Archived: Dr Kodaganallur Subramanian

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

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Kodaganallur Subramanian on 20 December 2016. We carried out a further visit on 24 January 2017 to review some of the areas of concern identified during the first inspection. Overall the practice is rated as inadequate.

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

• Patients were at risk of harm because systems and processes were not in place to keep them safe. There were no clear procedures in place for monitoring and managing risks to patient and staff safety, for example in relation to health and safety, fire safety and electrical safety.

• The approach to safety and the reporting and recording of significant events lacked order and transparency

• This practice’s performance was below local and national averages for management of the majority of long term conditions.

• Patient outcomes were hard to identify as little or no reference was made to audits or quality improvement. There was limited evidence that the practice was comparing its performance to others; either locally or nationally.

• Clinical staff, for example the practice nurse, had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. However the provider had no system for assuring themselves of this. There was no induction or training programme in place for staff.

• Patients were positive about their interactions with staff and said they were treated with compassion and dignity. However their views about their involvement in planning and making decisions about their care and treatment was less positive.

• Some information about services was available but there was no structured complaints process in place. Information about how to complain was not available. There was no evidence of improvements made to the quality of care as a result of complaints and concerns.

• Patients said they found it easy to make an appointment with the GP and there was continuity of care, with urgent appointments available the same day.

• At our first visit the practice did not have good facilities and was not well enough equipped to treat patients and meet their needs. For example they did not have a defibrillator or oxygen and their stock of emergency drugs was insufficient. At our second visit we found these were in place and adequate.

• There was a clear leadership structure in place, however there was no practice manager in post on the day of our initial inspection. As a result staff members reported feeling under pressure and inadequately supported. By the time of our subsequent visit a part time practice manager had been employed.

• The practice had limited formal governance arrangements. Not all mandatory training had been completed by staff.

• The practice did not proactively seek feedback from staff and patients.

• There was limited understanding of the requirements of the duty of candour.

The areas where the provider must make improvement are:

• Review the system for reporting, recording and sharing learning from significant events to ensure it was effective and that it supports the recording of notifiable incidents under the duty of candour.

• Ensure all mandatory training is completed by all staff including safeguarding (adult and child protection), fire, infection control and information governance.

• Assess the risks to the health and safety of service users of receiving the care or treatment and take steps to mitigate such risks, for example regarding health and safety, infection control, fire safety and the safety of electrical equipment.

• Ensure the practice is adequately equipped to respond in the case of an injury requiring first aid and the spillage of bodily fluids.

• Update the business continuity plan and ensure it contains contact details for all staff.

• Take steps to improve the practice’s performance in the management of long term conditions such as Diabetes, Mental health, Chronic Obstructive Pulmonary Disease (COPD) and Peripheral Arterial Disease.

• Ensure a continuous programme of quality improvement, for example clinical audits is introduced.

• Consolidate the complaints process and ensure learning from complaints is discussed and shared. Ensure any trends are analysed and action is taken to improve the quality of care as a result.

• Ensure systems and processes are in place at the practice, in particular regarding vision and strategy, governance, staffing, practice policies, performance awareness, quality improvement, risk management and leadership.

• Ensure systems and processes are in place to support appropriate recruitment checks for all future employees.

• Form a Patient Participation Group (PPG) and review how the practice obtains patient feedback

The areas where the provider should make improvement are:

• Improve access to a practice nurse.

• Review staffing levels for nursing and non-clinical roles to ensure there are sufficient numbers of staffon duty and that patients’ needs are met.

• Take steps to ensure patients are made aware of translation services.

• Review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is made available to them.

• Install a hearing loop to support patients with hearing impairments.

• Formalise meetings with staff to support staff feedback and maintain records of discussions and actions agreed upon.

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.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice