The Care Quality Commission
  • Doctor
  • GP practice

Dr Parmod Luthra Also known as Spring Grove Medical Practice

Overall: Good read more about inspection ratings

Thornbury Road Centre for Health, Thornbury Road, Isleworth, Middlesex, TW7 4HQ (020) 8630 1058

Provided and run by:
Dr Parmod Luthra

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 Parmod Luthra 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 Parmod Luthra, you can give feedback on this service.

29 April 2021

During an inspection looking at part of the service

We carried out a review of Dr Parmod Luthra (Spring Grove Medical Practice) on 29 April 2021. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection on 5 February 2020 the practice was rated Good overall and for the key questions effective, caring, responsive and well-led. The practice was rated requires improvement for providing safe services and issued a requirement notice for Regulation 17 Good governance.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Parmod Luthra (Spring Grove Medical Practice) on our website at www.cqc.org.uk.

Why we carried out this review

This was a focused review of information without undertaking a site visit inspection to follow up on breaches of Regulation 17 Good governance. At the last inspection we found;

  • Staff had not always had the appropriate authorisations such as Patient Specific Directions (PSDs) to administer flu injections.

We also followed up on ‘should’ actions identified at the last inspection. Specifically;

  • Review the system in place to ensure uncollected prescriptions are monitored effectively.
  • Improve the record keeping system to ensure a premises risk assessment is readily available.
  • Take appropriate actions to provide sepsis awareness training.
  • Continue to encourage and monitor the cervical and bowel cancer screening and childhood immunisation uptake.

How we carried out the review

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our reviews differently.

This review was carried out without visiting the location by requesting documentary evidence from the provider.

Our findings

We have rated this practice as Good overall and Good for providing safe services because:

We found that:

  • The practice had made the necessary improvements to the delivery of care to ensure patients were kept safe.
  • The practice informed us they had reviewed their protocol and only the practice nurse and the doctor had administered flu injections since the previous Care Quality Commission (CQC) visit in February 2020.
  • The practice informed us that the Healthcare Assistant (HCA) had not administered any vaccine since the previous CQC visit. However, they had provided a signed document by the HCA confirming they understood that they were only allowed to administer vaccines when they had the appropriate authorisations such as Patient Specific Directions (PSDs) in place.

In addition;

  • The practice had shared an uncollected repeat prescriptions policy which was reviewed on 20 December 2020. The practice had implemented monthly uncollected repeat prescriptions checks. We saw the records maintained by the practice and the last check was carried out on 30 March 2021.
  • The practice had provided the documented premises risk assessment carried out in August 2020 and informed us that it was accessible to all staff members.
  • We found that all staff members had received Sepsis Awareness training.
  • The practice had provided us with the recent unverified data from the electronic clinical system which demonstrated improvements and childhood immunisations rates of children aged 2 had increased to 90% (for quarter 1 October 2020).
  • The practice had provided current unverified data for cervical screening which was not comparable with the Public Health England published data (dated 30/09/2020). However, following national guidelines we have taken into account that cervical cancer screenings had been adversely affected during the Covid19 pandemic. We were also provided with evidence that the practice had plans in place to improve the call / recall system for eligible patients. The practice was offering additional clinics on weekends and weekday evenings for cervical cytology and immunisations.

Whilst we found no breaches of regulations, the provider should:

  • Improve cervical screening uptake to bring in line with the England average.

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

5 February 2020

During a routine inspection

We carried out an announced comprehensive inspection at Dr Parmod Luthra (also known locally as Spring Grove Medical Practice) on 5 February 2020 as part of our inspection programme.

At the last inspection in January 2019, we rated the practice as good overall and specifically requires improvement for providing safe services because:

  • Risks to patients were assessed and well managed in most areas, with the exception of those relating to the management of the spread of infections and the monitoring of fridge temperatures.

Previous reports on this practice can be found on our website at: www.cqc.org.uk/location/1-525624918.

We decided to undertake a comprehensive inspection of this practice following our annual regulatory review of the information available to us. At this inspection, we found that the practice had demonstrated improvements, however, we found additional risks and they were required to make further improvements and is rated as requires improvement for providing safe services.

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 good overall and good for all population groups, with the exception of working age people (including those recently retired and students) , which is rated as requires improvement.

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

  • Risks to patients were assessed and well managed in most areas, with the exception of those relating to the appropriate authorisations such as Patient Specific Directions (PSDs) to administer flu injections.
  • Staff understood and fulfilled their responsibilities to raise concerns, and report incidents and near misses. When incidents did happen, the practice learned from them and improved their processes.

We rated the practice as good for providing effective, caring, responsive and well-led services because:

  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The practice was encouraging patients to register for online services and 51% of patients were registered to use online Patient Access.
  • The practice was aware of and complied with the requirements of the Duty of Candour.
  • There was a clear leadership structure and staff felt supported by management.

We rated all population groups as good for providing responsive services. We rated all population groups as good for providing effective services, with the exception of working age people (including those recently retired and students), which is rated as requires improvement, because of low cervical screening.

The areas where the provider must make improvements as they are in breach of regulations are:

  • 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:

  • Review the system in place to ensure uncollected prescriptions are monitored effectively.
  • Continue to encourage and monitor the cervical and bowel cancer screening and childhood immunisation uptake.
  • Improve the record keeping system to ensure a premises risk assessment is readily available.
  • Take appropriate actions to provide sepsis awareness training.

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

3 January 2019

During a routine inspection

We carried out an announced comprehensive inspection at Dr Parmod Luthra (also known locally as Spring Grove Medical Practice) on 03 January 2019 as part of our inspection programme.

At the last inspection in December 2017 we rated the practice as requires improvement overall and specifically requires improvement for providing safe, effective and well-led services because:

  • The practice had failed to act on patient correspondence and pathology results in a timely manner.
  • We found concerns regarding the management of blank prescription forms, infection control, fire drills and effective monitoring of people experiencing poor mental health (including people with dementia).
  • There was a lack of good governance in some areas.

Previous reports on this practice can be found on our website at: https://www.cqc.org.uk/location/1-525624918

At this inspection, we found that the provider had demonstrated improvements in most areas, however, they were required to make further improvements in some areas and are rated as requires improvement for providing safe services.

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 good overall and good for all population groups, except requires improvement for Working age people (including those recently retired and students) for providing effective services, because of low cervical screening.

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

  • Risks to patients were assessed and well managed in most areas, with the exception of those relating to the management of the spread of infections to the patients and staff were not adequate.
  • Other risks to patients were assessed and well managed.
  • Staff understood and fulfilled their responsibilities to raise concerns, and report incidents and near misses. When incidents did happen, the practice learned from them and improved their processes.

We rated the practice as good for providing effective, caring, responsive and well led services because:

  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The practice was encouraging patients to register for online services and 40% of patients were registered to use online Patient Access.
  • The practice was aware of and complied with the requirements of the Duty of Candour.
  • There was a clear leadership structure and staff felt supported by management.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvements are:

  • Consider ways to improve the identification of carers to enable this group of patients to access the care and support they need.
  • Review ways to improve uptake of childhood immunisation, cervical and bowel cancer national screening.
  • Improve the system in place to assure that the appropriate recruitment checks are always carried out in accordance with regulations.
  • Take appropriate actions to reduce identified risks while waiting for concerns to be resolved.

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

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

14 December 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

This practice is rated as requires improvement overall.

(Previous inspection June 2015 - The practice was rated as good overall but effective domain was rated as requires improvement).

The key questions are rated as:

Are services safe? - Requires improvement

Are services effective? - Requires improvement

Are services caring? - Good

Are services responsive? - Good

Are services well-led? - Requires improvement

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People - Requires improvement

People with long-term conditions - Requires improvement

Families, children and young people - Requires improvement

Working age people (including those retired and students - Requires improvement

People whose circumstances may make them vulnerable - Requires improvement

People experiencing poor mental health (including people with dementia) - Requires improvement

We carried out an announced comprehensive inspection at Dr Parmod Luthra (also known locally as Spring Grove Medical Practice) on 14 December 2017. We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether Dr Parmod Luthra was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

At this inspection we found:

  • There were inconsistent arrangements in how risks were assessed and managed.
  • The practice did not always act on patient correspondence and pathology results in a timely manner.
  • Data showed patient outcomes were low for patients experiencing poor mental health, and the cervical and bowel cancer national screening programme uptakes.
  • The practice had a number of policies and procedures to govern activity, but it was not clear when they were written or when they had been reviewed.
  • We found that completed clinical audits were driving positive outcomes for patients.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Staff had received up to date training relevant to their role. Staff appraisals had been completed in a timely manner.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it. However, some patients raised concerns regarding the long waiting time in the waiting area and dissatisfaction about the service provided by some reception 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.
  • The practice proactively sought feedback from staff and patients, which it acted on.
  • 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, in their response the practice had not always included information of the complainant’s right to escalate the complaint to the Ombudsman if dissatisfied with the response.
  • There was a clear leadership structure and staff felt supported by management. However, some governance arrangements within the practice were not operated effectively.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.
  • 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:

  • Review the system in place to promote the benefits of cervical and bowel cancer national screening in order to increase patient uptake.
  • Review and take action to improve patient satisfaction with waiting times and reception staff.
  • Ensure a consistent approach to recording significant events.
  • Review and implement the system to invite patients aged over 75 for a formal routine health check to ensure continuity of care.
  • Review the process of identifying carers to enable them to access the support available via the practice and external agencies.
  • Ensure a response to complaints includes information of the complainant’s right to escalate the complaint to the Ombudsman if dissatisfied with the response.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

2 June 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Spring Grove Medical Practice on 2 June 2015. Overall the practice is rated as good.

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

Our key findings were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and accidents.
  • Patients said they were treated with compassion, dignity and respect. Information was provided to help patients understand the care available to them.
  • The practice worked with other organisations and with the local community in planning how services were provided to ensure that they met people’s needs.
  • The practice implemented suggestions for improvement and made changes to the way it delivered services as a consequence of feedback from patients.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Information about how to complain was available and easy to understand.

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

The provider should:

  • Ensure all clinical staff have a clear understanding of Gillick competencies.
  • Formalise the practice vision and share with staff, and develop a strategy to deliver it.
  • Develop a comprehensive business continuity plan to ensure continuity of care in the event of a major disruption to the service.
  • Develop action plans to improve the practice’s performance in the management of diabetes and childhood immunisations.
  • Review cervical screening programme to identify and address barriers to uptake amongst the local community.
  • Provide access to an automated external defibrillator (used to attempt to restart a person’s heart in cardiac emergencies) as recommended by the UK resuscitation council guidelines or carry out a risk assessment.
  • Establish a patient participation group (PPG) to engage with patients and involve them in the running of the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

3 January 2014

During a routine inspection

During our visit to the practice we provided people with comment cards to tell us about their experience of the service, and we received five of these completed by people. People told us they received a good service, that staff were helpful and they were treated with respect. Some comments received were 'excellent in all respects', 'staff are caring and everyone is polite'. We looked at the feedback forms that the practice asked people to complete, as well as the log of complaints received. We also looked at feedback people had put onto the NHS Choices website. This information helped us to gain an overview of people's experiences of the service.

We spoke with the lead GP and one other GP, a GP registrar, the practice manager, the healthcare assistant and administrative staff. We also spoke with a pharmacist from the Clinical Commissioning Group who carried out work at the service each week.

The staff demonstrated a clear understanding of safeguarding issues and the steps they needed to take when they suspected a child or adult might be at risk of abuse.

The staff received training and support for their work with people and enhancing their professional development.