Updated 15 April 2025
Date of Assessment: 19 March 2025 to 31 March 2025. Shirley Medical Centre is a GP practice and delivers service to approximately 7440 patients under a contract held with NHS England. The National General Practice Profiles states that the practice patient population is mainly White (59.7%) with Black (16.1%) and Asian (14.6%) the highest other ethnicities. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 8th decile (8 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. There were some vacancies for non-clinical staff, which were being filled. The service had recruited qualified, skilled and experienced staff but had not, at the time of recruitment, completed full pre-employment checks for every staff member. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff involved people in planning any changes. There were some groups of patients on medicines that had not had all the recommended reviews and monitoring. The practice was aware of these and had action plans in place for improvement.
Since the last inspection, the practice had made improvements and is no longer in breach of regulations. The practice had completed a fire risk assessment and completed a health and safety risk assessment, and undertaken actions recommended. The practice now ensured test results were dealt with in a timely manner and had appropriate systems in place for the safe management of medicines, including for monitoring of prescribing of controlled drugs.