The Care Quality Commission
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Archived: Dr Shakarchi's Practice

Overall: Good read more about inspection ratings

Belgrave Medical Centre, 13 Pimlico Road, London, SW1W 8NA (020) 7824 8827

Provided and run by:
Dr Shakarchi's Practice

Important: The provider of this service changed - see old profile

All Inspections

12 September 2019

During an inspection looking at part of the service

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

6 November 2018

During a routine inspection

This practice is rated as Requires Improvement overall.

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

We carried out an announced first comprehensive inspection at Dr Shakarchi’s Practice on 6 November 2018.

At this inspection we found:

  • Although risks to patients were assessed, the systems to address these risks were not implemented well enough to ensure patients were kept safe. For example, we found the management of infection prevention and control, emergency medicines, medical emergencies, patient clinical records, safety netting of two-week wait referrals and cervical screening required improvement.
  • 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 a system in place for reporting and recording significant events and we saw the practice had learned from those recorded. However, the process was not consistent.
  • Clinical staff we spoke with demonstrated they delivered care and treatment in line with current legislation, standards and guidance. However, the practice did not have a formal process in place for cascading new guidance to all clinical staff.
  • The was evidence of quality improvement to review and monitor the effectiveness and appropriateness of the care. However, there was no formal process to identify clinical audits or no programme of continuous audits.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients told us they found the appointment system easy to use and reported they were able to access care when they needed it. Some of the national GP patient survey results for access were above local and national averages.
  • There was a clear leadership structure and staff felt supported by management.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Continue to monitor patient outcomes in relation to the cervical screening programme and the child immunisation programme.
  • Continue to identify the number of carers registered at the practice so they can be offered further help and support.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

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