally easy to use and reported that they were usually able to access care when they needed it.
  • Feedback from patients was that they were treated with compassion, dignity and respect.
  • The practice was about to begin hosting an extended access pilot on weekday evenings and Saturdays, to improve appointment access for patients.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. (Please see the end of the report for details).

The areas where the provider should make improvements are:

  • Consider developing processes to improve take up of childhood immunisations, and cervical screening and to increase the percentage of patients diagnosed with schizophrenia, bipolar affective disorder and other psychoses who had their alcohol consumption recorded in the previous 12 months.
  • Consider how to check the health of patients aged 40 – 74, 75+ and patients who have learning difficulties.
  • Consider how to support patients with additional communication needs, e.g. by developing easy read materials.
  • Review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is made available to them.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

19 October 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of the Shirley Medical Centre on 16 and 17 October 2014. Breaches of legal requirements were found. Specifically, we had found that the practice waiting room was in a poor state of repair; concerns were found with the flooring and patient seating. This increased the risk of cross infection to patients visiting the practice. The practice also had no access to oxygen or an Automatic External Defibrillator (AED) to support patients requiring emergency treatment. After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements in relation to the breaches of regulation 12(1)(a)(b)(c) and regulation 12(2)(a)(c)(i) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

We undertook this focussed inspection on 19 October 2015 to check that they had followed their plan and to confirm that they now met the legal requirements. This report covers our findings in relation to those requirements and also where additional improvements have been made following the initial inspection. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Shirley Medical Centre on our website at www.cqc.org.uk.

Overall the practice is rated as Good. Specifically, following the focussed inspection we found the practice to be good for providing safe services.

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

  • The practice had Oxygen and an Automatic External Defibrillator (AED) in place to ensure the welfare and safety of service users in a medical emergency.
  • The patient waiting room had been refurbished to safeguard patients from the risk of infection.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

16 & 17 October 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

Shirley Medical Centre, located in Shirley in the London Borough of Croydon in south west London, provides a general practice service to 4,211 patients.

We carried out an announced comprehensive inspection on 16 and 17 October 2014. The inspection took place over one and a half days, this was due to specific staff not being available on the first day of inspection, and was undertaken by a lead inspector, along with a GP advisor. We looked at records, spoke with patients, members of the patient participation group (PPG), and staff including the management team. The practice is contracted for general medical services (GMS) and registered with the Care Quality Commission for the regulated activities of treatment of disease, disorder or injury, maternity services, family planning, surgical procedures and diagnostic and screening procedures at one location.

Overall the practice is rated as good.

Our key findings were as follows:

There were systems in place for reporting, recording and monitoring significant events to help provide improved care. Staff were clear of their roles in regards to monitoring and reporting of incidents, safeguarding vulnerable people and children, and followed infection prevention and control guidelines.

Staff shared best practice through internal arrangements and meetings and also by sharing knowledge and expertise with external consultants and other GP practices. There was strong multidisciplinary input into the service delivery to improve patient outcomes. Meetings with district nursing, mental health teams and health visitors were in place to further support patient care and treatment.

Feedback from patients about their care and treatment via the national and practice-run surveys was very positive. Patients were treated with kindness and respect and felt involved in their care decisions. Almost all the comment cards completed by patients who used the service in the two weeks prior to our inspection visit had very positive comments about the care and service provided by the surgery.

The practice valued the input, comments and suggestions from patients and used various methods to engage with the patient population group, these included an active Patient Participation Group (PPG); there was also a virtual patient group available via the provider’s website.

We observed that the patient waiting room flooring, was in a poor state of repair and required attention, the seating that was available was not easily cleanable and though subject to regular cleaning within the cleaning schedule there was no way to safeguard patients from the risk of infection.

The provider had conducted patient surveys to highlight concerns or recommendations directly related to the practice and its staff with evidence of shared learning and changes in practice having been implemented as a result of the surveys.

Patients were cared for in a kind and compassionate manner, were treated with dignity and respect and at all times.

The provider was promoting the spirit of community care within the practice, while engaging with the wider local community, patient services and organisations to support and deliver appropriate care to the patient population list.

The practice had a clear vision and strategic direction and was well-led.  Staff were suitably supported and patient care and safety was a high priority.

All the population groups including older people; people with long term conditions; mothers, babies, children and young people; the working age populations and those recently retired; people in vulnerable circumstances and people experiencing poor mental health received care that was effective, caring, responsive and well-led.

However, there were also areas of practice where the provider needs to make improvements.

The provider must:

·        Be able to respond immediately to the needs of a person who becomes seriously ill. Current guidance and national standards encourage practices to have a defibrillator and emphasise the use of oxygen. Shirley Medical Centre did not have a defibrillator and oxygen available.

In addition the provider should:

·         Improve the state of repair of the waiting area and the ease with which it can be kept clean.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice