The Care Quality Commission
  • Doctor
  • GP practice

Archived: Dr Nabil Shather Also known as Bilston Street Surgery

Overall: Requires improvement read more about inspection ratings

25 Bilston Street, Sedgley, Dudley, West Midlands, DY3 1JA (01902) 665700

Provided and run by:
Dr Nabil Shather

All Inspections

10 August 2016 and 6 September 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We undertook an announced comprehensive inspection of Dr Nabil Shather’s practice, at Bilston Street Surgery, on 10 August and 6 September 2016.

This inspection was also carried out to check that the provider had made improvements in line with the recommendations made as a result of our focussed inspection on 9 December 2015. This was because during our inspection on 9 December 2015, the practices rating remained as requires improvement for providing safe services as the provider had not made sufficient improvement in order to comply with legal requirements.

During our visit on 10 August 2016 we found that although some improvements had been made we identified further areas of concern pertaining to the practices systems for managing and monitoring high risk medicines. We also found that at this stage, we did not have sufficient evidence in order to make a fair and proportionate judgement of the service.

Therefore, we visited the practice further on 6 September 2016 to obtain further evidence and to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

This report covers our findings in relation our findings on 10 August and 6 September 2016. You can read the report from the practices previous comprehensive inspection, by selecting the 'all reports' link for Dr Nabil Shather on our website at www.cqc.org.uk

Overall the practice is rated as requires improvement. Our key findings across all the areas we inspected were as follows:

  • During our comprehensive inspection we found that the practice had made some improvements with regards to specific areas of medicines management. However, we noted a reactive approach to improvement and that sometimes the practice did not proactively improve and had not identified areas to improve on independently.
  • Furthermore, we found that the practice had made some improvements regarding systems and processes associated with medicines management. However, we identified that 78 patients on specific medication to reduce cholesterol levels in the blood were overdue for specific liver function tests.
  • The practice had improved their programme of continuous clinical and internal audit by using this to monitor quality and to make improvements. Staff worked with multidisciplinary teams to understand and meet the range and complexity of patients’ needs.
  • There were adequate arrangements in place to respond to emergencies and major incidents. There were some effective arrangements in place to the support processes for identifying, recording and managing risks.
  • During our inspection visits we saw that that members of staff were friendly, respectful and helpful to patients. Practice staff spoke positively about working at the practice.
  • Patients we spoke with and the completed comment cards we received described staff as helpful, caring and respectful.

The areas where the provider must make improvements are:

  • Ensure that effective systems and processes are established in order to proactively improve and to sustain improvement work across all areas of medicines management.

The areas where the provider should make improvements are:

  • Ensure that all aspects of medication needs are continually managed through well embedded systems to support that where required, necessary monitoring and reviews take place.
  • Ensure that records are well maintained to reflect emergency protocols such as fire drills.
  • Continue to identify carers and ensure that all carers are captured on the computer system, in order to provide further support where needed.
  • Consider contingency arrangements to provide continuity of medical and nursing care during annual leave.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

9 December 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We undertook an announced focused inspection on 9 December 2015. The aim of this inspection was to check that improvements had been made to meet legal requirements, following our comprehensive inspection in January 2015. This inspection will not result in a change to the practices published ratings.

The overall rating for this practice remains as good.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Dr Nabil Shather on our website at www.cqc.org.uk

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

  • Although risks to patients who used services were assessed, the systems and processes to address these risks were not implemented well enough. For example, there was no systematic approach to medication reviews and prescriptions pads were not securely stored.
  • Medication audits were completed in conjunction with the CCG pharmacist
  • There was no evidence of systematic checking or calibration of the two mercury sphygmomanometers. No mercury spillage kit was available and staff did not know how to manage a spillage of mercury.
  • The defibrillator, oxygen and emergency medicines were all stored in separate locations. Storing equipment in one location would enable staff to have immediate access when needed, thus reducing delay in an emergency.
  • Policies and procedure had been implemented but not monitored to ensure effectiveness and compliance, for example the uncollected prescriptions.
  • Appropriate recruitment checks had been undertaken prior to the employment of two new members of administration staff.
  • Administration staff could demonstrate the use of the computer system, for example, basic searches and monitoring.
  • Emergency medicines held in the practice did not include Penicillin.

The areas where the provider must make improvements are:

  • Ensure that equipment used is safe for use, properly maintained and available when needed without posing a risk to the service user.
  • Ensure medication reviews are carried out systematically and uncollected prescriptions are monitored
  • Ensure that access to prescription pads is secure.
  • Ensure there is a formal clinical audit plan

In addition the provider should:

  • Consider the monitoring of compliance to newly implemented policies and procedures.
  • Consider the range of emergency drugs held by the practice.
  • Consider storing emergency equipment and drugs in one location to ensure immediate access when needed, thus reducing delay in an emergency.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

27 January 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection at Bilston Street Surgery on 27 January 2015. The practice is registered with the Care Quality Commission to provide primary care services to its local population. This is the report of the findings from our inspection.

We found that the practice was good for providing an effective, caring, responsive and well-led service and required improvement for providing a safe service. We also inspected the quality of care for six population groups these are, people with long term conditions, families, children and young people, working age people, older people, people in vulnerable groups and people experiencing poor mental health. We rated the care provided to the six population groups as good. We rated the practice overall as good.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Recruitment practices were not robust as the practice were not always able to demonstrate that evidence of satisfactory conduct in previous employment had been obtained.
  • Lead roles had been assigned to manage infection control and staff were aware of who held the lead role. Infection prevention and control audits had taken place.
  • Systems were in place to review the care needs of those patients with complex health needs or those in vulnerable circumstances.
  • Patients said that the GPs listened to what they had to say and treated them with compassion, dignity and respect. Patients told us that they were involved in their care and decisions about their treatment.
  • Patients who required an urgent appointment were given an appointment on the same day that they telephoned.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • There was an open culture within the practice and staff were actively encouraged to raise concerns and suggestions for improvement.
  • There was an active Patient Participation Group (PPG) who met on a regular basis. The PPG reported an excellent relationship with the practice and confirmed that the practice listened and acted upon suggestions made by them.

The areas where the provider must make improvements are:

  • Ensure systems are in place regarding repeat prescribing to provide patients with a review on a regular basis.

The provider should:

  • Ensure that the practice follow recruitment procedures and obtain satisfactory evidence of conduct in previous employment.
  • Make sure that arrangements are made, wherever possible, to meet patients’ language and communication needs.
  • Provide the necessary support to staff to ensure they are confident and competent in using the full range of tasks on the practice’s computer systems.
  • Ensure that uncollected prescriptions are monitored and action taken. The practice should follow their newly implemented uncollected prescriptions protocol.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice