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Inspection Summary


Overall summary & rating

Good

Updated 23 April 2020

We carried out an announced comprehensive inspection at Shenley Green Surgery on 4 March 2020 as part of our inspection programme. This was to confirm that the practice had carried out their plan to meet the legal requirements in relation to the requirement notices served on the provider following our March 2019 inspection.

At this inspection, we found that the providers had moved in line with changes within the healthcare economy and had shaped the practice to sustain delivery of high quality services. Actions carried out supported the delivery of high quality services.

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 have rated this practice as good overall and good in all key questions; except for effective which we rated requires improvement. We also rated all population groups as good. Except for families, children and young people, working age people (including those recently retired and students) population group which we rated requires improvement for providing effective care.

We rated the practice as good for providing safe, caring, responsive and well-led services because:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • The practice recruitment system had been strengthened since our previous inspection and we saw all appropriate recruitment checks had been carried out.
  • Safety systems for managing environmental risks and equipment checks had been strengthened and the practice maintained records to evidence this.
  • The practice carried out actions to ensure services were organised and delivered to meet patients’ needs. In particular, the practice implemented changes to their appointment system as well as engaged with stakeholders to shape services to meet the needs of the local population.
  • Data from the 2019 national GP patient survey showed satisfaction was below local and national averages in areas such as continuity of care. However, there were areas where data showed patient satisfaction had improve since the 2018 national GP patient survey.
  • During our inspection, we saw that staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice was aware of areas where satisfaction was below local and national averages as well as less positive patient feedback and had taken a variety of actions as well as involvement in projects to improve patients’ satisfaction. Friends and Family test (FFT) results showed actions carried out had translated into positive patient feedback.
  • Actions carried out since our previous inspection such as strengthening the non-clinical management team as well as governance arrangements supported the delivery of high-quality, person-centre care.

We rated the practice as requires improvement for providing effective services because:

  • The uptake of national screening programmes such as cervical screening was below local and national averages. The practice demonstrated awareness of this and were taking action to improve uptake.
  • Data showed the uptake of childhood immunisation was below national targets. The practice demonstrated awareness of this and were taking action to improve the accuracy of records as well as encouraging the uptake of childhood immunisations.
  • Patients received care and treatment that met their needs. The practice operated a programme of quality improvement activities and routinely reviewed the effectiveness and appropriateness of care provided.
  • Data from the 2018/19 Quality Outcomes Framework (QoF) showed performance was above local and national averages for a number of clinical indicators.

Whilst we found no breaches of regulations, the provider should:

  • Continue taking action to improve the uptake of national screening programmes such as cervical screening.
  • Continue taking action to improve the uptake of childhood immunisations.
  • Monitor the impact of increased staffing levels to ensure progress in patient outcome indicators that were below local and national averages has been achieved.
  • Continue taking action to improve patient satisfaction in areas where satisfaction remains below local and national averages as well as areas identified through patient feedback obtained from a range of sources.
  • Continue taking actions to strengthen and increase the clinical team.

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

Safe

Good

Effective

Requires improvement

Caring

Good

Responsive

Good

Well-led

Good
Checks on specific services

People with long term conditions

Good

Families, children and young people

Requires improvement

Older people

Good

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)

Good

People whose circumstances may make them vulnerable

Good