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

Updated 19 September 2016

• Drs Shah & Partners also known as Bordesley Green Surgery is located in Bordesley Green, Birmingham and has approximately 3335 patients registered with the practice.
• The practice has three GP partners (two male and one female) and one female salaried GP. There is a female practice nurse, a healthcare assistant, a practice manager and four reception/administrative staff.
• The practice has a General Medical Services (GMS) contract. A GMS contract is a contract between NHS England and general practices for delivering general medical services.
• The practice is open between 9am and 6.30pm Monday to Friday. Appointments take place from 9.30am to 12.30pm and 4pm to 6.30pm daily. The practice offers extended hours on Mondays from 6.30pm to 7.30pm. In addition to pre-bookable appointments that can be booked for any time in advance, 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. The practice also has an arrangement in place with BADGER to provide cover between 8am and 9am.
• The practice has a higher proportion of patients who are children, young people and adults up to the age of 45 than the national average. They have a much lower than average number of patients who are over 50.
• The practice is in an area with high levels of social and economic deprivation.

Updated 19 September 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Drs Shah & Partners on 13 July 2016. Overall the practice is rated as requires improvement.

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

• Staff we spoke with understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. We saw evidence to demonstrate that learning was shared amongst staff.
• Some risks to patients were assessed and well managed. Risks linked to infection control which related specifically to the practice premises had been identified at the last infection control audit in July 2015. The practice told us of plans to move into new purpose-built premises which would remove the identified infection control issues. However, we saw that these plans were at a very early stage and robust interim infection control measures to address concerns with infection control practice had not been taken. Additionally, the legionella risk assessment had not been conducted effectively.
• 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.
• National patient survey results indicated that patient satisfaction with the practice was below local and national averages. For example, patient satisfaction rates related to phone access, appointment waiting times, interactions with reception staff and clinical consultations were rated lower. However, results were higher in a survey conducted by the practice.
• Patients we spoke with and comments cards we reviewed indicated that patients felt they were treated with compassion, dignity and respect.
• The practice had carried out clinical audits and in one case a repeat audit to improve and maintain patient outcomes.
• We saw evidence to demonstrate that the practice had carried out an analysis of its patient population profile and developed targeted services and made changes to the way it delivered services as a consequence. For example by offering more in-house services such as phlebotomy services or diabetes care.
• Information about services and how to complain was available and easy to understand.
• There was a clear leadership structure and staff felt supported by management. The practice had sought some feedback from patients via the patient participation group (PPG).
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvements are:

• Take action to address all identified concerns with infection prevention and control practice.
• Ensure that risks related to legionella are effectively assessed.

In addition the provider should:

• Further improve patient experiences, satisfaction and reduction in non-urgent appointment waiting times.
• Consider carrying out risk assessment on non-clinical staff to determine if disclosure and barring service (DBS) checks are necessary.
• Consider the promotion of national screening programmes to improve uptake.
• Further promote and encourage membership of the patient participation group and work with them to identify areas for improvement.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 19 September 2016

The provider was rated as requires improvement for safe and responsive. The issues identified as requiring improvement overall affected all patients including this population group. There were, however, examples of good practice.

• Clinical staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.
• Performance for diabetes related indicators for the practice was 86% which was comparable to the CCG average of 83% and a national average of 84%. The practice had engaged with a specialist diabetic nurse to further support these patients.
• Longer appointments and home visits were available when needed.
• Patients had a personalised care plan or structured annual review to check that their health and care needs were being met.
• For those patients with more complex needs, we identified that the GPs worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Updated 19 September 2016

The provider was rated as requires improvement for safe and responsive. The issues identified as requiring improvement overall affected all patients including this population group. There were, however, examples of good practice.

• Same day appointments were available for children and those with serious medical conditions.
• Immunisation rates for childhood vaccinations were comparable to CCG averages.
• The practice’s uptake for the cervical screening programme was 82%, which was above the CCG average of 78% and same as the national average of 82%.
• Uptake rates for national screening programmes for breast and bowel cancer were below local and national averages. However, more recent data provided by the practice post inspection indicated that breast screening uptake levels had significantly improved so that they were comparable to local and national averages.
• Appointments were available outside of school hours.
• Baby changing facilities were available.
• The practice also worked with health visitors and midwives to support young families.

Updated 19 September 2016

The provider was rated as requires improvement for safe and responsive. The issues identified as requiring improvement overall affected all patients including this population group. There were, however, examples of good practice.

• The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.
• A facility for online repeat prescriptions and appointments bookings was available.
• Patients were also able to book telephone consultations with the GP.
• A phlebotomy service was available at the practice for the convenience of patients requiring blood tests.
• An electrocardiogram (ECG) service (equipment to record electrical activity of the heart to detect abnormal rhythms and the cause of chest pain) was available onsite at the practice.
• There were longer appointments available for older patients and those over 75 were allocated a named GP.
• There were disabled facilities available and the practice had a level access entrance to the premises.
• The consultation rooms were all located on the ground floor.

Updated 19 September 2016

The provider was rated as requires improvement for safe and responsive. The issues identified as requiring improvement overall affected all patients including this population group. There were, however, examples of good practice.

• 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 offered extended hours on Mondays from 6.30pm to 7.30pm for working patients who could not attend during normal opening hours.
• Patients were able to book telephone consultations with the GP.
• Patients could book appointments or order repeat prescriptions online.
• The practice offered a full range of health promotion and screening that reflected the needs for this age group. This included the utilising of support from external providers.

Updated 19 September 2016

The provider was rated as requires improvement for safe and responsive. The issues identified as requiring improvement overall affected all patients including this population group. There were, however, examples of good practice.

• Performance for mental health related indicators was 97% which was above the CCG and national averages of 87%.
• There were longer appointments available for patients with dementia, a learning disability and patients experiencing poor mental health.
• Home visits were available for patients who had clinical needs which resulted in difficulty attending the practice.
• The practice had informed patients experiencing poor mental health about how to access various support groups and voluntary organisations.
• The GP we spoke with had good knowledge of the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005. We saw evidence that the GPs and other staff had completed online mental capacity training.
• Staff had a good understanding of how to support patients with mental health needs and dementia.

Updated 19 September 2016

The provider was rated as requires improvement for safe and responsive. The issues identified as requiring improvement overall affected all patients including this population group. There were, however, examples of good practice.

• The practice held a register of patients living in vulnerable circumstances and alerts were in place on the clinical patient record system.
• Translation services were available.
• Longer appointments were available for patients requiring an interpreter or for those with a learning disability.
• Home visits were available for patients who had clinical needs which resulted in difficulty attending the practice.
• Practice policies were accessible to all staff which outlined who to contact for further guidance if they had concerns about a patients welfare.
• There was a lead staff member for safeguarding and we saw evidence to show that staff had received the relevant training.
• Staff members we spoke with were able to demonstrate that they understood their responsibilities with regards to safeguarding.
• The practice also worked with health visitors to identify children who may be vulnerable.