Background to this inspection
Updated
5 November 2019
Dr Shakarchi’s Practice, located at Belgrave Medical Centre, 13-13A Pimlico Road, SW1W 8NA, operates from a converted building jointly owned with another GP practice. The building is set over two floors with stair access and has a total of three consultation rooms, two in the basement and one on the ground floor. The reception and waiting area are on the ground with another waiting room in the basement.
The practice provides NHS primary care services to approximately 4,000 patients living within the practice boundaries of Victoria, Pimlico, Belgravia, Westminster, Kensington, Chelsea and North Battersea. The practice operates under a Personal Medical Services (PMS) contract (an alternative to the standard GMS contract used when services are agreed locally with a practice which may include additional services beyond the standard contract). The practice is part of NHS Central London (Westminster) Clinical Commissioning Group (CCG).
The practice is registered as a partnership with the Care Quality Commission (CQC) to provide the regulated activities of diagnostic and screening procedures, treatment of disease, disorder or injury, maternity and midwifery services, surgical procedures and family planning.
The practice team comprises of a male GP partner and one female GP partner who collectively work a total of 13 clinical sessions per week. The GPs are supported by a part-time practice nurse and healthcare assistant, a practice manager and an administration and reception team.
The practice opening hours are from 8am to 6.30pm Monday to Friday. The practice provides extended hours from 7.30am to 8am Monday to Friday and from 10am to 12.45pm on Saturday. When the surgery is closed, out-of-hours services are accessed through 111 and details of this were included on the website.
The practice population is in the fourth most deprived decile in England, on a scale of one to 10 with one being the most deprived and 10 being the least deprived. People living in more deprived areas tend to have greater need for health services. The practice had a diverse patient population with 30% from Black and Minority Ethnic (BME) groups.
Updated
5 November 2019
We carried out an announced comprehensive inspection at Dr Shakarchi’s Practice (also known as Belgrave Medical Centre) on 6 November 2018. The overall rating for the practice was Requires Improvement. The full comprehensive report on the 6 November 2018 inspection can be found by selecting the ‘all reports’ link for Dr Shakarchi’s Practice on our website at www.cqc.org.uk.
This inspection, on 12 September 2019, was an announced focused inspection to confirm that the practice had carried out their plan to meet the requirements that we identified in our previous inspection on 6 November 2018. This report covers our findings in relation to those requirements and any improvements made since our last inspection. The practice is now rated as Good overall.
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 have rated this practice as good overall and good for all population groups, except the population group families, children and young people which is rated as requires improvement.
We found that:
- The practice had been proactive and addressed the findings of our previous inspection which included infection prevention and control, emergency medicines, medical emergencies, patient clinical records and safety-netting of two-week wait referrals and cervical screening.
- 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.
- There was an open and transparent approach to safety and systems were in place for recording, reporting and sharing learning from significant events.
- The service reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
- There was a programme of quality improvement including clinical audit which had a positive impact on quality of care and outcomes for patients.
- Staff had the skills, knowledge and experience to deliver effective care.
- Leaders demonstrated they had the capacity and skills to deliver high-quality, sustainable care.
- The provider engaged with patients and staff to improve the service.
- The provider was aware of the duty of candour and examples we reviewed showed the service complied with these requirements.
- There was a focus on continuous learning and improvement at all levels of the organisation.
Whilst we found no breaches of regulations, the provider should:
- Continue to address the outstanding actions from the recent infection prevention and control (IPC) audit.
- Consider the IPC lead having additional guidance and training to support them in this extended role.
- Continue with efforts to improve the uptake of child immunisations and cervical screening.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care