All inspections: Dr Devanna Manivasagam

We carried out an unannounced comprehensive inspection at Stone Cross Medical Centre on 8 January 2020, due to concerns identified at an inspection of the provider’s practice Clifton Medical Centre and its branch surgery on 19 December 2019. As there were concerns identified at a provider level, highlighting a lack of effective leadership and clinical oversight, a decision was made to inspect each of the providers (Dr Devanna Manivasagam’s) four practices on 8 January 2020. Following the inspection we took urgent enforcement actions against the provider and imposed conditions to their registration.

This GP Focused Inspection Pilot (GPFIP) in September 2020, was undertaken to follow up the conditions imposed on the providers registration with no site visit undertaken therefore was not rated.

This report was created as part of a pilot which looked at new and innovative ways of fulfilling CQC’s regulatory obligations and responding to risk in light of the Covid-19 pandemic. This was conducted with the consent of the provider.The inspection consisted of remote interviews and reviews of clinical records.

We based our judgement of the quality of care at this service on a combination of:

what we found as part of the GP Focused Inspection Pilot
information from our ongoing monitoring of data about services and
information from the provider, patients, the public and other organisations.

We found that:

The practice was unable to demonstrate that there was clear oversight of governance arrangements to ensure risks to patients were considered, managed and mitigated appropriately.
On reviewing a random sample of clinical records, patient consultations had not always been undertaken in line with recommended guidance.
There was limited monitoring of the outcomes of care and treatment. Some clinical audits were available, however they did not demonstrate quality improvement or improved patient outcomes over a period of time.
Medication reviews had not been completed in line with recognised guidance. On reviewing a random sample of patients records, we found some patients had not received the appropriate monitoring before medicines had been prescribed.
The practice had implemented a system of peer review for the clinical team. We found on reviewing a sample of patient records that the system was ineffective as the performance of employed clinical staff could not be demonstrated through their prescribing decisions and reviews of their consultations.
The practice had safeguarding registers in place, however on reviewing the registers we found them to be inaccurate and not maintained appropriately.
The provider had strengthened the leadership team and had recently employed a new manager, GPs and nurse to strengthen the teams.
Staff training had been strengthened and a training matrix had been implemented to ensure all staff were up to date with training relevant to their role.
Staff recruitment processes had been strengthened to ensure appropriate checks were undertaken of new staff.

The areas where the provider must make improvements are:

Ensure that care and treatment is provided in a safe way.
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

Continue taking action to improve the uptake of cervical screening appointments.

This service will remain in a period of extended special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take 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 a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced comprehensive inspection at Dr Devanna Manivasagam (also known as Stone Cross Medical Centre) on 7 August 2017. The overall rating for the service was Good.

We carried out an unannounced comprehensive inspection at Stone Cross Medical Centre on 8 January 2020. We inspected at Stone Cross Medical Centre due to concerns identified at an inspection of Clifton Medical Centre and its branch surgery, Victoria Road Surgery on 19 December 2019. As there were concerns identified at a provider level, highlighting a lack of effective leadership and clinical oversight, a decision was made to inspect each of the providers (Dr Devanna Manivasagam’s) services on 8 January 2020.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected.

• information from our ongoing monitoring of data about services and.

• information from the provider, patients, the public and other organisations.

We have rated this practice as inadequate overall.

We rated the practice as inadequate for providing safe services because:

The practice did not have clear and effective processes for managing risks, issues and performance.
The practice did not have clear systems and processes to keep patients safe and safeguarded from abuse.
There were gaps in systems to assess, monitor and manage risks to patient safety, including recruitment, infection prevention and control and safety checks for the premises.
The practice did not have reliable systems in place for the appropriate and safe use of medicines, included regular monitoring arrangements for patients on high risk medicines and those with long term conditions.
Staff did not always have the information they needed to deliver safe care and treatment.
There was no systematic structured approach with effective clinical oversight of patient information including clinical data.
The practice was unable to demonstrate that it acted on safety alerts and learnt and made improvements when things went wrong.

We rated the practice as inadequate for providing effective services because:

There was no systematic, structured approach to the management of patients care and treatment including patients on high risk medicines and those with long term conditions.
The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles, were up to date with training and received appropriate supervision.
We did not see a systematic, coordinated approach to address any areas requiring ongoing improvements such as cervical screening and diabetes.
There were no examples of clinical audits or quality improvement activity.

We rated the practice as inadequate for providing responsive services because:

There was no systematic, structured approach to the management of patients care and treatment to ensure the practice was responsive to patients’ needs.
People were not always able to access care and treatment in a timely way.
The results of the recent national GP survey showed the practice was below the local and national averages for questions relating to access. The practice had not reviewed the results or undertaken an in house survey to explore these areas further.
The practice had not completed an audit or risk assessment to ensure the premises was accessible for a wide range of potential users.
There was no evidence of a comprehensive system for managing complaints and the complaints procedure was not easily accessible.

We rated the practice as inadequate for providing well led services because:

Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
There was a lack of leadership oversight and the absence of comprehensive systems and processes to monitor the quality and effectiveness of the service and the care provided.
The practice did not have a clear vision, supported by a credible strategy to deliver high quality sustainable care.
There was no formal system in place to assess and monitor the governance arrangements in place.
The practice did not have fully embedded assurance systems and had not proactively identified and managed risks.
The practice did not always act on appropriate and accurate information.
Patient feedback was not analysed or acted on to improve services and culture.
We saw little evidence of systems and processes for learning, continuous improvement and innovation.

We rated the practice as requires improvement for providing caring services because:

Results from the latest national GP patient survey was below the local and national averages for questions related to patients experience of a caring service.
The practice was not proactive in obtaining patient feedback to support service improvement.

The areas where the provider must make improvements are:

Ensure that care and treatment is provided in a safe way.
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

Make clear the arrangements in place to ensure confidentiality at the reception desk.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take 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 a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Devanna Manivasagam also known as Stone Cross Medical Centre on 21 April 2016. The overall rating for the practice was good; however, the practice was rated requires improvement for providing effective services. This was because clinical performance for some patient population groups such as long-term conditions and mental health were below local and national averages. The full comprehensive report on the April 2016 inspection can be found by selecting the ‘all reports’ link for Dr Devanna Manivasagam on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 7 August 2017; this report also covers our findings in relation to areas in effective where additional improvements had been made since our last inspection. Overall, the practice is rated as good.

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

There was an open and transparent approach to safety and a system in place, which supported staff to report and record significant events.
The practice had clearly defined and embedded systems to minimise risks to patient safety. For example, the practice had arrangements for responding to non-medical major incidents. However, the practice did not consider an alternative medicine in the absence of a specific emergency medicine to manage pain and the practice had not carried out a risk assessment to mitigate risks.
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.
Data from the Quality and Outcomes Framework showed patient outcomes were comparable to the local and national average. However, exception reporting for some clinical domains were above average. However, exception reporting (the removal of patients from QOF calculations where, for example, the patients are unable to attend a review meeting or certain medicines cannot be prescribed because of side effects) for some clinical domains were above average. Staff we spoke with were aware of the practices high exception rates and saw that patient reviews were being managed appropriately.
In some areas, the practice carried out various quality improvement activities such as clinical audits, which demonstrated areas where improvements had been achieved. However, the practice were not carrying out audits of their minor surgery service.
Staff were aware of current evidence based guidance and staff had the skills and knowledge to deliver effective care and treatment.

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. Improvements were made to the quality of care as a result of complaints and concerns. However, we saw that staff were not following the practice complaints policy and procedure to its entirety.
Patients comments from completed Care Quality Commission comment cards we received during the inspection showed that 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 areas where the provider should make improvement are:

Ensure that risk is effectively assessed and managed in the absence of specific emergency medicines
Consider alternative methods to understand and improve exception reporting rates and assess the effectiveness of improvements as part of a continuous improvement cycle.
Ensure effective oversight of governance arrangements to ensure practice policies and processes are well embedded.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Devanna Manivasagam practice on 21 April 2016. Overall the practice is rated as good.

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

There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. However, medical emergencies that had been effectively handled had not been recorded.
Risks to patients were assessed and well managed. The practice had defined and embedded systems, processes and practices to keep people safe and safeguarded from abuse.
Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
The practice had a programme of continuous clinical audit to demonstrate and monitor quality improvements.
Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
Information about services and how to complain was available and easy to understand. However the complaint letter did not signpost patients to external agencies if they were not satisfied with the response received from the practice. Improvements were made to the quality of care as a result of complaints and concerns.
Patients 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.
The practice did not have all the recommended emergency drugs and no risk assessment had been completed.
The practice had a business continuity plan in place for major incidents, however the plan did not include emergency contact numbers.
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 areas where the provider should make improvement are:

The provider should ensure all significant events, including medical emergencies are recorded to improve opportunities for learning.
The provider should complete risk assessments to ascertain what emergency drugs are required.
The provider should include emergency contact numbers in the business continuity plan.
The provider should consider providing information on how to escalate complaints that are not satisfactorily resolved.
Review data in relation to long term conditions and mental health to consider ways of improving uptake.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Archived: Dr Devanna Manivasagam Also known as Stone Cross Medical Centre

All Inspections

14 September 2020 to 2 October 2020

During an inspection looking at part of the service

8 January 2020

During a routine inspection

7 August 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)

21 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)