Archived: Drs Shah & Partners Also known as Bordesley Green Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Drs Shah & Partners on 13 July 2016. Overall the practice is rated as requires improvement.

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

• Staff we spoke with understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. We saw evidence to demonstrate that learning was shared amongst staff.
• Some risks to patients were assessed and well managed. Risks linked to infection control which related specifically to the practice premises had been identified at the last infection control audit in July 2015. The practice told us of plans to move into new purpose-built premises which would remove the identified infection control issues. However, we saw that these plans were at a very early stage and robust interim infection control measures to address concerns with infection control practice had not been taken. Additionally, the legionella risk assessment had not been conducted effectively.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
• National patient survey results indicated that patient satisfaction with the practice was below local and national averages. For example, patient satisfaction rates related to phone access, appointment waiting times, interactions with reception staff and clinical consultations were rated lower. However, results were higher in a survey conducted by the practice.
• Patients we spoke with and comments cards we reviewed indicated that patients felt they were treated with compassion, dignity and respect.
• The practice had carried out clinical audits and in one case a repeat audit to improve and maintain patient outcomes.
• We saw evidence to demonstrate that the practice had carried out an analysis of its patient population profile and developed targeted services and made changes to the way it delivered services as a consequence. For example by offering more in-house services such as phlebotomy services or diabetes care.
• Information about services and how to complain was available and easy to understand.
• There was a clear leadership structure and staff felt supported by management. The practice had sought some feedback from patients via the patient participation group (PPG).
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvements are:

• Take action to address all identified concerns with infection prevention and control practice.
• Ensure that risks related to legionella are effectively assessed.

In addition the provider should:

• Further improve patient experiences, satisfaction and reduction in non-urgent appointment waiting times.
• Consider carrying out risk assessment on non-clinical staff to determine if disclosure and barring service (DBS) checks are necessary.
• Consider the promotion of national screening programmes to improve uptake.
• Further promote and encourage membership of the patient participation group and work with them to identify areas for improvement.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice