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Dr Kodaganallur Subramanian Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 9 February 2018

Letter from the Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Kodaganallur Subramanian on 20 December 2016 and 24 January 2017. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. The full comprehensive report on the December 2016 and January 2017 inspections can be found by selecting the ‘all reports’ link for Dr Kodaganallur Subramanian on our website at www.cqc.org.uk.

This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 23 October 2017. Overall the practice is now rated as requires improvement.

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

  • There was an effective system for reporting, recording, investigating and learning from significant events. However, two recent incidents had not been investigated in a timely manner.
  • There was an ineffective system for reviewing and cascading safety alerts.
  • Improvements to risk management had been made. However, some risks to patients, staff and visitors were not adequately assessed and well managed.
  • There had been improvements in arrangements to deal with emergencies and major incidents.
  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • Data from the Quality and Outcomes Framework (QOF) demonstrated a positive change in patient outcomes. However, further improvements were still required to benefit patients.
  • Some new staff members had not completed necessary training including Safeguarding, chaperoning and equality and diversity.
  • The practice followed up patients recently discharged from hospital and had worked with other health care professionals when necessary to understand and meet the range and complexity of patients’ needs.
  • 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients we spoke with said they found it easy to book appointments with a named GP and there was continuity of care, with urgent appointments available the same day.
  • Improvements to governance arrangements at the practice had taken place. However, further improvements to risk assessment, governance and management were found to be required.
  • There was a clear leadership structure and staff felt supported by management. The practice gathered 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;

  • Ensure care and treatment is provided in a safe way to patients.
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.
  • 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;

  • Record the daily visual checks of the cleanliness of the practice environment.
  • Increase uptake of childhood immunisations.
  • Consider installing a hearing loop for patients who are hearing aid users.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Requires improvement

Updated 9 February 2018

The practice is rated as requires improvement for providing safe services.

  • The practice had not identified, recorded and investigated two significant events.
  • Some risk assessments had been completed, however, the practice had not conducted a Control of Substances Hazardous to Health assessment (COSHH) but not all recommended actions had been carried out.
  • When things went wrong patients received reasonable support, truthful information, and a written apology. They were told about any actions to improve processes to help prevent the same thing happening again.
  • There were systems, processes and practices to help keep patients safe and safeguarded from abuse. However, some new staff members had not completed safeguarding children training relevant to their role.
  • Improvements to risk management had been made. However, some risks to patients, staff and visitors were not adequately assessed and well managed.
  • There was an ineffective system for reviewing and cascading safety alerts.
  • There had been improvements in arrangements to deal with emergencies and major incidents.

Effective

Requires improvement

Updated 9 February 2018

The practice is rated as requires improvement for providing effective services.

  • Data from the Quality and Outcomes Framework (QOF) demonstrated a positive change in patient outcomes. However, further improvements were still required to benefit patients.
  • Staff were aware of current evidence based guidance.
  • Clinical audits demonstrated quality improvement.
  • Staff had the skills and knowledge to deliver effective care and treatment.
  • There was some evidence of appraisals and personal development plans for staff. Some recently employed staff records we looked at contained no details of any appraisal being carried out or had a date scheduled.
  • Staff worked with other health care professionals as necessary to understand and meet the range and complexity of patients’ needs.
  • End of life care was coordinated with other services involved.

Caring

Good

Updated 9 February 2018

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice higher than others for most aspects of care.
  • Survey information we reviewed showed patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
  • Information for patients about the services available was accessible.
  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.
  • The practice supported patients who were also carers and had identified 18 which represented 1% of the practice population.

Responsive

Good

Updated 9 February 2018

The practice is rated as good for providing responsive services.

  • The practice maintained good local knowledge and awareness of the needs of its local patient population and used this understanding to meet their needs.
  • The practice took account of the needs and preferences of patients with life-limiting conditions, including patients with a condition other than cancer and patients living with dementia.
  • Home visits were available for patients who were not able to visit the practice.
  • All the patient feedback we received indicated they found it easy to book appointments with a named GP and there was continuity of care, with urgent appointments available the same day.
  • Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Requires improvement

Updated 9 February 2018

The practice is rated as requires improvement for being well-led.

  • The practice had a clear vision and strategy to deliver high quality care and promote good outcomes for patients.
  • Improvements to governance arrangements at the practice had taken place. However, further improvements to risk assessment, governance and management were found to be required.
  • There was a clear leadership structure and staff felt supported by management.
  • The practice had a number of policies and procedures to govern activity and held regular governance meetings. However, policies still needed updating and personalising to the practice
  • The provider was aware of and complied with the requirements of the duty of candour. The GP encouraged a culture of openness and honesty.
  • The practice had systems for notifiable safety incidents and ensured this information was shared with staff to help ensure appropriate action was taken.
  • The practice valued feedback from patients, the public and staff.
Checks on specific services

Older people

Requires improvement

Updated 9 February 2018

The practice is rated as requires improvement for the care of older people. The provider is rated as requires improvement for providing safe, effective and well-led services and good for providing caring and responsive services. The resulting overall rating applies to everyone using the practice, including this patient population group.

  • Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns.
  • The practice offered proactive, personalised care to meet the needs of the older people in its patient population.
  • The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.
  • The practice involved older patients in planning and making decisions about their care, including their end of life care.
  • The practice followed up on older patients discharged from hospital to help ensure that their care records were updated to reflect any additional needs.
  • Patients over the age of 75 years had a designated GP to oversee their care and treatment requirements.
  • Practice staff visited patients who lived in local residential homes when required as well as annually to review their needs and provide annual influenza immunisations. 

People with long term conditions

Requires improvement

Updated 9 February 2018

The practice is rated as requires improvement for the care of people with long-term conditions. The provider is rated as requires improvement for providing safe, effective and well-led services and good for providing caring and responsive services. The resulting overall rating applies to everyone using the practice, including this patient population group.

  • Patients at risk of hospital admission were identified as a priority.
  • Performance for diabetes related indicators was comparable to the local clinical commissioning group (CCG) average and national average. For example, 75% of the practice’s patients with diabetes, on the register, whose last IFCC-HbA1c was 64mmol/mol or less in the preceding 12 months compared with the local CCG average of 74% and national average of 80%. 77% of the practice’s patients with diabetes, on the register, had a last measured total cholesterol of 5mmol/l or less compared with the local CCG average of 74% and national average of 80%.
  • The practice followed up on patients with long-term conditions discharged from hospital to help ensure that their care records were updated to reflect any additional needs.
  • All these patients had a named GP and there was a system to recall patients for a structured annual review to check their health and medicines needs were being met.
  • For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care when required.

Families, children and young people

Requires improvement

Updated 9 February 2018

The practice is rated as requires improvement for the care of families, children and young people. The provider is rated as requires improvement for providing safe, effective and well-led services and good for providing caring and responsive services. The resulting overall rating applies to everyone using the practice, including this patient population group.

  • There were systems to identify and follow up children living in disadvantaged circumstances and who were at risk. For example, children and young people who had a high number of accident and emergency attendances.
  • Childhood immunisation rates for the vaccines given to children under two years of age were below the national averages.
  • All the patient feedback we received indicated that children and young people were treated in an age-appropriate way and were recognised as individuals.
  • The practice’s uptake for the cervical screening programme was 76%, which was comparable to the local CCG of 82% and national average of 81%.
  • Appointments were available outside of school hours and the premises were suitable for children and babies.

Working age people (including those recently retired and students)

Requires improvement

Updated 9 February 2018

The practice is rated as requires improvement for the care of working-age people (including those recently retired and students). The provider is rated as requires improvement for providing safe, effective and well-led services and good for providing caring and responsive services. The resulting overall rating applies to everyone using the practice, including this patient population group.

  • The needs of these populations had been identified and the practice had adjusted the services it offered to help ensure these were accessible, flexible and offered continuity of care.
  • The practice was proactive in offering some online services, as well as a full range of health promotion and screening that reflects the needs for this age group.

People whose circumstances may make them vulnerable

Requires improvement

Updated 9 February 2018

The practice is rated as requires improvement for the care of people whose circumstances may make them vulnerable. The provider is rated as requires improvement for providing safe, effective and well-led services and good for providing caring and responsive services. The resulting overall rating applies to everyone using the practice, including this patient population group.

  • The practice held a register of patients with a learning disability.
  • End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.
  • Although patients with learning disabilities were not routinely offered longer appointments by the practice, staff confirmed that the clinicians always gave enough time to these patients, overrunning appointment times whenever necessary.
  • The practice worked with other health care professionals when required in the case management of vulnerable patients.
  • The practice had information available for vulnerable patients about how to access various support groups and voluntary organisations.
  • Staff knew how to recognise signs of abuse in children, young people and adults whose circumstances may make them vulnerable. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.
  • The practice supported patients who were also carers and had identified 18 which represented 1% of the practice population.

People experiencing poor mental health (including people with dementia)

Requires improvement

Updated 9 February 2018

The practice is rated as requires improvement for the care of people experiencing poor mental health (including people with dementia). The provider is rated as requires improvement for providing safe, effective and well-led services and good for providing caring and responsive services. The resulting overall rating applies to everyone using the practice, including this patient population group.

  • Performance for mental health related comparable to CCG and national scores. For example, 82% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which was comparable to both the local clinical commissioning group (CCG) average of 81% and national average of 80%. We looked at a random sample of these patients’ records which confirmed this. 100% the practice’s patients with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive, agreed care plan documented in their records in the preceding 12 months compared with the local CCG average of 91% and national average of 90%. This was an increase of 33% over the 2015/2016 figures. 100% of patients with schizophrenia, bipolar affective disorder and other psychoses had their alcohol consumption recorded, in the preceding 12 months compared to the local CCG average and national averages of 91%.
  • The practice worked with multi-disciplinary teams when required in the case management of patients experiencing poor mental health, including those with dementia.
  • The practice had information available for patients experiencing poor mental health about how to access various support groups and voluntary organisations.
  • The practice had a system to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.
  • Staff had a good understanding of how to support patients with mental health needs and dementia.