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Archived: Dr Tirunelveli Ashok Kumar Good

Reports


Inspection carried out on 24 May 2016

During a routine inspection

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

Inspection carried out on 29 July 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Tirunvelveli Ashok Kumar, also known as Highwoods Surgery, on 29 July 2015. Overall the practice is rated as requires improvement.

Specifically, we found the practice to be inadequate for safe and requires improvement for providing effective, responsive and well led services. It also required improvement for providing services for older people with long-term conditions, families, children and young people, working age people (including those recently retired and students), people living in vulnerable circumstances, and people experiencing poor mental health (including people with dementia). It was good for providing a caring service.

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

  • Not all staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about significant incidents was not consistently recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and managed, with the exception of those relating to the management of medicines.
  • Data showed patient outcomes were average for the locality. Although some audits had been carried out, there was no evidence that audits were driving improvement in performance to improve patient outcomes.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Urgent appointments were usually available on the day they were requested.
  • The practice had a number of policies and procedures to govern activity, but these would benefit from being revised to reflect current practice and ensure staff were familiar with them. The practice held informal governance meetings, they were not recorded and issues were discussed at ad hoc.
  • The practice had no formal system for encouraging or capturing feedback from staff and patients. However, they had reviewed and changed their clinical practices in response to comments from partner agencies.
  • Staff told us they felt supported by the practice and enjoyed their working environment.

The areas where the provider must make improvements are:

  • Ensure the proper and safe management of medicines.
  • Ensure there are sufficient systems or processes to assess monitor and improve the quality and safety of service. This includes, capturing service users experiences, arrangements for reporting and investigating significant events and learning from both significant events and complaints and introduce a programme of clinical audits to monitor quality and systems to identify where action should be taken
  • Establish and operate an effective and accessible system for identifying, receiving, recording, handling and responding to complaints.
  • Ensure personnel files contain all necessary checks to comply with relevant legislation.
  • Ensure staff receive appropriate training, supervision and appraisal.

In addition the provider should:

  • Maintain records of staff discussions, practice, clinical and management meetings

Where, as in this instance, a provider is rated as inadequate for one of the five key questions or one of the six population groups it will be re-inspected no longer than six months after the initial rating is confirmed. If, after re-inspection, it has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we will place it into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice