The Care Quality Commission
  • Doctor
  • GP practice

Archived: Dr Ravindrasena Muthiah Also known as Salisbury Surgery

Overall: Inadequate read more about inspection ratings

Salisbury Surgery, 178 Dawes Road, Fulham, Fulham, SW6 7HS (020) 7381 9195

Provided and run by:
Dr Ravindrasena Muthiah

All Inspections

10 and 17 September 2020

During an inspection looking at part of the service

We carried out an announced focused inspection at Dr Ravinsendra Muthiah on 10 and 17 September 2020.

This report was created as part of a pilot which looked at new and innovative ways of fulfilling CQC’s regulatory obligations and responding to risk in light of the Covid-19 pandemic. This was conducted with the consent of the provider. We obtained the information in it by undertaking a remote clinical records review, desk-based inspection and a short on-site visit at the practice premises. As part of the desk-based inspection a GP specialist advisor spoke with the Lead GP by telephone and we have reviewed documentary evidence submitted by the practice.

The practice was previously inspected on 11 February 2020. Following this inspection, the practice was rated Inadequate overall and in the safe, effective and well-led domains and placed in special measures. We issued warning notices for breaches of Regulation 12 (safe care and treatment) and Regulation 17 (good governance). The practice was required to address the concerns regarding Regulation 12 by 08 April 2020 and for Regulation 17 by 10 June 2020.

We did not review the ratings awarded to this practice at this inspection.

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 the provider had made not made sufficient improvements in providing safe services regarding:

  • The safe management of medicines.
  • Safe care and treatment including missed diagnoses.
  • Safeguarding systems.
  • Recruitment checks.
  • Infection prevention and control.
  • The management of patient safety alerts.
  • Fire safety practices.
  • Premises management.
  • Premises risk assessments.
  • Cold chain.

We found the provider had not made sufficient improvements for providing effective services regarding:

  • Staff did not have the skills, knowledge and experience to deliver effective care, support and treatment.
  • Clinical supervision for the healthcare assistant
  • Appraisals for the healthcare assistant.

We found the provider had not made sufficient improvements to concerns we found in the well led domain. They could not demonstrate they had:

  • Effective processes in place for managing risks, issues and performance.
  • A fail-safe system to monitor and manage patients who had been referred via the urgent two week-wait referral system.
  • A fail-safe system to monitor and manage patient safety alerts.
  • A fail-safe system in place to safely manage and monitor cervical smear screening.

The areas where the provider must make improvements are:

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

(Please see the specific details on action required at the end of this report).

The service will remain in special measures until we have undertaken the next inspection and this will be reviewed at that time. This will be kept under review and if needed could be escalated. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

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

11 February 2020

During a routine inspection

We decided to undertake an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions:

  • Safe
  • Effective
  • Well led
  • Responsive
  • Caring

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 inadequate overall.

We rated the practice as inadequate for providing safe services because:

  • The practice did not have clear systems and processes to keep patients safe.
  • The practice did not have reliable systems and processes to keep patients safeguarded from abuse.
  • The provider did not have safe practices regarding emergency medicines and equipment.
  • The practice did not have reliable infection prevention and control practices in place.
  • The practice did not maintain adequate records to monitor and manage the cold chain effectively.
  • The practice did not have complete fire safety systems in place.
  • The practice did not have reliable systems in place to manage the practice premises safely.
  • The practice did not have appropriate systems in place for the safe management of medicines.
  • The practice did not have a safe and effective system in place regarding the management of sepsis.
  • The practice could not demonstrate they always learnt and made improvements when things went wrong.

We rated the practice as inadequate for providing effective services because:

  • Clinical care was not delivered consistently in line with national guidance.
  • There was limited monitoring of the outcomes of care and treatment.
  • The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles.
  • The practice was unable to show that it always obtained consent to care and treatment.
  • Some performance data was significantly below local and national averages.

This area affected all population groups; so we rated all population groups in the effective domain as inadequate.

We rated the practice as inadequate for providing well-led services because:

  • Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
  • The practice could not demonstrate they had a clear vision and a credible strategy.
  • The practice culture did not effectively support high quality sustainable care.
  • The overall governance arrangements were ineffective.
  • The practice did not have clear and effective processes for managing risks, issues and performance.
  • The practice did not always act on appropriate and accurate information.
  • We saw no evidence of systems and processes for learning, continuous improvement and innovation.

We rated the practice as good for providing caring services because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.

We rated the practice as requires improvement for providing responsive services because:

  • The practice did not organise and deliver services to meet patients’ needs. Patients could access appointments to receive care and treatment during limited time periods.

This area affected all population groups; so we rated all population groups in the responsive domain as requires improvement.

The areas where the provider must make improvements are:

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

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Ensure that information for patients is available in different languages and easy to read formats on the practice premises.
  • Consider how to improve ts identification of carers within the practice and how they may be better supported.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

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

20 February 2018

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Ravindrasena Muthiah also known as Salisbury Surgery on 15 June 2016 and the overall rating for the practice was good. The practice was rated good for providing safe, caring, responsive and well-led services and requires improvement for providing effective services. This was in relation to aspects of quality monitoring and governance as there were some deficiencies in the arrangements for monitoring performance and improving quality. This specifically related to accuracy of clinical coding, QOF performance in some areas and absence of clinical audit to monitor and drive improvements.

We issued a requirement notice to the provider in respect of good governance. In response to the requirement notice issued, the provider sent us an action plan outlining the improvements that would be put in place to address the concerns identified at our previous inspection in order to meet the regulations.

The full comprehensive reports on the 15 June 2016 inspection can be found by selecting the ‘all reports’ link for Dr Ravindrasena Muthiah (Salisbury Surgery) on our website at www.cqc.org.uk.

This inspection, carried out on 20 February 2018, was an announced comprehensive inspection to review in detail the actions taken by the practice since our last inspection on 15 June 2016 to improve the quality of care and to confirm that the provider was now meeting legal requirements.

Overall the practice is rated as good.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) – Good

Our key findings were as follows:

The practice had made improvements since our previous inspection of 15 June 2016 and the concerns that we identified had been addressed.

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • There were systems, processes and practices to keep patients safe and to minimise most risks.
  • Staff had the skills, knowledge and experience to carry out their roles.
  • The practice demonstrated that it used information about its performance to monitor and improve the quality of care. Improvement in QOF performance had been made since the previous inspection. However there were areas that could be further improved.
  • The practice carried out clinical audit and there was evidence of completed full cycle audits to show improved patient outcomes.
  • The practice promoted good health and prevention and provided patients with advice and guidance.
  • Data from the national GP Patient survey showed the practice was comparable with local and national averages for its satisfaction scores on consultations with GPs and for nurses.
  • The practice had an effective system for proactively identifying patients who were carers to offer them additional support.
  • There was an effective complaints system in place and those received were responded to appropriately to improve the quality of care.
  • The practice had completed a review of their policies and procedures to ensure they were up to date and operating as intended.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

However, there were also areas of practice where the provider needs to make improvements.

The provider should:

  • Review the arrangements for the documentation of emergency medicines and equipment checks and of all cleaning task schedules.
  • Review the arrangements for acceptance of staff DBS checks undertaken by previous employers.
  • Consider the installation of an independent fridge temperature thermometer.
  • Review the arrangements for the documentation of multidisciplinary team meetings.
  • Continue to monitor and further improve Quality and Outcomes Framework (QOF) performance.
  • Continue to monitor and improve uptake of childhood immunisations and cervical screening programmes.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

15 June 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Salisbury Surgery on 15 June 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.

  • Data showed some patient outcomes were low compared to the national average. Although some audits had been carried out, we saw no evidence that audits were driving improvements to patient outcomes.

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment and there was continuity of care, with urgent appointments available the same day.
  • There was a clear leadership structure and staff felt supported by the lead GP.
  • The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvements are:

  • Review the read-coding procedures to improve the practice performance for QOF and the services provided for patients, with particular focus on long term conditions.

  • Review all practice policies and procedures to ensure these are up to date and practice-specific.

  • Develop a practice programme of quality improvement including clinical audit and re-audit to drive improvements and monitor quality.

The areas where the provider should make improvements are:

  • Provide regular performance reviews or appraisals for all staff.

  • The provider should improve the childhood immunisation rates and cervical screening uptake in line with the national averages.

  • The provider should ensure an infection control audit is undertaken annually and action is taken to address any improvements identified as a result.

  • The provider should improve its identification of patients who are carers and the support offered to them by the practice.

  • Consider improving communication with patients who have a hearing impairment.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

31 March 2014

During an inspection looking at part of the service

On our previous inspection in November 2013 we found that there was no working portable oxygen supply or defibrillator available in the practice which meant that appropriate emergency equipment was not available. We also found that paper records were being stored in a room that was accessible to patients and not actively supervised by staff.

On this inspection we found that a portable oxygen supply was now in place and there was a system in place to ensure that this was in good working order. In addition, the paper records had now been moved to secure filing cabinets within a staff office. However, it was noted that there was still no defibrillator in place (contrary to best practice guidance).

7 November 2013

During a routine inspection

We spoke to people using the service and their family members. They told us that the doctor explained the health conditions people had "very well" and what treatments involved. They said that they were provided with leaflets as appropriate. They said that the doctor "takes an interest" and that they were "treated very well". The service was accessible to people using wheelchairs. Staff reported that most people who did not speak English attended with someone who could translate for them, but that they had access to a translation service if they needed it. If advance notice was given a female chaperone could be arranged for individual consultations.

Before people received care or treatment appropriate medical histories were taken and people were treated at the practice or referred to other services as appropriate. However, whilst the provider had emergency drugs, they did not have a working portable oxygen supply or a defibrillator which meant that appropriate equipment was not available for use in a medical emergency.

People who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and knew how to respond to situations where abuse was suspected.

Staff received appropriate professional development and the provider had a system in place for monitoring the quality of the service provided at the practice.

Clinical records were not always stored securely.