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Inspection Summary

Overall summary & rating


Updated 7 August 2019

We carried out an announced focussed inspection at Shipdham Surgery on 18 July 2019 to follow up on breaches of regulations identified at a previous inspection in November 2018.

At the last inspection we rated the practice as requires improvement for providing safe services because:

  • The practice was not always assured that locum staff had appropriate training and safety checks to carry out their role safely and checks carried out were not always documented.
  • The stock of emergency medicines kept in the practice was not in line with guidelines and the practice had not assessed the risks of not having these medicines.
  • Access to the dispensary was not restricted, and the arrangements for managing standard operating procedures and monitoring compliance was not always effective.

We also identified areas the practice could improve at our last inspection including:

  • Monitor and improve the time patients wait beyond their appointment time.
  • Review the system for identifying and providing support to carers.
  • Complete structured annual reviews for patients with learning disabilities in a timely manner.

At this inspection we rated the practice as good for providing safe services because sufficient improvements had been made since our last inspection:

  • The practice had collected appropriate recruitment and training records for existing long-term locums and put in place a recruitment checklist for new locum staff.
  • The practice stock of emergency medicines had been risk assessed and updated to include relevant medicines in line with guidelines.
  • The practice had reviewed security arrangements in the dispensary and had brought forward scheduled security upgrades. Dispensary access restrictions were improved to include non-dispensary staff not entering the dispensary, using messaging services for questions and queries and challenging any unauthorised access. Arrangements also included scheduling cleaning to occur when the dispensary was open and supervised. Standard operating procedures (SOP) were reviewed and updated and all dispensary staff signed individual SOPs with compliance monitored through governance meetings and monitoring of near misses and incidents.
  • The practice had identified where patients were waiting longer than expected beyond their appointment time. Average wait times were monitored and improved from 8.7 minutes between arrival and being seen to 6.5 minutes.
  • The practice had introduced better identification and read coding of carers onto the clinical computer system including through new patient registration forms. The practice provided carers information packs, offered annual flu vaccines and signposted carers to additional support. The numbers of carers in the practice was 54 (Approximately 1.3% of the practice population).
  • The practice had appointed a lead clinician to oversee health checks for patients with learning disabilities, including attending the local residential homes to ensure these patients had access to health checks. At the time of inspection, the practice had 28 patients registered and had completed 16 annual health checks with 12 scheduled for completion.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas










Checks on specific services

People with long term conditions


Families, children and young people


Older people


Working age people (including those recently retired and students)


People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable