The Care Quality Commission
  • Doctor
  • GP practice

Dr Selvaratnam Kulendran

Overall: Good read more about inspection ratings

13-15 Chase Cross Road, Collier Row, Romford, Essex, RM5 3PJ (01708) 749918

Provided and run by:
Dr Selvaratnam Kulendran

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Dr Selvaratnam Kulendran on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Dr Selvaratnam Kulendran, you can give feedback on this service.

3 July 2019

During an annual regulatory review

We reviewed the information available to us about Dr Selvaratnam Kulendran on 3 July 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

22 May to 22 May 2018

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Dr Selvaratnam Kulendran practice on the 10 July 2017. At this inspection we rated the practice as good overall and for the key questions of safe, effective, caring and responsive with the exception of well-led which we rated requires improvement. The full comprehensive report on the inspection can be found by selecting the ‘all reports’ link for Dr Selvaratnam Kulendran on our website at www.cqc.org.uk.

We carried out an announced focused inspection at Dr Selvaratnam Kulendran practice on the 22 May 2018. This inspection was carried out to review the actions taken by the practice to improve the quality of care and to confirm whether the practice was providing a well-led service and was now meeting legal requirements.

The key questions are rated as:

  • The overall rating for the service is Good.
  • Are services well-led? - Good

At this inspection we found:

  • We found the provider had a clear vision and a mission statement that was patient focused and informative.
  • The practice used information about care and treatment from the Quality Outcomes Framework to make improvements.
  • Clinical staff had completed clinical audits.
  • The practice had a patient participation group (PPG) with six members and had held one group meeting on the 23 March 2018. The meeting had agreed terms of reference. The meeting had discussed the recent report from Havering Healthwatch and what actions the provider should take.
  • Staff were clear on their roles and accountabilities.
  • The practice manager had established policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.
  • The practice had carried out a series of patient surveys, looking at the work of the doctor, the nurse and the reception staff which they had collated, reviewed and where appropriate implemented actions for improvement.
  • The practice had sought, reviewed and taken action on patient feedback.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice.

10 July 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Selvaratnam Kulendran (also known as Chase Cross Medical Centre) on 28 July 2016. The overall rating for the practice was requires improvement. The full comprehensive report on July 2016 inspection can be found by selecting the ‘all reports’ link for Dr Selvaratnam Kulendran on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 10 July and 19 July 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 28 July 2016. (We visited the practice twice in July 2017 as the practice manager had informed us they would be unavailable on the 10 July 2017 and therefore we were unable to complete the inspection on that day). This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is rated as good.

At the inspection on 28 July 2016 we found the following areas of concern:

  • The system for reporting and recording significant events required reviewing.

  • Recruitment arrangements did not include all necessary employment checks for all staff and did not comply with practice recruitment policy.

  • Risk assessments had not been carried out for staff who carried out chaperoning duties.

  • All staff had not received and completed required training to carry out their roles effectively, including safeguarding, infection control and information governance.

  • Systems in place to monitor repeat prescriptions and safety alerts were not adequate.

  • There was no system of continuous quality improvement in place.

  • Achievement for childhood immunisations was below average.

  • There was no patient participation group (PPG) or equivalent arrangement in place to support the collecting of feedback from patients about how the practice was run.

Our key findings at the inspection in July 2017 were as follows:

  • There was an effective system in place for reporting and recording significant events.

  • The practice had clearly defined and embedded systems, processes and practices in place to keep patients safe and safeguarded from abuse.

  • Risks to patients were assessed and well managed.

  • The practice had adequate arrangements in place to respond to emergencies and major incidents.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.

  • Exception reporting for Mental Health indicators remained above average.

  • Achievement for childhood immunisations was in line with national averages.

  • Staff had completed information governance, safeguarding and infection control training.

  • The provider had an improvement plan for the practice, however they were unable to demonstrate how progress towards achieving the planned improvements was being measured or achieved.

  • The practice still did not have a PPG in place although efforts were being made to form one.

In addition, at the inspection on 28 July 2016 we told the provider they should:

  • Review systems to identify carers in the practice to ensure they receive appropriate care and support.

  • Consider ways to support patients who have a hearing impairment.

  • Display notices in the reception areas informing patients that interpreting services are available.

At the inspection in July 2017 we found:

  • The patient registration form was updated following the inspection to include a question about whether or not the patient was a carer. We saw information on display and in a folder in the waiting area about available support for patients who were carers.

  • A hearing loop had been installed.

  • A number of notices had been removed from the display whilst the premises were undergoing renovation. We were told a notice about interpreters would be displayed once the renovations were completed.

However, there remained areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care, specifically in relation to monitoring practice performance, introducing a programme of continuous quality improvement and seeking patient feedback.

Additionally, the provider should:

  • Ensure the care and treatment of patients is appropriate and meets their needs, specifically in relation to patients with poor mental health.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

28 July 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Selvaratnam Kulendran’s practice on 28 July 2016. Overall, the practice is rated as requires improvement.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, there were no systems in place to audit safety alerts.
  • Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks, legionella and staff training.
  • Data showed patient outcomes were comparable to the CCG and national averages, with the exception of mental health indicators where the exception reporting was higher and children’s immunisations were lower than national averages.
  • Data showed patient outcomes were low compared to the national average for GP consultations. Although some audits had been carried out, we saw no evidence that audits were driving improvements to patient outcomes.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment, with the exception of lack of training in: information governance, safeguarding and infection control.
  • The majority of patients said they were treated with compassion, dignity and respect. However, not all felt listened to or feel they were involved in decisions about their care and treatment.
  • The practice had identified relatively few carers who might need extra support.
  • The practice told us that there was a virtual patient participation group (PPG).
  • Information about services was available.
  • The practice had a number of policies and procedures to govern activity.

The areas where the provider must make improvements are:

  • Ensure recruitment arrangements include all necessary employment checks for all staff and comply with practice recruitment policy.
  • Ensure risk assessments for DBS are carried out for staff who carry out chaperoning duties.
  • Ensure all staff receive and complete required training to carry out their roles effectively, including safeguarding, infection control and information governance.
  • Ensure systems are in place to monitor repeat prescriptions and safety alerts.

In addition the provider should:

  • Implement a programme of quality improvement including audits to show improvements in patient outcomes.
  • Review systems to identify carers in the practice to ensure they receive appropriate care and support. Consider ways to support patients who are hard of hearing.
  • Improve childhood immunisation rates for five year olds to bring in line with national averages.
  • Ensure the risk of legionella is managed in the practice.
  • Display notices in the reception areas informing patients that translation services are available.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice