This practice is rated as Good overall. (Previous rating March 2015 – Good)

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Shipdham Surgery on 11 November 2018 as part of our inspection programme.

At this inspection we found:

• Arrangements for emergency medicines, the security of the dispensary and the management of recruitment and training records for locum staff required improvement.
• The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes, however some processes and procedures required further improvement.
• 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.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it, however waiting times could be improved.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements are:

• Ensure systems and processes are established and operated effectively to ensure good governance.

The areas where the provider should make improvements are:

• Monitor and improve the time patients wait beyond their appointment time.
• Review the system for identifying and providing support to carers.
• Complete structured annual reviews for patients with learning disabilities in a timely manner.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Letter from the Chief Inspector of General Practice

Shipdham Surgery has a practice population of approximately 3580 patients. The surgery offers a medicine dispensing service for patients who lived in excess of one mile of a pharmacy.

We carried out a comprehensive inspection at Shipdham Surgery on 4 November 2014.

We have rated each section of our findings for each key area. We found that the practice provided a safe, effective, caring, responsive and well led service for the population it served. The overall rating was good and this was because the practice staff demonstrated enthusiasm and worked together in providing comprehensive care for patients. Since their employment the practice manager had made significant improvements and had identified where further work was needed in the day to day operations of the practice. For example, arrangements had been made for staff to attend a range of training courses to ensure they had appropriate knowledge and skills to carry out their roles effectively.

Our key findings were as follows:

• We found evidence that the practice staff worked together well to make ongoing improvements for the benefit of patients.

• The senior GP had developed a register of all vulnerable patients and was carrying out an audit of each patient as part of the hospital admission avoidance scheme.

• The practice was able to demonstrate a good track record for safety. Effective systems were in place for reporting safety incidents. Untoward incidents were investigated and where possible improvements made to prevent similar occurrences.

• We found that patients were treated with respect and their privacy was maintained. Patients informed us they were very satisfied with the care they received.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice