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Dr Sumedha Tillu Requires improvement Also known as Hawthorns Medical Centre

Inspection Summary


Overall summary & rating

Requires improvement

Updated 9 January 2018

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Sumedha Tillu on 30 November 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for Dr Sumedha Tillu on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 08 November 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the improvements we had identified in our previous inspection on 30 November 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice continues to be rated as requires improvement.

  • During our previous inspection on 30 November 2016 we found that staff assessed patients’ needs and delivered care in line with current evidence based guidance. Information received with regards to the delivery of effective care prompted us to re look at this key question. Random sampling of patient records demonstrated that patients care needs were being effectively managed.

  • The practice had developed a comprehensive action plan in place to improve all areas of the GP patient survey published in July 2016. The practice was able to demonstrate improvements in most areas of the survey published in July 2017. However, the results were still significantly below both CCG and national averages.

  • During our previous inspection in November 2016 responses to the national patient survey results (July 2016) regarding access were generally lower than both the local and national averages. The practice was now taking part in hub working arrangements to offer seven day access to appointments. The latest survey results showed that the practice had made improvements in almost all aspects. However, the practice achievement still remained below local CCG and national averages.

The areas where the provider should make improvements are:

  • Continue to explore ways to improve patient satisfaction and health screening.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 16 May 2017

The practice is rated as good for providing safe services.

  • There was an effective system in place for reporting and recording significant events. The systems in place, to monitor trends and ensure timely review required formalising.

  • Lessons were shared to make sure action was taken to improve safety in the practice.

  • When things went wrong patients received reasonable support, truthful information, and a written apology. They were told about any actions to improve processes to prevent the same thing happening again.

  • The practice generally 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 effective systems in place for the management of repeat prescriptions.Repeat prescriptions were reviewed and organised monthly, weekly or daily as required. They were then passed to the GP’s for action, and the patient was seen where necessary.

Effective

Good

Updated 9 January 2018

The practice is rated as good for providing responsive services.

At our previous inspection on 30 November 2016 we rated the practice as good for providing effective services. The practice continued to demonstrate an effective service and it continues to be rated as good.

  • Random sampling of patient records showed that patients were being effectively managed with appropriate diagnosis.

  • Records we looked at demonstrated that patients were being prescribed medicines appropriately for their conditions.

  • Cancer screening data showed that the practice achievement was below local CCG and national averages. However, evidence we looked at demonstrated that the practice was proactive and were working to improve this.

Caring

Requires improvement

Updated 9 January 2018

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

At our previous inspection on 30 November 2016, we rated the practice as requires improvement for providing caring services. The national GP patient survey showed that patient’s satisfaction scores for consultations with GPs were lower than that of the local CCG and national averages. The practice was able to demonstrate improvements but the results remained significantly below both CCG and national averages. The practice explained that this was still work in progress and they were continuing to work on making further improvements.

  • We saw that the practice had a comprehensive action plan in place to improve all areas of the GP patient survey. For example, to ensure that patients were given enough time during consultation, GPs were advised to reduce administration time by using the eReferral system rather than paper based system. To use electronic tasks to administration /reception staff rather than using paper slips.

  • The practice had increased the use of electronic prescription system (EPS) more to save time during consultations as GPs were previously printing prescriptions and signing them.

  • Administration staff were sent on e-referral training in September 2017 to ensure they were aware of the process.

  • We saw examples where the practice had added catch-up and administration slots for some GPs to ensure they were not rushing patients if they fell behind.

Responsive

Requires improvement

Updated 9 January 2018

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

At our previous inspection on 30 November 2016, we rated the practice as requires improvement for providing responsive services. The responses to the national patient survey results (July 2016) regarding access were generally lower than both the local and national averages. The July 2017 survey results demonstrated improvements but still remained below local CCG and national averages.

  • The practice developed a plan to improve the responsiveness of the service. For example, the practice now offered access to appointments from 8am to 8pm Mondays to Fridays through hub working arrangements. Saturday and Sunday opening was also available.

Well-led

Good

Updated 16 May 2017

The practice is rated as good for being well-led.

  • The practice principal GP stated they had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to it.

  • There was a clear leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity and held regular governance meetings. All senior staff had clearly defined key areas of responsibility.

  • There was an overarching governance framework which supported the delivery of the strategy and good quality care. This was largely informal; however it included arrangements to monitor and improve quality and identify risk.

  • The provider was aware of and complied with the requirements of the duty of candour. The partners encouraged a culture of openness and honesty.

    The practice had systems in place for notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken.

  • The practice proactively sought feedback from staff and patients, which it acted on. The patient participation group met regularly to discuss ways in which the needs of the local population might be better met including widening representation on the group.

  • There was a strong focus on continuous learning and improvement at all levels.

Checks on specific services

Older people

Requires improvement

Updated 9 January 2018

The provider was rated as requires improvement for caring and responsive services. The issues identified as requiring improvement overall affected all patients including this population group.

People with long term conditions

Requires improvement

Updated 9 January 2018

The provider was rated as requires improvement for caring and responsive services. The issues identified as requiring improvement overall affected all patients including this population group.

Families, children and young people

Requires improvement

Updated 9 January 2018

The provider was rated as requires improvement for caring and responsive services. The issues identified as requiring improvement overall affected all patients including this population group.

Working age people (including those recently retired and students)

Requires improvement

Updated 9 January 2018

The provider was rated as requires improvement for caring and responsive services. The issues identified as requiring improvement overall affected all patients including this population group.

People whose circumstances may make them vulnerable

Requires improvement

Updated 9 January 2018

The provider was rated as requires improvement for caring and responsive services. The issues identified as requiring improvement overall affected all patients including this population group.

People experiencing poor mental health (including people with dementia)

Requires improvement

Updated 9 January 2018

The provider was rated as requires improvement for caring and responsive services. The issues identified as requiring improvement overall affected all patients including this population group.