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

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

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. At this assessment, the rating has changed to good. The practice had responded to the previous assessment and responded to the CQC report’s findings.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice manager told us they and a GP partner were responsible for oversight, action and learning from significant events. The practice had implemented a new significant event policy and process, which included a register of actions taken, discussion, and review in clinical meetings but these was not fully embedded at the time of the assessment. The practice had a duty of candour policy in place last reviewed May 2025.

At our previous assessment in 2023, we found the practice had not followed and acted on safety alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA). At this assessment, several sets of patient clinical record searches were undertaken by a CQC GP specialist adviser. The searches were visible to the practice. We reviewed a sample of patient records who may have been affected by a MHRA alert and found the practice had followed them up and patients were informed of any adverse effects of the medicine were appropriate. The pharmacist explained they were responsible for the identification and response to medicines alerts which affected patients.

At the time of the assessment the practice had implemented an effective system to assure all urgent referrals to secondary care were prompt and followed up. The practice had a referral policy and procedure in place last reviewed March 2023. Leaders and staff told us there was a designated lead for referrals who monitored the system to ensure both routine and urgent referrals to specialist services were documented, contained the correct information, and ensured there were no delays.

The provider explained that regular meetings with other healthcare professionals to establish and maintain safe systems of care had ceased during the Covid pandemic and not been reinstated. The provider explained contact with the healthcare professionals to discuss complex cases assessments was carried out when requested. The provider was responsible for three care homes; the practice pharmacist called the care homes weekly to identify any care issues. In addition, they provided seasonal flu, COVID vaccines to the patients. During the assessment we were not provided with evidence the practice staff attended a regular multidisciplinary team meetings regarding care homes or palliative care. Following the assessment the provider informed us they had reinstated the meetings

The practice had oversight of the workflow tasks to ensure they were all responded to promptly. On the day of the assessment, we did not find any delays in the patient workflow tasks.

The systems to identify review and safeguard patients were mostly effective. The practice had implemented a system for staff to identify when patients may have been at risk, as recommended by the Royal College of General Practitioners safeguarding toolkit. The practice responded to Multi-Agency Risk Assessment Conference reports.

The practice had contacted the local safeguarding team to obtain outcomes of some investigations. Most staff had completed the appropriate level of adult and children’s safeguarding training with the exception of two clinicians who had not completed their recent adult’s training.

Most risks were assessed, and people and staff understood them. At the previous assessment we found the practice did not stock all the required emergency medications, nor did they have a risk assessment for not having these medications at the practice. At this assessment we found the practice held appropriate emergency medicines, risk assessments were in place to determine the range of medicines held, and a system was in place to monitor stock levels and expiry dates.

Receptionists told us the actions they would take if they encountered a deteriorating or acutely unwell patient. Staff said they had undergone training to enable them to navigate patients to the correct clinician and triage guidance had recently been introduced for staff to follow.

The practice had mostly detected and controlled the potential risks in the care environment. The premises were owned by the providers. At the time of the assessment the practice had a health and safety risk assessment in place carried out by an independent contractor in January 2025. The assessment identified some high risks which required an immediate response, the actions plan showed most had been completed or were being progressed.

The practice had a fire risk assessment carried out by an independent contractor in August 2024. This identified high serious and good practice risks such as fire actions notices and insufficient emergency lighting, fire detection and warning system deemed suitable for use in the building.The action plan demonstrated some of the risks had been mitigated.

All staff had completed their fire safety training and most staff had completed the principles of health and safety training.

We observed there was damage to the corridor wall on the ground floor, which could be an infection risk. In addition, the practice had not responded to the medical device alert (EFA/2010/077 July 2010) regarding unsafe looped cords or chains on window blinds. This was immediately responded to.

The national GP patient survey carried out from January to March 2024 had 107 responses. This found 83% of patients had confidence and trust in the health care professional they saw or spoke with, and 75% stated the health care professional was good at treating the patient with care and concern. In addition, 79% stated that their needs were met. 55% found the receptionists helpful. The patients’ responses for these categories were below the national and local area averages.

The practice had carried out their own patient survey during April and May 2025, where they had 14 responses. The responses were more positive than the GP national survey. For example, 13 found their experience of using the practice very good or good, and most patients were either partially or fully satisfied with GP, nurse and receptionist care.

The practice directly employed all administration staff, other staff such as experienced nursing or GPs were employed on a locum basis, due to the difficulty in recruiting salaried GPs.The practice had started to introduce new systems and policies to ensure safe recruitment and staff competency. For the permanent and locum staff they implemented a human resource tracker which demonstrated the practice had carried out some of the necessary recruitment checks, which included references and Disclosure and Barring Service (DBS) checks and were in the process of putting employment contracts in place. The practice submitted a recruitment policy last reviewed in October 2024; this did not include the required checks to ensure safe recruitment.

The practice had a training matrix in place this demonstrated most staff had completed their mandatory training, however further assurance of role specific training was required from some of the clinical staff to ensure they were competent for their role.

We were told locum clinical staff had supervision of the competency of their patient consultations; however, we were told this was informal.

The practice were recruiting new reception staff to strengthen the administration team, as they had established that further staff were required to improve access. We found there were less GPs working full time per patient than the national average for each GP. This would have increased GP workload.

The practice assessed and managed the risk of infection. We visited the practice and found appropriate standards of cleanliness and hygiene were being met. The most recent infection control audit was carried out in May 2024. The practice manager was the lead for infection control, and they carried out regular infection prevention and control checks of the premises. In addition, the cleaners carried out daily cleaning and staff carried out daily checks of the rooms they worked in. A legionella risk assessment was carried out in November 2023; however, we found there was no written scheme of control and no responsible person. Most staff had completed infection prevention and control training.

The practice mostly made sure that medicines and treatments were safe and met people’s needs. As part of our assessment a number of set clinical record searches were undertaken by a CQC GP specialist advisor. These searches were visible to the practice. Overall, we found the monitoring of patient’s medicines mostly followed national guidelines. For example, we found all the patients who were prescribed medicines for disease-modifying antirheumatic, mood stabilisers, and high blood pressure were monitored fully. However, the monitoring of patients with reduced renal function could be improved, as we found 9 patients were overdue their monitoring. The practice had completed 422 medication reviews in the last three months, we reviewed five and found all had been completed satisfactorily.

The NHS Business Services Authority medicines data on 1 January to 31 December 2024 reviews hypnotic, multiple psychotropics and antibacterial prescribing results

were either in line or better than the national average. The partner explained they were the lowest prescriber of antibiotics in their local area.

At the time of the assessment staff had not fully ensured vaccines were stored safely. For example, air could not efficiently circulate around the vaccines, and the temperature log showed the storage temperatures had been out of range. Our findings were immediately responded to by the practice.