Letter from the Chief Inspector of General Practice

This inspection was an announced comprehensive inspection, carried out on 18 September 2017. We previously inspected, Dr Shah & Partners, also known as Bordesley Green Surgery on 13 July 2016 as part of our comprehensive inspection programme. The overall rating for the practice was requires improvement. The full comprehensive report on the July 2016 inspection can be found by selecting the ‘all reports’ link for Dr Shah & Partners on our website at www.cqc.org.uk. Since the inspection the provider had joined with Our Health Partnership (OHP) group as a partner. The registered provider is now Our Health Partnership. .

During the inspection in 2016, we found the practice was in breach of legal requirements. This was because appropriate processes were not in place to mitigate risks in relation to the safety 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 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

We found all risks identified had been mitigated and improvements had been made and as a result of our inspection findings the practice is now rated as good overall.

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

• At this inspection we found the practice had undergone a refurbishment, had reviewed their infection control procedures and had completed an audit and all risks previously identified had been mitigated.
• At the previous inspection the practice did not have an effective legionella risk assessment in place. At this inspection we found a risk assessment had been completed and monthly monitoring of water temperatures was taking place and staff completed training to allow effective monitoring of water temperatures.
• The practice had actively tried to encourage patients to join the patient participation group and had advertised the group in various languages in the waiting area. Since the last inspection, the practice had held two meetings with patients, with a third meeting planned for October 2017.
• The practice participated in the Birmingham Cross City Clinical Commissioning Group’s (CCG) programmes, Aspiring to Clinical Excellence (ACE) at Foundation and ACE Excellence levels which enabled the CCG to work with GPs to develop and deliver improved health outcomes for patients.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
• Staff understood their responsibilities to raise concerns, incidents and near misses and there was a system in place for reporting and recording significant events. Reviews and investigations were discussed with the team at staff meetings to mitigate further risks.
• Patients we spoke with and comments cards we reviewed indicated that patients felt they were treated with compassion, dignity and respect.
• Arrangements were in place to safeguard children and vulnerable adults from abuse, and local requirements and policies were accessible to all staff.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

There were areas where the practice should make improvements:

• Continue to encourage patients to attend national screening programmes such as bowel cancer screening.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice