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Drs. Taylor, Sreelatha and Thachankary Inadequate Also known as Stuart Road Surgery

Inspection Summary


Overall summary & rating

Inadequate

Updated 26 May 2021

We carried out an announced focused inspection at Drs. Taylor, Sreelatha and Thachankary (at the time of inspection operating as Drs. Taylor and Sreelatha) between 23 March and 25 March 2021. Overall, the practice is rated as Inadequate.

We have rated the practice as follows:

Safe - Inadequate

Effective - Inadequate

Caring – Not inspected or rated

Responsive – Not inspected or rated

Well-led - Inadequate

Following our previous inspection on 10 May 2016, the practice was rated Good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Drs. Taylor, Sreelatha and Thachankary on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focused inspection to follow up on concerns which had been raised about the operation of the practice. In light of these concerns we inspected the following key questions:

  • Safe
  • Effective
  • Well-led

The ratings in relation to Caring and Responsive are carried forward from the inspection undertaken in 2016 and remain Good.

How we carried out the inspection

Throughout the pandemic the Care Quality Commission (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 inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews by telephone
  • Completing clinical searches on the practice’s patient records remotely
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting and reviewing evidence from the provider
  • Reviewing information received from third parties
  • A short site visit

Our findings

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

We have rated this practice as Inadequate overall, and inadequate for all population groups

We found that:

  • The provider did not review all patients after they had an unplanned admission to hospital.
  • Searches of patient records showed that the practice had not ensured that all patients who showed a potential diagnosis of a long-term condition had received further care and treatment appropriate to their needs.
  • Several protocols, procedures and policies were found to be out of date. In addition, it proved difficult for staff to find a number of these documents on the practice computer system.
  • There was no risk assessment in place to support decisions made into which emergency medicines the practice held.
  • The provider did not have adequate systems in place for the dissemination of medicine and patient safety alerts.
  • The provider did not ensure that medicines were being effectively managed. For example, blood test results had not been updated on patient records. There was evidence in some patient records of the incorrect coding of authorisations in respect of medicine reviews and repeat prescription requests.
  • The provider did not ensure that the premises was kept clean. The last infection prevention and control (IPC) audit had been undertaken in June 2019.
  • Staff engagement was ineffective; meetings were not being held on a regular basis.
  • The significant event and incident processes were not consistent or effective. Not all events had been recorded and learning from events was not disseminated. In addition, there was limited evidence that learning and actions resulting from complaints had been undertaken.
  • The provider had undertaken limited quality improvement work. The last clinical audit had been undertaken in August 2019 and lacked detail and depth.
  • The provider did not ensure that health and safety, and fire safety were being effectively managed. For example, there was no evidence that either a fire evacuation drill, or a fire safety risk assessment had been recently undertaken.
  • There was a backlog in dealing with incoming correspondence and a significant backlog of new patient records being summarised. At the time of inspection, the incoming correspondence backlog dated to 22 February 2021.
  • We found evidence that some referrals to other services had not been fully completed prior to submission to the relevant body.
  • Patient engagement in the practice was low, and the patient participation group had not met for some time.
  • There was evidence that non-clinical staff had been tasked to undertake duties which required some clinical knowledge. Staff had been trained to undertake these duties, however there was no monitoring in place to give assurance that these duties were being effectively and safely undertaken.
  • Supervision and support for staff was found to be limited. Staff appraisals had not been undertaken for around three years.
  • Some training was found to be out of date or had not been undertaken. For example, the last infection prevention and control (IPC) training we saw recorded was in 2017.
  • Leadership visibility and engagement with practice staff was reported to be limited.
  • Staff reported low morale and high workloads. The practice was undertaking additional recruitment at the time of the inspection.

We found three breaches of regulations. The provider must:

  • Ensure that 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.
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision, and appraisal necessary to enable them to carry out the duties.

The provider should:

  • Maintain records to demonstrate that staff are vaccinated in line with Public Health England Guidance.
  • Re-examine the decision to not develop a Safeguarding Register of vulnerable children and adults.
  • Undertake care reviews of patients who had received a new diagnosis of cancer, and patients who had been subject to an unplanned admission.
  • Develop, embed, and monitor a practice business plan.
  • Undertake a risk assessment to determine the range of emergency medicines to be held within the practice.
  • Develop processes to give assurance that professional staff continue to meet the standards set by their own regulating bodies.

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

Inspection areas

Safe

Inadequate

Effective

Inadequate

Caring

Good

Responsive

Good

Well-led

Inadequate
Checks on specific services

People with long term conditions

Inadequate

Families, children and young people

Inadequate

Older people

Inadequate

Working age people (including those recently retired and students)

Inadequate

People experiencing poor mental health (including people with dementia)

Inadequate

People whose circumstances may make them vulnerable

Inadequate