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Review carried out on 4 April 2019

During an annual regulatory review

We reviewed the information available to us about Shifa Surgery on 4 April 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 28/03/2018

During an inspection looking at part of the service

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

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 carried out on 20 July 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Shifa Surgery on 20 July 2017. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events. We saw that learning from significant events was communicated with staff effectively and staff were aware of any changes implemented as a result in order to minimise the risk of the event being repeated.
  • The practice had clearly defined and embedded systems to minimise risks to patient safety.
  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • Results from the national GP patient survey showed patients had rated the practice in line with others for many aspects of care. Patient feedback we received as part of the inspection process indicated patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • While some patients expressed concerns regarding appointment access, we saw that the practice was taking action to address these concerns and there was improved 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.
  • There was a clear leadership structure and staff felt strongly supported by management.
  • The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of the requirements of the duty of candour.

The areas where the provider should make improvement are:

  • An action plan following an infection control audit should be produced to document that all required actions have been completed in a timely manner.

  • Clinician’s professional registration status should be consistently recorded in order to document that the check has been carried out.

  • Work to validate the carers list should be completed and alerts on the electronic records used to facilitate and maximise access to appropriate support services.

  • Continued work should be undertaken and monitored to address patient concerns around access to appointments.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice