Archived: Dr Kiran Kunwar Also known as North Hyde Surgery

Updated 24 March 2016

Dr Kiran Kunwar provides NHS primary medical services to around 1,460 patients in Southall, in the London Borough of Hounslow. The practice has one surgery, known as North Hyde Medical Practice. The service is provided through a General Medical Services contract.

The current practice staff team comprises one full-time principal GP (who owns the practice), a part-time practice nurse, one permanent receptionist and two temporary receptionists. The practice also contracts a data summariser to assist with maintaining the electronic patient records system, who attends the practice once a month. The clinical staff and receptionists in this practice are female.

The practice is open between 9.15am-1.00pm and 4:45pm-6.30pm on weekdays with the exception of Wednesday when the surgery is closed after 1.00pm. Appointments are available from 10.00am in the morning and 5.00pm in the early evening until the practice closes. Telephone consultations with a GP are also available at these times. The GP undertakes home visits for patients who are housebound or are too ill to visit the practice.

The practice has opted out of providing out-of-hours services to its own patients. Patients can use the out-of-hours primary care service provided locally by Care UK. Patients ringing the practice when it is closed are provided with recorded information on the practice opening hours and instructions to call the “111” telephone line for directions on how to access urgent and out-of-hours primary medical care or, in an emergency, to attend A&E.

The practice has higher than average proportions of adults in the 20-39 and 55-59 age ranges and relatively few patients over the age of 65 years or with long-term limiting health problems. The majority of registered patients are from a minority ethnic background, with patients predominantly originating from Punjabi and Sikh backgrounds. The overall income deprivation level is close to the national average but children in the area are more likely to live in deprived circumstances than the national norm.

The practice is registered with the Care Quality Commission to provide the regulated activities of diagnostic and screening procedures; maternity and midwifery services; and treatment of disease, disorder and injury.

Updated 24 March 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Kiran Kunwar on 2 June 2015. Overall the practice is rated as inadequate.

Specifically, we rated the practice as inadequate for providing safe, effective, caring and for being well led. It is rated as inadequate for providing services for older people; people with long term conditions; families children and young people; working age people; people whose circumstances may make them vulnerable; and, people experiencing poor mental health. The practice is rated as requires improvement for providing responsive services.

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. For example appropriate recruitment checks on staff had not been undertaken prior to their employment.
• Incidents, near misses and concerns were reported but there was no evidence of wider learning and communication with staff.
• There was insufficient assurance to demonstrate people received effective care and treatment. For example, apart from patients on the learning disability register, the practice had not developed care plans for patients with long-term needs.
• Patients were positive about their interactions with staff and said they were treated with compassion and dignity although national GP patient survey scores for the practice were consistently lower than the Hounslow average for the quality of patient consultations
• Urgent appointments were usually available on the day they were requested.
• The practice had ineffective formal governance arrangements to monitor its performance, learn and improve.

The areas where the provider must make improvements are:

• The practice must ensure that learning from incidents, complaints, audits and other sources of information about quality are systematically shared within the practice.
• The practice must ensure that clinical staff are appropriately supervised and monitored.
• The practice must put in place effective systems to ensure that any allegations of abuse are identified and acted on immediately
• The practice must audit its infection control practice from time to time and ensure that a Legionella risk assessment has been carried out and any identified risks acted on.
• The practice must ensure that emergency oxygen is available or carry out a risk assessment to show why this is not necessary
• The practice must ensure that it can show that equipment in use is safe and reliable and maintained in line with the manufacturer’s instructions
• The practice must ensure that recruitment procedures include and document all necessary pre-employment checks for all staff including DBS clinical records checks where appropriate.
• The practice must ensure that there is an effective induction process for new and temporary members of staff
• The practice must put systems in place to ensure all clinicians are kept up to date with national guidance and guidelines
• The practice must ensure there are formal governance arrangements in place including systems for assessing and monitoring risks and the quality of the service provision.
• The practice must ensure that staff have access to appropriate policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.
• The practice must ensure that all staff are competent to use the electronic patient records system including running reports to monitor the quality of service where appropriate
• The practice must ensure that the electronic patient records system includes accurate details of action and follow-up actions taken following diagnostic testing, health reviews or other changes to a patient’s health or treatment
• The practice must not discourage patients from registering at the practice on non-clinical grounds, for example, their ability to speak English.
• The practice must ensure that interpreting services are offered to patients when required so that patients understand their treatment and can give informed consent.
• The practice must ensure it has a business continuity plan in place.

The areas where the provider should make improvement are:

• The practice should review its workforce needs and ensure it can respond should a member of staff take leave at short notice
• The practice should consider the introduction of effective care planning for those patients who would benefit from coordinated, multidisciplinary care
• The practice should consider opportunities to engage more widely with health and social care professionals for the benefit of patients and staff development
• The practice should embed clinical audit further into routine practice and complete the audit cycle to ensure that improvements are sustained
• The practice should consider developing the information it provides to patients, for example by providing a website
• The practice should consider some further investigation of the reasons for its patient satisfaction scores being lower than the local average.
• The practice should keep records of mandatory staff training.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 21 March 2016

The provider was rated as inadequate for providing safe, effective and caring services and for being well-led. It was rated as requires improvement for providing responsive services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

Patients with a range of long-term conditions were offered annual reviews to check that their health and medication needs were being met and in line with current guidance. There was a recall system in place to provide preventative and continuing care for patients. We spoke with one patient who confirmed they were telephoned by the practice when their check was due.

The practice was achieving higher than average results for its management of a range of long-term conditions as part of the Quality and Outcomes Framework, for example for its diabetes care. However we were concerned that it was not thoroughly investigating areas where its performance looked more unusual, such as its low prevalence of Chronic Obstructive Pulmonary Disorder (COPD).

Although the GP told us they carried out care planning for those people with the most complex needs, they were unable to show us any completed care plans.

Updated 21 March 2016

The provider was rated as inadequate for providing safe, effective and caring services and for being well-led. It was rated as requires improvement for providing responsive services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

The practice had ineffective systems in place to identify and follow-up children at risk of abuse. The practice could not provide evidence that staff had been trained to the appropriate level in child protection and were aware of the procedures to follow if they were concerned about a child’s wellbeing. We were told that the practice had never needed to raise a safeguarding alert and did not have any children who were known to be at risk. There was little active communication between the practice and social services or other healthcare professionals in relation to safeguarding.

Practice appointments were available after school hours.

Updated 21 March 2016

The provider was rated as inadequate for providing safe, effective and caring services and for being well-led. It was rated as requires improvement for providing responsive services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

Patients over the age of 75 years of age had a named GP. We spoke with two older patients who commented on the value of seeing the same GP over a period of time.

The practice had achieved higher than average uptake rates for the influenza immunisation programme of over 65s in 2014.

Home visits were provided for patients who were housebound. The practice told us they did not have any patients receiving palliative care at the time of the inspection. The practice was unable to show us evidence of how they had previously worked with other specialists to provide effective and coordinated end-of-life care.

Updated 21 March 2016

The provider was rated as inadequate for providing safe, effective and caring services and for being well-led. It was rated as requires improvement for providing responsive services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

The practice did not operate extended hours but was open in the early evening allowing people who worked locally to make an appointment outside normal working hours. The national GP patient survey found that patients generally found it easy and convenient to obtain an appointment.

Telephone consultations were available on request during opening hours.

The practice offered health checks for new patients and patients aged 40-74.

Updated 21 March 2016

The provider was rated as inadequate for providing safe, effective and caring services and for being well-led. It was rated as requires improvement for providing responsive services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

Practice recall systems were in place for mental health reviews and physical health checks for patients with enduring mental health problems

Updated 21 March 2016

The provider was rated as inadequate for providing safe, effective and caring services and for being well-led. It was rated as requires improvement for providing responsive services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

The practice had a register of patients with learning disabilities and offered annual health checks and longer appointments to this group. Seven out of seven patients on the register had had a health check in the previous 12 months. However, these checks had not resulted in any changes in their management or treatment as a result and the computerised notes were sparse. The GP principal told us that these patients were stable in terms of their health and no changes were required.

An interpreting service was available for patients whose first language was not English or one of the languages spoken by staff in the practice. The GP did not use this service and instead relied on patients’ bringing family and friends. Friends and family may not always be appropriate interpreters.

The practice did not have effective systems in place to prevent and act on allegations of abuse in vulnerable adults.