Archived: Dr Tirunelveli Ashok Kumar

Updated 13 September 2016

Dr Tirunelveli Ashok-Kumar (Also known as Highwoods Surgery) is situated in North Colchester, Essex. The practice is one of 42 practices in the North East Essex Clinical Commissioning Group. The practice holds a personal medical services contract with the NHS.

There are approximately 6400 patients registered at the practice. The practice has one male full-time senior GP; they employ two locum GPs one male and one female. The GPs are supported by one nurse practitioner, two practice nurses, and a healthcare assistant. The administrative team were led by the practice manager, and included a secretary, and five further administrative and reception members of staff. Support staff members at the practice work a range of hours including full and part-time.

The practice opening hours are: 7am to 6.15pm on Mondays, 7am to 7.30pm on Tuesdays, 8.45am to 4.30pm on Wednesdays, 8.45am to 7.30pm on Thursdays, and 8.45am 6.15pm on Fridays. The practice closes for a lunch-time period between 12 noon and 2pm. Consultations are held by GPs and nurses during these daily opening times. The practice has opted out of providing 'out of hour’s’ services to their own patients which is now provided by Care UK, another healthcare provider. Patients can also contact the NHS 111 service to obtain medical advice if necessary.

The practice is registered to provide the following regulated activities: diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury. They hold directed enhanced services (DES); a DES is a service which requires an enhanced level of service provision above what is required under their core contracts. They hold a DES for; the childhood vaccination and immunisation scheme, influenza and pneumococcal immunisations, extended hours, facilitating timely diagnosis and support for people with dementia, improving patient online access, learning disabilities, risk profiling and case management, rotavirus and shingles immunisation and admission avoidance.

We previously carried out a comprehensive inspection at Dr Tirunelveli Ashok-Kumar (Also known as Highwoods Surgery) on 29 July 2015. The practice was rated as requires improvement overall. We issued the provider with requirement notices for improvement.

Updated 13 September 2016

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection at Dr Tirunelveli Ashok-Kumar’s Surgery also known as Highwoods Surgery on 29 July 2015. The practice was rated as requires improvement overall. Specifically they were rated as good for caring services, inadequate for safe, and requires improvement for effective, responsive, well-led services.

In particular, on 29 July 2015, we found the following breaches of the regulations at the practice;

• Medicines were not stored appropriately.

• Systems to identify or monitoring risks were ineffective and not mitigated.

• Staff were unaware how to report potential safety incidents or act when they occurred.

• The practice nurses and healthcare assistant were not authorised to administer some vaccinations nor had appropriate training and competency checks to administer them safely.

• Infection prevention and control procedures required strengthening; this included cleaning, environmental checks, and audit.

• Governance systems or processes insufficient to assess monitor and improve the quality and safety of the service.

• Staff lacked understanding regarding the reporting, and investigation of significant incidents. They did not share incident findings or learning with staff members.

• There was no system to processes, record, or investigate complaints and share findings and lessons learned with staff members.

• There was a lack of monitoring and assessing the quality services and patient outcomes at the practice, this included acting on patient feedback.

As a result of our findings at the inspection we issued the provider requirement notices and told the provider they must send a report to the CQC that stated what action they were g going to take to make the required improvements. This related specifically to the following regulations;

Regulation 12 – Safe care and treatment.

Regulation 16 – Receiving and acting on complaints.

Regulation 18 – Staffing.

Regulation 17 – Good Governance.

Regulation 19 – Fit and proper persons employed.

Following the inspection on 29 July 2015 the practice sent us an action plan that explained what actions they would take to meet the regulations in relation to the requirement notices we issued.

The report of the 29 July 2015 inspection was published in January 2016. When a provider is rated as inadequate for one of the five key domains or one of the six population groups it needs to be re-inspected no longer than six months after the initial rating was confirmed.

We therefore carried out a further comprehensive inspection at Dr Tirunelveli Ashok-Kumar’s Surgery on 24 May 2016 to check whether the practice had made the required improvements from the July 2015 inspection and those contained within the requirement notices. We found that the required improvements had been made.

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

• Medicines were stored securely and only accessible to authorised staff members. Medicines seen at the practice were within the expiry date for use. Records showed us that medicines requiring cold storage were kept in refrigerators that were maintained and monitored daily to ensure medicines was stored at their optimum temperature.

• There was a system in place to identify risks and rated to show priority, likelihood, action required and learning. The system to assess risks included those associated with; premises, equipment, medicines, and infection control.

• Staff members knew how to raise concerns, and report safety incidents. The policy showed the practice complied with the requirements of the duty of candour. Safety information was recorded and any issues identified were shared with staff members.

• The nurses and healthcare assistant could evidence authorisation to administer all vaccinations provided for patients at the practice through guidance directives. They had received appropriate training and competency checks to ensure patient safety.

• The practice maintained satisfactory standards of cleanliness and hygiene. The infection control lead had received specific training and the policy in place met national and local guidance and legal requirements.

• The practice performed an audit and an annual statement setting out standards stated within their policy of quality and safety at the practice.

• There was a system to process, record, or investigate complaints and share findings with any lessons learned with staff members. Information regarding how to complain was available at the practice and in an easy to read format.

• The quality services and patient outcomes were monitored in practice meetings, and they acted on patient feedback to improve services.

• Patient care was planned and provided to reflect best practice using recommended current clinical guidance.

• Patient comments were positive about the practice during the inspection and told us they were treated with dignity and respect. Members of the practice patient participation group told us they were involved with practice development.

• There were urgent appointments available on the day they were requested.
• The practice had suitable facilities and equipment to treat patients and meet their requirements.
• The leadership structure at the practice was clear and understood by all the staff members.

The areas where the provider should make improvements:

• Review all policies and procedures to ensure they are updated and meet current guidance and legislation.

• Increase efforts to identify patients that are carer’s, currently the number identified were 34 this equated to 0.5% of the practice patient population.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 13 September 2016

The practice is rated as good for providing services, for people with long-term conditions.

Examples of the care provided were:

• All patients in this population group had a named GP.

• The GP worked with relevant local health care professionals to support patients with complex needs.

• The practice delivered enhanced services to meet the needs of patients in this population group for example; warfarin testing, and hypertension monitoring.

• They also provided an in-house blood taking service and echocardiography (ECG).

• The practice held reviews for patients with long term conditions with a robust recall system.

• Patients in this population group had care plans documented in patient records and their homes for those with complex needs, and/or those seen by multiple healthcare agencies to ensure continuity of care. Consistent templates were used in the clinical system to ensure all patient treatments and progress could be monitored.

Appointments are used efficiently to ensure all tests, injections and reviews for patients are completed at one visit to the surgery where ever possible.

Updated 13 September 2016

The practice is rated as good for providing services for families, children and young people.

Examples of the care provided were:

• A process to identify and follow up children living in disadvantaged circumstances had attended accident and emergency services or were at risk.

• Immunisation rates were average for all standard childhood immunisations compared with local surgeries.

• The national quality performance data showed the percentage of women aged 25-64 whose notes record that a cervical screening test has been performed in the preceding five years at the practice was 80% and nationally was 81%.

• Appointments were available outside of school hours, and extended hours to provide later appointments.

• Patients from this population group access to on-line repeat prescriptions requests and appoints.

• There was child health surveillance at the practice, and GPs attended child protection forums when available.

• There was a policy regarding Gillick competence and permission to inform / share with parents or carers if children under 16 attended the practice alone.

• A number of specific clinics were available for this populations group for example; family planning, weight management, smoking cessation, immunisations, ante-natal and wart removal.

Women’s health and screening services that reflect the needs of this population group were provided.

Updated 13 September 2016

The practice is rated as good for providing services for older people.

Examples of the care provided were:

• All patients in this population group had a named GP.

• Older people at the practice were provided with urgent access to appointments, and longer appointments could also be requested. The practice offered home visits for those with mobility or enhanced needs.

• The practice held a register of patients that were carers from this population group, they were supported with health checks and flu vaccination to protect their health.

• Information was shared with the out of hours provider computer system if consent to share information had been given. This ensured continuity of care if seen outside the practice core hours.

• Flu vaccination, pneumococcal and shingles vaccines were offered to patients over the age of 65 annually.

• Patients were followed-up and reviewed after hospital treatment or accident and emergency visits.

• Palliative patients were reviewed in regular multidisciplinary team meetings.

• Computer templates to avoid admission to hospital were used to plan care for this population group.

• The practice provided space for clinics to run at the surgery normally held at Colchester General Hospital, or at other outside health providers. This facility was made available for patients registered at the practice and from other surgeries in the area clinics were available for hearing tests, abdominal aortic aneurysm screening and urology.

There was a care advisor attached to the surgery that supported patients with their social needs, for example completing benefit forms, accessing services from the community for both medical and social needs and any specialist equipment needs.

Updated 13 September 2016

The practice is rated as good for providing services for working age people (including those recently retired and students).

Examples of the care provided were:

• Patients from this population group could order their repeat prescriptions and appointments on-line.

• Telephone consultations were available with doctors and nurses.

• A range of health promotional services such as smoking cessation, weight management, health checks, and flu vaccination clinics were available outside week day core hours.

A range of health promotion was offered, seen on notices and leaflets in the waiting/reception area.

Updated 13 September 2016

The practice is rated as good for providing services for people experiencing poor mental health (including people with dementia).

Examples of the care provided were:

• The practice provided people experiencing poor mental health information about how to access support and voluntary groups in leaflet format in the reception area.

• Patients in this population group had their next of kin details and identified power of attorney on their records.

• Data from 2014-2015 showed:100%

The practice used consistent, clinical, good practice templates to ensure care plans and optimum treatment was in place to support people experiencing poor mental health (including people with dementia).

Updated 13 September 2016

The practice is rated as good for providing services for people whose circumstances may make them vulnerable.

Examples of the care provided were:

• Longer appointments for patients with a learning disability.

• There were 63 patients identified as living with a learning disability, all these patients had been offered an annual learning disability check. There was a GP that had a special interest for learning disability and looked after these patients providing them a yearly health check.

• Staff knew how to recognise the signs of abuse in vulnerable adults and children, they were also aware of their responsibilities. This included information sharing, documentation of safeguarding concerns and who to contact. Practice staff knew they could ask the safeguarding lead GP at the practice for advice if they had any concerns.

• Information was shared with the out of hours provider computer system if consent to share information had been given. This ensured continuity of care if seen outside the practice core hours.

• Home visits were offered to those patients unable to attend for routine or emergency care, including vaccination.

• Consistent template care plans were in place to support people from this population group.

• Residential care homes were visited on a weekly basis by the GP and the nurse visited monthly to undertake any blood tests that needed to be taken. The care homes all had an emergency telephone number to allow access to speak with a GP on a daily basis when required.

Currently the practice had identified 34 carer’s this equated to 0.5% of their patient population.