Archived: OHP-Drs Shah & Partners Also known as Bordesley Green Surgery

Updated 23 October 2017

Our Health Partnership (OHP) - Dr Shah & Partners also known as Bordesley Green Surgery is a practice located in Bordesley Green, an area of the West Midlands.

The practice has a General Medical Services contract (GMS) with NHS England. A GMS contract ensures practices provide essential services for people who are sick as well as, for example, chronic disease management and end of life care and is a nationally agreed contract. The practice also provides some enhanced services such as childhood vaccination and immunisation schemes.

The practice provides primary medical services to approximately 3,300 patients in the local community. In May 2017 the practice joined with Our Health Partnership, a GP partnership formed of 38 practices in Birmingham, Walsall and Sutton Coldfield. The practice staffing comprises of two GP partners (one male and one female). The nursing team consists of one practice nurse (female) and one health care assistant (female). The non-clinical team consists of administrative and reception staff and a practice manager.

The practice has a higher proportion of patients who are children, young people and adults up to the age of 45 years than the national average, with 48% of the practice population being between the ages of 15 years and 44 years of age. The practice is in an area with high levels of social and economic deprivation and based on data available from Public Health England, the levels of deprivation in the area served by the practice are below the national average ranked at one out of ten, with ten being the least deprived. Data provided by the practice shows 41% of the practice population are non-English speaking, in comparison to the national average of 10%.

The practice is open between 9am and 6.30pm Monday to Friday. Appointments are available from 9.30am to 12.10pm on Monday morning and 9.40am to 12pm Tuesday to Friday morning. Afternoon appointments are available from 5pm to 6.30pm on Monday, 4pm to 5.50pm Tuesday to Friday. The practice offers extended hours on Mondays from 6.30pm to 7.30pm. In addition to pre-bookable appointments that can be booked up to six weeks in advance, the majority of appointments are available to book on the day and urgent appointments are also available for people that need them.

The practice has opted out of providing out-of-hours services to their own patients and this service is provided by Birmingham and District General Practitioner Emergency Rooms (BADGER) medical service. Patients are directed to this service on the practice answer phone message. When the practice is closed, primary medical services are also provided by Badger and NHS 111 service and information about this is available on the practice website.

Updated 23 October 2017

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

Updated 23 October 2017

• Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.
• The practice took part in the CCG’s Aspiring to Clinical Excellence Foundation and ACE Excellence programmes. This ensured that high standards of chronic disease management were met.
• The practice had commenced a diabetes prevention programme in conjunction with the Clinical Commissioning Group (CCG) to offer advice and support to patients who were at risk of developing diabetes. The practice nurse had also completed a nutrition diploma to offer advice on healthy diet and lifestyle.
• Patients had a named GP and a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the named GP worked with relevant health and car e professionals to deliver a multi disciplinary package of care. Reception staff tried to book consecutive appointments with a nurse and GP appointments in order to avoid the patient attending twice for a review.
• Longer appointments and home visits were available when needed.
• The practice offered a range of services to support the diagnosis and management of patients with long term conditions.

Updated 23 October 2017

• There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances.
• Immunisation rates for childhood vaccinations were comparable to CCG and national averages.
• Appointments were available outside of school hours and baby changing facilities were available.
• The practice offered a full range of family planning services, including intrauterine Contraceptive Device (IUCD) and implants.
• We saw positive examples of joint working with midwives and health visitors. Patients accessed antenatal care at the local centre.
• There were policies, procedures and contact numbers to support and guide staff should they have any safeguarding concerns about children.
• The practice’s uptake for the cervical screening programme was 81% which was comparable to the national average of 82%.

Updated 23 October 2017

• The practice offered proactive, personalised care to meet the needs of the older people in its population.
• The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs. This included blood tests and vaccinations for those patients who were unable to attend the practice.
• The practice had systems in place to identify and assess patients who were at high risk of admission to hospital. Patients who were discharged from hospital were reviewed to establish the reason for admission and care plans were updated.

Updated 23 October 2017

• The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.
• The practice was proactive in offering online services as well as a full range of health promotion and screening that reflected the needs for this age group.
• The practice provided a health check to all new patients and carried out routine NHS health checks for patients aged 40-74 years.
• The practice offered extended hours to suit the working age population, with late evening appointments available once a week.
• The practice offered a latent Tuberculosis (TB) service in conjunction with the clinical commissioning group. The service was offered to patients between the ages of 16 and 35 years of age.
• Patients could sign up to receive text messages for appointment reminders.
• The practice used the electronic prescribing system, so patients could collect their medicines directly from the pharmacist.

Updated 23 October 2017

• The latest published data from the Quality and Outcomes Framework (QOF) of 2015/16 showed 100% of patients diagnosed with dementia had their care reviewed in a face-to-face meeting in the last 12 months, which was higher than the national average of 84%. Exception reporting rate was 2.7% which was lower than the national average of 10%.
• The practice had told patients experiencing poor mental health how to access various support groups and voluntary organisations.
• Data provided by the practice showed 50 patients on the mental health register. QOF data (2015/16) showed 97% of patients on the mental health register had received a care plan in the past 12 months; this was higher than the national average of 89%.
• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.
• The practice offered a range of enhanced services, for example, facilitating timely diagnosis and support for patients with dementia.
• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations and a counsellor held weekly sessions at the practice to offer support to patients with mental health needs.
• Staff had a good understanding of how to support patients with mental health needs and dementia.

Updated 23 October 2017

• The practice held a register of patients living in vulnerable circumstances including those with a learning disability and longer appointments were available for vulnerable patients.
• The practice informed vulnerable patients about how to access various support groups and voluntary organisations and signposted patients to relevant services available.
• Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.
• The practice also worked with health visitors to identify children who may be vulnerable.
• The practice’s computer system alerted GPs if a patient was also a carer. Since the previous inspection, the practice had seen an increase in patients on the register from 30 to the current total of 59; this was 2% of the practice list.