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Archived: Dr Swaminathan Ravi Inadequate

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Inspection Summary


Overall summary & rating

Inadequate

Updated 1 September 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection on 1 July 2016 at Dr Swaminathan Ravi at Cope Street Surgery. The practice was placed in special measures due to non-compliance with the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 following our previous inspection in November 2015.

During this inspection, we found the practice had made some improvements since our last inspection and most of the issues raised had been rectified. However fresh concerns and breaches of regulations were noted.

The provider is in breach of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 12 Safe Care and Treatment, Regulation 17 Good Governance and Regulation 18 Staffing.

We found the practice to be inadequate in areas relating to safe, effective and well led. The practice was rated as requires improvement for areas related to being responsive and was rated as good at caring for patients.

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

  • During this inspection we found the practice had reviewed some of their systems to ensure risks to patients were addressed and managed. For example a fire risk assessment had been completed along with Control of Substances Hazardous to Health (COSHH) and Legionella risk assessments. However we found shortfalls in other areas. For example, the safeguarding policy had been updated but did not contain details of local social services and clinical commissioning team safeguarding contacts.
  • Staff were not clear about reporting incidents, near misses and concerns and there was no evidence of learning and communication with staff.
  • Patient outcomes were hard to identify as little or no reference was made to audits or quality improvement and there was no evidence that the practice was comparing its performance to others; either locally or nationally.

  • Patients were positive about their interactions with staff and said they were treated with compassion and dignity.
  • The practice had no clear leadership structure, insufficient leadership capacity and limited formal governance arrangements.

The areas where the provider must make improvements are:

  • Introduce robust processes for reporting, recording, acting on and monitoring significant events, incidents and near misses.
  • To review the findings of the infection prevention and control audit to reflect a true picture of the practice and act in accord with the findings.
  • Ensure the guidance from NHS Protect security of prescription forms is implemented and systems established.
  • Ensure paper and electronic records are held securely meeting the requirements of the Data Protection Act 1998.

  • Ensure that all staff performing chaperone duties have received a disclosure and barring service (DBS) check. DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.

  • Ensure processes are in place for the safe management of returned or unwanted medicines.
  • Ensure patient outcomes are reviewed and recommendations made to contribute to a programme of continuous quality improvement.
  • To review the staff appraisal process so that all staff have regular appraisals and performance reviews.

The areas where the provider should make improvement are:

  • Ensure a GP lone worker risk assessment is completed. The GP was the sole provider for clinical care and took the lead for everything. There was no risk assessment undertaken for the GP being a lone clinical worker

    nor clear instructions to follow if they were unable to work

    .

This service was placed in special measures on 30 November 2015. Insufficient improvements have been made such that there remains a rating of inadequate for safe, effective and well led. Therefore we are taking 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 six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas

Safe

Inadequate

Updated 1 September 2016

The practice is rated as inadequate for providing safe services and improvements must be made.

  • Not all staff we spoke with were clear about reporting incidents, near misses and concerns. The procedure for dealing with significant events was not embedded and staff did not report near misses and lower risk events.
  • Some arrangements were in place to safeguard adults and children from abuse which reflected relevant legislation and local requirements and policies were accessible to all staff. The policies did not contain local social services and clinical commissioning team contact details for further guidance if staff had concerns about a patient’s welfare.
  • There was a lead member of staff for safeguarding; however staff we spoke with were not sure who lead was.
  • Not all staff who acted as chaperones had received a disclosure and barring service (DBS) check. We were shown an email to confirm the DBS service had received DBS applications for administration staff on 29 June 2016.
  • Staff had not yet undertaken chaperone training as they were waiting for their DBS checks to be completed. Some staff told us they still performed chaperone duties, other staff told us the practice nurse would chaperone patients if they were on site when a chaperone was needed.
  • Processes were in place for safe management of medicines, however we found some shortfalls, and we found a number of medicines prescribed for specific patients in a basket in an unlocked cupboard. One medicine was a sedative, another was anti-epileptic medication.
  • There was an infection prevention and control (IPC) protocol in place and staff had received up to date training. However we found that the protocol was not always followed, for example we observed a sharp's box, which was over full, half secured with a needle sticking out. The GP was made aware of these immediately.
  • We found expired dressings and equipment that had significantly passed it's expiry date, for example gloves available for use with an expiry date of 2002.
  • During this inspection we found the practice had reviewed some of their systems to ensure risks to patients were addressed and managed.For example a fire risk assessment had been completed along with COSHH and Legionella risk assessments.

Effective

Inadequate

Updated 1 September 2016

The practice is rated as inadequate for providing effective services and improvements must be made.

  • Staff did not always understand the relevant consent and decision making requirements of legislation and guidance, for example when gaining consent from children and young people.

  • Data showed that care and treatment was not always delivered in line with recognised professional standards and guidelines. Not all staff could demonstrate how to access policies and guidelines.

  • Patient outcomes were hard to identify as little reference was made to audits or quality improvement and there was little evidence that the practice was comparing its performance to others; either locally or nationally.

  • There was limited recognition of the benefit of an appraisal process for staff and little support for any additional training that may be required.  Not all staff had received training relevant to their role. For example,basic life support and chaperone training for reception staff.

Caring

Requires improvement

Updated 1 September 2016

The practice is rated as requires improvement for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice higher than others for several aspects of care with the exception of the number of patients who said that the GP was good at explaining tests and treatments. This was 75% compared to the CCG average of 86% and the national average of 86%.

  • Patients told us they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.

  • There was no system in place to record patients with caring responsibilities.
  • Information for patients about the services available was easy to understand and accessible.

  • We saw staff treated patients with kindness and respect and maintained patient and information confidentiality.

Responsive

Requires improvement

Updated 1 September 2016

The practice is rated as requires improvement for providing responsive services.

  • Although the practice had reviewed the needs of its local population, it had not put in place a plan to secure improvements for all of the areas identified.

  • Feedback from patients reported that access to the GP and continuity of care was available with urgent appointments available the same day.

  • Patients could get information about how to complain in a format they could understand.

  • There was limited use of systems to record and report safety concerns, incidents and near misses and no evidence of shared learning with staff.

Well-led

Inadequate

Updated 1 September 2016

The practice is rated as inadequate for being well led.

  • The practice did not have a clear vision and strategy. Staff were not clear about their responsibilities in relation to the vision or strategy.

  • There was no clear leadership structure and staff did not feel supported by management.

  • The practice did not have clearly defined and embedded systems, processes and practices in place to keep people safe. Whilst there were some practice specific policies and procedures available to staff we found that staff were not always aware of them.

  • All staff had received inductions but not all staff had received regular performance reviews, had clear objectives or attended staff meetings and events.

  • The practice had sought feedback from patients and had a patient participation group.

Checks on specific services

People with long term conditions

Inadequate

Updated 1 September 2016

The practice is rated as inadequate for being safe, effective and well led. The concerns which led to these ratings apply to everyone using the practice, including this population group.

  • Performance in the asthma related indicators at 28% was substantially lower than the CCG average of 88% and the national average of 97%.

  • Performance for diabetes related indicators at 63% was substantially lower than the CCG average of 84% and the national average of 89%.

  • Longer appointments and home visits were not available for the review of patients with long term conditions.

  • These patients did not have a personalised care plan.

  • Annual reviews were not actively offered to check that patients’ health and care needs were being met.

Families, children and young people

Inadequate

Updated 1 September 2016

The practice is rated as inadequate for being safe, effective and well led. The concerns which led to these ratings apply to everyone using the practice, including this population group.

  • The GP could not demonstrate that there was a system in place to identify and follow up patients in this group who were living in disadvantaged circumstances and who were at risk.

  • Staff did not always understand the relevant consent and decision making requirements of legislation and guidance, including when providing care and treatment for children and young people. The GP told us that he has never used Gillick competency assessment (a way of assessing whether a child or young person has the capacity to understand information given and make informed decisions).

  • The practice’s uptake for the cervical screening programme was 88%, which was higher than the CCG average of 83% and the national average of 82%. There was not a policy to offer telephone reminders for patients who did not attend for their cervical screening test and staff we spoke with were unsure how these patients would be followed up.

  • Appointments were available outside of school hours and the premises were suitable for children and babies.

Older people

Inadequate

Updated 1 September 2016

The practice is rated as inadequate for being safe, effective and well led. The concerns which led to these ratings apply to everyone using the practice, including this population group.

  • Care and treatment of older people did not always reflect current evidence based practice, and some older people did not have care plans where necessary.

  • Nationally reported data showed that outcomes for patients for conditions commonly found in older people

    were poor. For example, performance in indicators for hypertension (raised blood pressure) was 74% which is 20% lower than the CCG average and 24% below the national average.

  • Home visits were available for patients that could not attend the practice.

Working age people (including those recently retired and students)

Inadequate

Updated 1 September 2016

The practice is rated as inadequate for being safe, effective and well led. The concerns which led to these ratings apply to everyone using the practice, including this population group.

  • The practice offered early morning appointments three days a week for patients who found it difficult to attend during normal hours.

  • The practice offered online services as well as health promotion and screening that reflects the needs for this age group. These services did not appear to be promoted.

People experiencing poor mental health (including people with dementia)

Inadequate

Updated 1 September 2016

The practice is rated as inadequate for being safe, effective and well led. The concerns which led to these ratings apply to everyone using the practice, including this population group.

  • Of those patients diagnosed with dementia, 52% had received a face to face review of their care in the last 12 months, which is substantially lower than the CCG and national average of 77%.

  • Performance for mental health related indicators at 67% was substantially lower than the CCG average of 82% and the national average of 93%.

  • The practice had worked with multi-disciplinary teams in the case management of people experiencing poor mental health.

  • The practice did not carry out advance care planning for patients living with dementia.

  • The practice did not have a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.

  • Staff had not received training on how to care for people with mental health needs and assessing capacity to consent to care and treatment.

People whose circumstances may make them vulnerable

Inadequate

Updated 1 September 2016

The practice is rated as inadequate for being safe, effective and well led. The concerns which led to these ratings apply to everyone using the practice, including this population group.

  • The practice held a register of patients living in circumstances that might make them vulnerable including homeless people, travellers and those with a learning disability. However there was no system in place to alert staff of these patients.
  • We were told that the practice offered longer appointments for patients with a learning disability although there was no system in place to alert staff of these patients when they requested an appointment.
  • The practice worked with other health care professionals in the case management of patients whose circumstances might make them vulnerable.
  • Patients whose circumstances might make them vulnerable were advised about how to access various support groups and voluntary organisations only if they requested this information.
  • Staff knew how to recognise signs of abuse in adults and children. Staff were aware of their responsibilities regarding information sharing,