Background to this inspection
Updated
23 April 2020
Shenley Green Surgery is located at 22 Shenley Green, Birmingham, West Midlands B29 4HH. The surgery has good transport links and there is a pharmacy located nearby.
Dr. Katerina Gaspar and Dr. Amanda Sinclair are the registered providers of Shenley Green Surgery. The providers are registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury.
Shenley Green Surgery is situated within Birmingham and Solihull Clinical Commissioning Group (CCG) and provides services to 6,000 patients under the terms of a general medical services (GMS) contract. This is a contract between general practices and NHS England for delivering services to the local community.
The practice has two female GP partners, two female salaried GPs and one male long term locum GP. The clinical team also includes one locum practice nurse and a health care assistant. The non-clinical team consists of a practice manager, a deputy practice manager, a reception supervisor and a team of receptionists and administrators.
The surgery is a training practice providing placements and supervision to speciality registrars and foundation year GPs. At the time of our inspection, there was one female and one male GP (ST3) registrars and one male GP (FY2) trainee assigned to the practice.
When the practice is closed, out of hours cover for emergencies is provided by Birmingham and District General Practitioner Emergency Room group (Badger).
Shenley Green Surgery is in one of the more deprived areas of Birmingham. The practice catchment area is classed as being within a deprived area in England. The practice scored three on the deprivation measurement scale; the deprivation scale goes from one to 10, with one being the most deprived. People living in more deprived areas tend to have greater need for health services. National General Practice Profile describes the practice ethnicity as being 81% white British, 8% Asian, 5% black, 5% mixed and 2% other non-white ethnicities. The practice demographics show a slightly higher than average percentage of people in the 65+ year age group. Average life expectancy is 79 years for men and 83 years for women compared to the national average of 79 and 83 years respectively. The general practice profile shows that 61% of patients registered at the practice have a long-standing health condition, compared to 50% locally and 52% nationally.
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