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Inspection carried out on 18 July 2019

During an inspection looking at part of the service

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 carried out on 8 November 2018

During a routine inspection

This practice is rated as Good overall. (Previous rating March 2015 – Good)

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Shipdham Surgery on 11 November 2018 as part of our inspection programme.

At this inspection we found:

  • Arrangements for emergency medicines, the security of the dispensary and the management of recruitment and training records for locum staff required improvement.
  • The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes, however some processes and procedures required further improvement.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it, however waiting times could be improved.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements are:

  • Ensure systems and processes are established and operated effectively to ensure good governance.

The areas where the provider should make improvements are:

  • 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.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Inspection carried out on 4 November 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

Shipdham Surgery has a practice population of approximately 3580 patients. The surgery offers a medicine dispensing service for patients who lived in excess of one mile of a pharmacy.

We carried out a comprehensive inspection at Shipdham Surgery on 4 November 2014.

We have rated each section of our findings for each key area. We found that the practice provided a safe, effective, caring, responsive and well led service for the population it served. The overall rating was good and this was because the practice staff demonstrated enthusiasm and worked together in providing comprehensive care for patients. Since their employment the practice manager had made significant improvements and had identified where further work was needed in the day to day operations of the practice. For example, arrangements had been made for staff to attend a range of training courses to ensure they had appropriate knowledge and skills to carry out their roles effectively.

Our key findings were as follows:

  • We found evidence that the practice staff worked together well to make ongoing improvements for the benefit of patients.

  • The senior GP had developed a register of all vulnerable patients and was carrying out an audit of each patient as part of the hospital admission avoidance scheme.

  • The practice was able to demonstrate a good track record for safety. Effective systems were in place for reporting safety incidents. Untoward incidents were investigated and where possible improvements made to prevent similar occurrences.

  • We found that patients were treated with respect and their privacy was maintained. Patients informed us they were very satisfied with the care they received.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice