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Inspection Summary


Overall summary & rating

Good

Updated 8 May 2018

We carried out an announced comprehensive inspection on Shifa Surgery on 20 July 2017. The overall rating for the practice was good, although the practice was rated as requires improvement for responsiveness. The full comprehensive report on the July 2017 inspection can be found by selecting the ‘all reports’ link for Shifa Surgery on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 28 March 2018 to confirm that the practice had carried out their plan to make improvements following the last inspection.

The practice is now rated as good for responsive services, and overall the practice is rated as good.

Our key findings were as follows:

  • The practice had considered, discussed and taken action to improve patient access.
  • At our previous inspection we recommended that comprehensive records of clinicians’ professional registration were kept. For this inspection, the practice sent us evidence of a screen shot of a computer system that had been introduced to monitor and record this.
  • At our previous inspection we recommended that the practice carers list should be validated to ensure its correctness. The practice assured us this process continues through checks in clinical consultations and contact with administrative staff.

The areas where the provider should make improvements are:

  • Continue work to record and action areas identified in the annual infection control audit in a timely manner.

  • Review the latest GP Survey results, when available, to consider the efficacy of the action taken to improve access.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 8 May 2018

Effective

Good

Updated 8 May 2018

Caring

Good

Updated 8 May 2018

Responsive

Good

Updated 8 May 2018

Well-led

Good

Updated 8 May 2018

Checks on specific services

People with long term conditions

Good

Updated 27 September 2017

The practice is rated as good 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.

  • Performance against the Quality and Outcomes Framework for long term conditions was variable when compared with local and national averages.

  • 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.

Families, children and young people

Good

Updated 27 September 2017

The practice is rated as good for the care of families, children and young people.

  • We saw there were systems 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 accident and emergency (A&E) attendances.

  • Immunisation rates were relatively high for all standard childhood immunisations.

  • The practice had implemented actions to improve the uptake of cervical screening.

  • Patients told us, on the day of inspection, that children and young people were treated in an age-appropriate way and were recognised as individuals.

  • Appointments were available outside of school hours and the premises were suitable for children and babies.

  • The practice worked with midwives, health visitors and school nurses to support this population group. For example, in the provision of ante-natal, post-natal and child health surveillance clinics.

  • The practice had produced a bespoke card which it sent out to families congratulating them on the arrival of a new child and signposting them to relevant health services in order to promote uptake of the relevant checks.

  • The practice had emergency processes for acutely ill children and young people and for acute pregnancy complications.

Older people

Good

Updated 27 September 2017

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

  • Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns.

  • The practice offered proactive, personalised care to meet the needs of the older patients in its population.

  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs.

  • The practice identified at an early stage older patients who may need palliative care as they were approaching the end of life. It involved older patients in planning and making decisions about their care, including their end of life care.

  • The practice followed up on older patients discharged from hospital and ensured that their care plans were updated to reflect any extra needs.

  • Where older patients had complex needs, the practice shared summary care records with local care services.

  • Older patients were provided with health promotional advice and support to help them to maintain their health and independence for as long as possible.

Working age people (including those recently retired and students)

Good

Updated 27 September 2017

The practice is rated as good 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, extended opening hours appointments.

  • 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. It had made increased efforts to promote these services in response to patient feedback around access to appointments, in an effort to raise patient awareness of alternatives available.

People experiencing poor mental health (including people with dementia)

Good

Updated 27 September 2017

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

  • The practice carried out advance care planning for patients living with dementia.

  • The percentage of patients diagnosed with dementia whose care had been reviewed in a face to face review in the preceding 12 months was 78% compared to the CCG average of 87% and national average of 84%.

  • The practice specifically considered the physical health needs of patients with poor mental health and dementia.

  • The practice had a system for monitoring repeat prescribing for patients receiving medicines for mental health needs.

  • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those living with dementia.

  • Patients at risk of dementia were identified and offered an assessment.

  • 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.

People whose circumstances may make them vulnerable

Good

Updated 27 September 2017

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.

  • End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.

  • 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.

  • The practice had information available for vulnerable patients about how to access various support groups and voluntary organisations.

  • Staff interviewed knew how to recognise signs of abuse in children, young people and adults whose circumstances may make them vulnerable. They 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.