• Doctor
  • GP practice

The Steven Shackman Practice

Overall: Good read more about inspection ratings

Mountwood Surgery, Rickmansworth Road, Northwood, Middlesex, HA6 2RG (01923) 828488

Provided and run by:
The Steven Shackman Practice

All Inspections

During an assessment under our new approach

Date of Assessment: 17/06/26 to 18/06/26. The Steven Shackman Practice is a GP practice registered as a partnership since its CQC registration in April 2013. The practice was last assessed in 2016. This comprehensive assessment was undertaken because of the length of time since the last assessment.

The Steven Shackman Practice delivers service to approximately 11,300 patients under a contract held with NHS England in the London Borough of Hillingdon and is part of the North Connect Primary Care Network (PCN). It is also a registered GP training practice.

The National General Practice Profiles states that the ethnicity of the patient population is 50% White, 38% Asian, 4% Black, 4% Mixed and 4% Other. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the tenth decile (10 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. The service had some effective systems and processes in place to protect people and keep them safe. However, we identified concerns with the management of test results, staff recruitment and staff immunisations.

Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated.

People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people took decisions in people’s best interests where they did not have capacity.

People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. The service supported staff wellbeing.

People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care.

Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was an excellent culture of learning and continuous improvement with staff given time and resources to try new ideas.

We found breaches of regulation in relation to safe care and treatment. We have asked the provider for an action plan in response to the concerns found at this assessment.

31 August 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of the practice on 12 January 2016 where breaches of legal requirements were found. After the inspection, the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach of Regulation 12 Safe care and treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We undertook this desk-based focussed inspection on 31 August 2016 to check that the practice had followed their plan to confirm that they now met the legal requirements. This report covers our findings in relation to those requirements and also where additional improvements have been made following the initial inspection. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for The Steven Shackman Practice on our website at www.cqc.org.uk.

Overall the practice is rated as Good. Specifically, following the focussed inspection we found the practice to be good for providing safe services.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

12 January 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at 8.30am on 12 January 2016. 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. However there were inconsistencies in the recording of significant events, and analyses were not always thorough.
  • 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.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they did not have to wait too long for an appointment although an appointment with a named GP could take up to three weeks. Urgent appointments were available the same day.
  • The practice had adequate facilities and was equipped to treat patients and meet their needs.
  • 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.
  • The provider was aware of and complied with the requirements of the Duty of Candour.
  • There was a vision to deliver high quality care and promote good outcomes for patients.
  • There was a programme of clinical audit in place to monitor and improve outcomes for patients.

We saw one area of outstanding practice:

The practice operated a ‘Health Information Station’ run by a team of patient volunteers. The volunteers help patients to find information on health related issues from books, leaflets, DVDs/CDs and the internet. The books, DVDs and CDs were available to patients on free loan. The volunteers also helped patients access local support groups such as those for weight loss, social services and local fitness classes as well as signposting patients to community events.

However there were areas of practice where the provider must make improvements:

  • Review the procedures for managing significant events and national patient safety alerts.
  • Review safeguarding policies and procedures.
  • Ensure actions are completed from infection control audits and maintain records of the cleaning of the privacy curtains in the consultation rooms.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

18 February 2014

During a routine inspection

During our inspection we spoke with seven people using the service, the practice manager, a GP who was the senior partner, a nurse practitioner, a practice nurse, a health care assistant and two reception staff. The majority of people we spoke with were satisfied with the service provided. However, three people told us that sometimes they had to wait a long time to get a routine appointment and the doctors were usually running late on the day of their appointment. Comments included, 'I sometimes have to wait up to two weeks for a routine appointment' and 'Once I had to wait more than one hour in the waiting room to see the doctor.'

People told us that although sometimes they waited longer than they expected to see the doctor their consultations were never rushed even though the doctors were running late. People said the doctors always listened to them and they were involved in their treatment. One person said, 'the doctors explain my medical conditions and the treatment options in detail.'

Procedures were in place to manage cross infection risks and ensure the risks were minimised. The practice was clean, hygienic and well equipped and staff had been adequately trained in infection control procedures.

Staff had received appropriate support and training to ensure they were able to meet the needs of people using the service. This included mandatory training, training specific to the job role, a comprehensive induction programme when they started working at the service and annual appraisals to monitor performance.

Systems were in place to monitor the standards of care and treatment provided including annual patient satisfaction surveys and a range of clinical audits. Where shortfalls were identified, improvements to the service had been made. Risk assessments had also been carried out to ensure the environment was safe for people using the service.