The Care Quality Commission
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  • GP practice

Archived: Dr Shamim Sameja

Overall: Good read more about inspection ratings

High Street Surgery, Pelsall, Walsall, West Midlands, WS3 4LX (01922) 694186

Provided and run by:
Dr Shamim Sameja

Important: The provider of this service changed. See new profile

All Inspections

17 July 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We first inspected, Dr Shamim Sameja’s surgery on 13 October 2016 as part of our comprehensive inspection programme. The overall rating for the practice was inadequate. The full comprehensive report on the October 2016 inspection can be found by selecting the ‘all reports’ link for Dr Shamim Sameja’s surgery on our website at www.cqc.org.uk. During the inspection, we found the practice was in breach of legal requirements and placed into special measures. This was because appropriate processes were not in place to mitigate risks in relation to the safety and quality of the services offered. Following the inspection, the practice wrote to us to say what they would do to meet the regulations.

This inspection, was an announced comprehensive inspection, carried out on 17 July 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations we identified in our previous inspection. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

We found effective clinical and managerial leadership had been implemented and significant improvements had been made to the concerns raised at the previous inspection and as a result of our inspection findings the practice is now rated as Good.

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

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Since the previous inspection, an effective system had been implemented to ensure all incidents were acted on and learning shared with all staff members. The practice carried out an analysis of each event with a documented action plan.
  • At this inspection, we found that all staff had received an appraisal and development plans were in place. A training matrix had been introduced following our previous inspection to monitor staff training and ensure all staff had received the appropriate training relevant to their role.
  • At this inspection, we found staff had undertaken clinical coding training and systems were now in place to ensure all urgent referrals were coded appropriately and followed up to ensure patients referrals had been acted on.
  • At this inspection, we saw evidence to confirm that staff had received chaperone training and appropriate checks with the disclosure and barring service (DBS).
  • A comprehensive business continuity plan had been implemented since the previous inspection so all staff were aware of the procedures to follow if a major incident occurred.
  • The practice had implemented a system to record staff immunisation status and vaccinations since our October 2016 inspection.
  • The management team had started holding team meetings and clinical staff meetings on a monthly basis which were minuted to ensure all staff were kept up to date with changes within the practice.
  • At our previous inspection, we were told that patient feedback was not sought and there was no patient participation group. At this inspection, we found a patient participation group had been set up and meetings were being held monthly.
  • Following our previous inspection, the practice recruited two new managers. Staff we spoke with told us they felt supported by management and were positive about the changes that had been implemented since our previous inspection.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

13 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Shamim Sameja on 13 October 2016. Overall the practice is rated as inadequate.

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

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses, but we found the provider was unable to demonstrate that following an incidents an investigation was completed, lessons learnt and actions taken to mitigate the risk of further occurrence.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. The practice had processes and practices in place to keep people safe and safeguarded from abuse.
  • There was no effective system in place to monitor staff training and to ensure staff were up to date with the latest guidelines for health and safety and infection control. Non clinical staff carrying out chaperone duties had not received training and were unaware of the correct procedures to follow and no regular reviews or annual appraisals had been completed.
  • The practice had no register of staff immunisation status or vaccinations, except Hepatitis B status for the practice nurse and health care assistant.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • The practice worked closely with other organisations in planning how services were provided to ensure that they meet patients’ needs. For example the practice held a diabetic liaison service every two months run by a diabetic specialist nurse.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • We identified learning needs for some of the team in the use of the clinical system. The practice were not fully utilising the clinical system and we found that coding of some referrals was not being completed.
  • Notices in the patient waiting room told patients how to access a number of support groups and organisations.
  • The practice actively reviewed complaints and how they were managed and responded to, and made improvements as a result. The provider was aware of the requirements of the duty of candour.

There were areas of practice where the provider must make improvements:

  • Ensure all significant events and incidents are reported effectively and discussed with the team.
  • Review current training processes to ensure staff have the appropriate skills and knowledge required for their role and ensure staff have regular reviews and appraisals to support professional development.
  • Ensure risk assessments have been undertaken in the absence of staff immunisation status to identify duties, risks and actions to minimise the risk to staff.
  • Seek patient and staff views and act on feedback to evaluate and improve services.
  • Ensure policies are embedded to support governance arrangement and systems within the practice.
  • Ensure an effective business plan is in place to maintain service provision and monitor future strategy.

There were areas of practice where the provider should make improvements:

  • Review registers to ensure they are up to date and improve current practice for coding referrals and information on medical records to support the accuracy of patient registers .
  • Review how the practice could proactively identify carers in order to offer them support where appropriate.
  • Consider in the absence of infection control training how the provider assure themselves that all staff have the necessary skills and knowledge for the appropriate management of infection control.
  • Review systems and processes to manage business continuity.
  • In the absence of regular team meetings the practice should consider how they ensure all staff members are kept updated and informed with information relevant to their role.
  • Review the need to publicise the on line services provided by the practice.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice