The Care Quality Commission
  • Doctor
  • GP practice

Dr A K & S Shah Also known as Goodmayes Medical Centre

Overall: Good read more about inspection ratings

4 Eastwood Road, Goodmayes, Ilford, Essex, IG3 8XB (020) 8590 1169

Provided and run by:
Dr A K & S Shah

All Inspections

During an assessment under our new approach

We carried out an announced inspection at Dr A K S Shah GP practice from the 22 April to the 2 June 25. We carried out this assessment to review the changes made at the previous assessment in October 2023, where the practice was found in breach of regulation 17 good governance and was rated requires improvement overall and in all the key questions. At this assessment we have reviewed all the key questions. Dr A K S Shah GP is a GP practice registered for the following regulated activities: diagnostic and screening procedures, family planning, maternity and midwifery services, and treatment of disease, disorder or injury for approximately 7,400 patients. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 6th decile (6 of 10). The lower the decile, the more deprived the practice population is relative to others. Safe - At our previous assessment in October 2023, we found the recording and acting on safety alerts was not always effective, the practice did not have the required emergency equipment and medication and did not maintain a safeguarding register. The practice had responded to the previous assessment and responded to the CQC report’s findings. Effective - At our previous assessment in October 2023, we found patients with a potential missed diagnosis of diabetes had not received care in line with best practice guidance and they were below the national targets for the uptake of childhood immunisation and cervical screening. At this assessment we have rated this key question good, because we found the practice had responded and improvements had been made to the care of patients with diabetes and the uptake of childhood immunisations and cervical screening had improved. Caring - At the previous assessment in October 2023, the results of the 2023 national GP patient survey were lower than local and national averages for providing caring services and there was limited work being carried out to address this. At this assessment, the practice had responded to the national GP patient survey and had commenced collecting their own patient feedback to enable them to make further improvements. Responsive - At the previous assessment in October 2023, the national GP patient survey results were lower than local and national averages for accessing the service. In addition, there was limited work being carried out to address this. At this assessment, although the practice had responded to the survey and made some improvements, the national survey for 2024 remains below local and national average. Well led - At the previous assessment in October 2023, we found the structures, processes, and systems to support good governance were in place but not fully embedded into practice and the leaders at the practice could not demonstrate they had the capacity and skills to deliver high quality sustainable care. At this assessment we found the practice was reviewing and improving the systems, processes and policies but some further work was still required to ensure they were fully embedded.

31 October 2023

During a routine inspection

We carried out an announced comprehensive inspection at Dr A K & S Shah. Overall, the practice is rated as requires improvement.

Safe - requires improvement,

Effective - requires improvement,

Caring - requires improvement,

Responsive - requires improvement,

Well-led – requires improvement.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr A K & S Shah on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A short site visit.

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We found that:

  • Structures, processes, and systems to support good governance were not fully embedded into practice.
  • Leaders at the practice could not demonstrated they had the capacity and skills to deliver high quality sustainable care.
  • The management of patients on lithium was not in line with best practice guidelines.
  • The system for recording and acting on safety alerts was not always effective.
  • The practice did not have all the required emergency equipment and medication.
  • The practice were below local and national targets in the uptake of childhood immunisation and cervical cancer screening.
  • GP patient survey were lower than local and national averages for providing caring services. There was limited work being carried out to address this.
  • Results from the 2023 national GP patient survey were lower than local and national averages for accessing the service. There was limited work being carried out to address this.

We found one breach of regulation. The provider must:

  • Ensure effective systems and processes to ensure good governance in according with fundamental standards of care.

Additionally, the provider should:

  • Implement measures to ensure a safeguarding register is maintained.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

18 October 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Goodmayes Medical Centre on 9 October 2015. At that time we found the practice was breaching legal requirements in relation to safe care and treatment, and, good governance. Specifically:

  • The practice did not have adequate procedures in place to protect patients and staff from the risk of infection.
  • We also found the practice was not ensuring that patients had reasonable access to the service.

The previous comprehensive inspection report can be found by selecting the ‘all reports’ link for Dr A K & S Shah on our website at www.cqc.org.uk.

Following our inspection in October 2015, the practice wrote to us with details of the actions they would take to meet the legal requirements.

We undertook this focused inspection to check that the practice had followed their plan and to confirm that the practice was now meeting the legal requirements. This inspection included a visit to the practice on 18 October 2016. This report covers our findings from this focused inspection.

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

  • The practice was providing safe services. We have rated the practice as good for providing safe care. The practice had improved the systems in place to protect patients and staff from the risk of infection.
  • The practice was providing responsive services. We have rated the practice as good for providing responsive care. The practice had taken some steps to improve access to appointments and this was reflected in improved patient feedback.

The areas where the provider should make improvement are:

  • There is scope to further improve access to the service, for example,  the ease of getting through to the practice by telephone.
  • The practice should assess whether it has sufficient clinical capacity for example through a systematic appointments audit.
  • The practice should also review any outstanding areas for improvement identified at our previous inspection.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

9 October 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr A K & S Shah on 9 October 2015. Overall the practice is rated as requires improvement.

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

  • There was an open approach to safety and a system in place for reporting and recording significant events.
  • Most risks to patients were assessed and well managed. The practice needs to improve on infection control.
  • 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.
  • There was mixed feedback from patients about whether they were treated with compassion, dignity and respect and whether they were involved in decisions about their treatment. The 2015 National GP Patient Survey results for the practice were poor. In contrast, comments we received from patients and the Patient Participation Group were very positive about these aspects of the service.
  • Patients said it was difficult to make appointments and this was reflected in the practice’s 2015 National GP Patient Survey results.
  • Information about services and how to complain was available and easy to understand.
  • The practice had suitable premises and was well 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 areas where the provider must make improvement are:

  • The practice must ensure systems are in place to protect patients and staff from the risk of acquired infection. The practice should ensure that its infection control and related policies are up to date and reflect current requirements.

  • The practice must ensure that the service is accessible to patients in need of primary health care and the appointment system is fit for purpose.

The areas where the provider should make improvement are:

  • The practice should encourage the positive reporting of events and incidents to provide opportunities to learn and improve patient safety.

  • The practice should have a written locum pack for locum doctors to refer to.

  • The practice should review whether there is a need for staff to have training on the Mental Capacity Act 2005. Staff were not fully confident about their obligations under the Act.

  • The practice should ensure that policies are reviewed and updated periodically to ensure they reflect current practice.

  • Patient experience as reported by the 2015 National Patient GP survey was poor. The practice should further investigate the reasons for its poor performance as this may indicate areas for improvement.

  • The practice did not provide written information, for example, its practice leaflet, in other languages.

  • The practice did not have its own website.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

26 September 2013

During a routine inspection

People expressed their views and were involved in making decisions about their care and treatment. They said the doctors explained treatment and tests to them in a way they could understand and they were able to give their own views. One comment was "I like (my doctor) because (they'll) discuss my care and treatment with me. It's very good."

People's needs were assessed and care and treatment was planned and delivered in line with their individual treatment plan. People's comments included "I feel confident about my doctor", "(they've) been very good" and "I believe they are genuine and consistent in their care."

People who used the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. People said they felt safe using the service. One person said "I feel very safe, no problems."

There were effective recruitment and selection processes in place. Non-clinical staff did not undergo Disclosure and Barring Service (DBS) checks. We told the provider they should be able to show that a risk assessment has been undertaken, especially where they have decided not to undertake a check.

People who used the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. There was evidence that learning from incidents / investigations took place and appropriate changes were implemented.