Shiregreen Medical Centre

We carried out an announced focused inspection at Shiregreen Medical Centre on 23 July 2019. At this inspection we followed up on breaches of regulations identified at a previous inspection on 20 November 2018.

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.

At the last inspection in November 2018 we rated the practice as requires improvement for providing safe and well led services because safety risk management processes and systems and processes to ensure good governance in accordance with the fundamental standards of care were not effective.

At this inspection, we found the provider had satisfactorily addressed these issues.

We have rated this practice as good overall.

We rated the practice good for providing safe and well led services because:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• The provider had established effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

We reviewed areas where we recommended the practice should improve from the November 2018 inspection and found the practice had acted on these recommendations. For example:

• A system had been implemented to check prescriptions prescribed to patients with poor mental health had been ordered by patients.

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

• Take action to monitor antibiotic prescribing data to ensure it is effective.

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

This practice is rated requires improvement overall. (Previous rating 29 March 2017 – Good)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We carried out an announced comprehensive inspection at Shiregreen Medical Centre on 20 November 2018 as part of our inspection programme.

At this inspection we found:

• There were gaps in the practice’s governance arrangements resulting in risk management processes not being comprehensive. For example, there was insufficient oversight to ensure mitigating actions identified on safety risk assessments had been completed.
• The practice had systems to identify and investigate safety incidents so that they were less likely to happen again. When incidents did happen, the practice learned from them and improved their processes.
• 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.
• The appointment system had been changed in recent months. Patient feedback was mostly positive, though there were some mixed comments about being able to access an appointment.
• Staff told us they felt respected, supported and valued. They told us they worked well as a team and were proud to work in the practice.

The areas where the provider must make improvements as they are in breach of regulations are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Review the process to check and record medicines prescribed to patients with poor mental health are being ordered by patients.
• Take action to ensure all recruitment checks are documented.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice