Archived: Dr Risiyur Nagarajan Also known as Dr R. K. Nagarajan

Updated 29 September 2017

Dr Risiyur Nagarajan (Queens Park Health Centre) operates from a purpose-built health centre co-located with two other GP practices and community services. The practice is situated on the ground floor and has access to three consulting room. There is a shared waiting area and a dedicated reception desk.

The practice provides NHS primary care services to approximately 3,000 patients and operates under a General Medical Services (GMS) contract (a contract between NHS England and general practices for delivering general medical services and is the commonest form of GP contract).

The practice is part of NHS West London Clinical Commissioning Group (CCG).

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

The practice staff comprises of a male principal GP totalling eight sessions per week and a long-term sessional male GP five sessions per week. At the time of our inspection the practice did not have a female GP or a practice nurse. The clinical team are supported by a full-time job-share practice manager, a phlebotomist and a team of administration and reception staff.

The practice population is in the second most deprived decile in England. People living in more deprived areas tend to have greater need for health services.

The practice is open between 9am and 6.30pm on Monday, Tuesday, Wednesday and Friday and from 9am to 12.30pm on Thursday. Extended hours appointments are available on Monday from 6.30pm to 8pm. On Thursday afternoons and outside of normal opening hours patients are directed to a GP out-of-hours service or the NHS 111 service.

Updated 29 September 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Risiyur Nagarajan (Queens Park Health Centre) on 7 January 2015. The overall rating for the practice was requires improvement. The full comprehensive report on the 7 January 2015 inspection can be found by selecting the ‘all reports’ link for Dr Risiyur Nagarajan on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 3 August 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 7 January 2015. This report covers our findings in relation to those requirements and any improvements made since our last inspection.

Overall the practice remains rated as requires improvement.

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

• Although risks to patients were assessed, the systems to address these risks were not implemented well enough to ensure patients were kept safe. For example, we found the processes and management of significant events, patient safety alerts and some aspects of prescription management required improvement.
• Staff demonstrated that they understood their responsibilities with regards safeguarding and we saw that clinical staff had been trained to safeguarding level three. However, non-clinical staff and a phlebotomist had not received safeguarding children training relevant to their role.
• 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. However, there were gaps in training which the practice had identified as mandatory, for example, fire safety awareness and information governance.
• There was evidence of appraisals for all employed staff but the practice did not have a formal induction programme for newly appointed staff.
• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• Information about services and how to complain was available.
• Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of the requirements of the duty of candour. An example we reviewed showed the practice complied with these requirements.

The areas where the provider must make improvement are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• 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.

The areas where the provider should make improvement are:

• Consider the infection control lead undertaking enhanced training to support them in this extended role.
• Review the fire evacuation procedure to ensure all staff understand, and continue to understand, the plan in the event of a fire.
• Review the process to regularly check that the shared defibrillator is ready for use at all times.
• Consider keeping a copy of the business continuity plan off site and include the names and contact details of all staff members.
• Continue to monitor patient outcomes in relation to the childhood immunisation and the cervical screening programme.
• Review the use of the urgent two-week referral pathway to ensure all patients within its criteria are being appropriately referred to improve early diagnosis and timely treatment.
• Consider including the long-term sessional GP in the appraisal programme.
• Continue to actively recruit a female GP and a practice nurse to enable patient preferences and outcomes to be met.
• Review how carers are identified and recorded on the clinical system to ensure information, advice and support is made available to them.
• Consider recording verbal complaints to capture all patient feedback in order to identify trends and enable learning.
• Consider developing a practice website.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Updated 29 September 2017

The provider was rated as requires improvement for safe, effective and well-led. The issues identified as requiring improvement overall affected all patients including this population group. However, there was evidence of some good practice.

• GPs had lead roles in long-term disease management and patients at risk of hospital admission were identified as a priority.
• Performance for diabetes related indicators was comparable to the CCG and national averages. For example, the percentage of patients with diabetes, on the register, in whom the last HbA1c was 64 mmol/mol or less in the preceding 12 months was 77% (CCG average 74%; national average 78%).
• The practice followed up on patients with long-term conditions discharged from hospital and ensured that their care plans were updated to reflect any additional needs.
• There were emergency processes for patients with long-term conditions who experienced a sudden deterioration in health.
• 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.

Updated 29 September 2017

The provider was rated as requires improvement for safe, effective and well-led. The issues identified as requiring improvement overall affected all patients including this population group.

• From the sample of documented examples we reviewed we found 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 (A&E) attendances.
• Immunisation rates were below target for standard childhood immunisations.
• Appointments were available outside of school hours and the premises were suitable for children and babies.
• The practice worked with midwives, health visitors and school nurses to support this population group. For example, in the provision of ante-natal, post-natal and child health surveillance clinics.
• The percentage of patients with asthma, on the register, who have had an asthma review in the preceding 12 months that includes an assessment of asthma control was 85% (CCG average 77%; national average 76%).
• The practice’s uptake for the cervical screening programme was 48%, which was significantly below the CCG average of 75% and the national average of 81%.

Updated 29 September 2017

The provider was rated as requires improvement for safe, effective and well-led. The issues identified as requiring improvement overall affected all patients including this population group. However, there was evidence of some good practice.

• The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs.
• The practice offered proactive, personalised care to meet the needs of the older patients in its population. For example, the practice liaised with local pharmacies regarding dossette boxes (a pill container and organiser for storing scheduled doses of a patient’s medication) and repeat dispensing for this cohort.
• The practice identified at an early stage older patients who may need palliative care as they were approaching the end of life. It involved older patients in planning and making decisions about their care, including their end of life care.
• Older patients were provided with health promotional advice and support to help them to maintain their health and independence for as long as possible. In addition, patients requiring additional support could be referred to a Primary Care Navigator who helped signpost patients to health, social care and voluntary sector services.
• Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns.
• The practice held regular multi-disciplinary team meetings with district nurses, community matrons, palliative care team, social services and the mental health team to coordinate and maintain the care of this cohort.

Updated 29 September 2017

The provider was rated as requires improvement for safe, effective and well-led. The issues identified as requiring improvement overall affected all patients including this population group. However, there was evidence of some good practice.

• The needs of these populations had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care, for example, extended opening hours on Monday evening from 6.30pm to 8pm and telephone consultations.
• The practice was proactive in offering online services which included booking appointments and requesting repeat prescriptions.

Updated 29 September 2017

The provider was rated as requires improvement for safe, effective and well-led. The issues identified as requiring improvement overall affected all patients including this population group. However, there was evidence of some good practice.

• The practice carried out advance care planning for patients living with dementia.
• Patients at risk of dementia were identified and offered an assessment.
• The percentage of patients diagnosed with dementia who had had their care reviewed in a face-to-face meeting in the last 12 months was 94% (32 patients) compared with the CCG average of 85% and the national average 84%.
• The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a comprehensive, agreed care plan documented in the record, in the preceding 12 months was 100% (23 patients) compared with the CCG average of 91% and the national average of 89% and the percentage of patients with schizophrenia, bipolar affective disorder and other psychoses whose alcohol consumption has been recorded in the preceding 12 months was 100% (23 patients) compared with the CCG average 89% and the national average of 89%.
• The practice had a system for monitoring repeat prescribing for patients receiving medicines for mental health needs.
• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those living with dementia.
• The practice had information available for patients experiencing poor mental health about how they could 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 interviewed had a good understanding of how to support patients with mental health needs and dementia.

Updated 29 September 2017

The provider was rated as requires improvement for safe, effective and well-led. The issues identified as requiring improvement overall affected all patients including this population group. However, there was evidence of some good practice.

• The practice held a register of patients living in vulnerable circumstances including those 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.
• The practice offered longer appointments for patients with a learning disability and those requiring an interpreter.
• The practice regularly worked with other health care professionals in the case management of vulnerable patients.
• Staff interviewed knew how to recognise signs of abuse in children, young people and adults whose circumstances may make them vulnerable. They 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.