Shipley Medical Centre Also known as Affinity Care

We carried out an announced comprehensive inspection at Shipley Medical Centre on 1 and 7 December 2022. Overall, the practice is rated as requires improvement.

Safe - requires improvement

Effective - requires improvement

Caring - good

Responsive - good

Well-led - good

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities. This was the first inspection of this provider since they registered with the Care Quality Commission.

How we carried out the inspection/review

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews in person and using video conferencing.
• Staff questionnaires sent to staff ahead of the inspection.
• Speaking with patients either on site or by telephone.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A shorter site visit.

Our findings

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 found that:

• There were systems in place to safeguard children and vulnerable adults from abuse and staff we spoke with knew how to identify and report safeguarding concerns.
• Leaders reviewed the effectiveness and appropriateness of the care the service provided. They ensured that care and treatment was delivered according to evidence-based guidelines.
• There was a programme of quality improvement, this included clinical audit.
• Staff had the skills, knowledge and experience to deliver effective care.
• The practice had a good understanding of the needs of the local population and delivered services to meet these needs.
• The practice operated effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Leaders and managers in the practice demonstrated they had the capacity and skills to deliver high-quality, sustainable care.
• Staff were generally positive about the level of support they received at work.
• The segmented care model adopted by the practice had established some dedicated teams designed to meet the needs of the local population. For example, the complex health care teams delivering care to vulnerable and housebound patients and those in residential care, and the availability of assigned duty doctors.
• Complaints had not always been handled in a manner consistent with the provider’s own policy. This had been recognised by the provider and improvement measures had been put in place.
• The practice had a strong focus on community engagement and the delivery of wider population health and wellbeing in conjunction with other partners and stakeholders.

We found a breach of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients (refer to the requirement notice at the end of the report for more detail).

In addition, the provider should:

• Continue to promote and increase uptake of cervical cancer screening and child immunisations.
• Continue to review and redress areas of low patient satisfaction regarding patient consultations and access to services.
• Fully re-establish staff annual appraisal processes.
• Establish and imbed the role of a Freedom to Speak Up Guardian within the practice.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services