Drs Thachankary and Krishnan Also known as Stuart Road Surgery

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm. At our last inspection on 13 and 14 June 2023, we rated this key question as requires improvement. At this assessment, the rating remains the same, we identified that the practice still needed further improvement regarding medicines management reviewing and supporting patients with long-term conditions and embed improvements. The practice was in breach of legal regulation in relation to safe care and treatment and fit and proper persons employed. We have asked the provider for an action plan in response to the concerns found at this assessment.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice had policies and systems in place to manage significant events, incidents and complaints. Staff told us that incidents and complaints were appropriately investigated, with outcomes and learning circulated to relevant teams. The practice shared their ideas for improving the complaints process and had appointed a new staff member to lead in this area. Staff knew how to escalate their concerns and could confidently signpost patients on how to raise any concerns or queries appropriately. However, not all staff felt that feedback from significant events or learning was shared with them. We saw examples of audits, some of which were two-cycle and could evidence where changes or improvements were made. The practice did not have oversight of what audits were being completed or required throughout the practice, such as independent prescribing or consultations. Following the assessment, the provider told us that they had updated their assurance framework and were undertaking audits of non-medical prescribers (NMP) regularly. The practice advised they would improve communication to ensure there was oversight of audit management.

There was a policy and systems in place to manage referrals, including the urgent two week wait referrals. The practice had oversight of referrals and checked daily for any referrals that were rejected and could also access a list of patients awaiting appointments. The practice told us that they would receive letters for patients who did not attend these appointments, and the referring clinician would be notified, so that they could take the necessary actions. As part of our assessment a Care Quality Commission GP Specialist Advisor (GP SpA) undertook some remote clinical searches of patient records on the practice’s clinical system on 1 May 2025. We found 1,277 open tasks on the clinical system, some of which dated back to February 2025. We reviewed a sample of these and saw that many were for information purposes only and used as a prompt for staff to ensure follow up action was taken. The practice advised how they utilised the task function within their clinical system to ensure that any outstanding tasks could be seen by everyone, until actioned. There was a policy and systems in place for pathology/blood test management and how results were managed. During the assessment we found that there was no system in place to ensure that the practice received a result for all cervical screening samples sent to the laboratory by the locum staff nurses covering for the substantive staff nurse. The substantive nurse did have a system in place. The practice advised that they would implement a monthly report to to identify all patients that have had a cervical smear, but no result recorded.

The practice had a safeguarding lead and deputy for both adults and children, and a safeguarding handbook covering both adults and children. We saw confirmation that staff had received training in safeguarding adults and children. Staff knew who the lead was, how to access the handbook and felt able to escalate concerns. The practice held regular safeguarding children meetings but no formal information sharing for safeguarding adults. There was a policy for chaperoning and staff had undertaken training as required. There were posters prominently displayed in patient areas at the practice.

The practice had guidance that outlined resuscitation guidelines and had systems in place to ensure that the automated external defibrillator (AED) battery was checked daily. We saw monthly checks of the crash trolley, emergency drug cupboard and doctor boxes (for home visits). Staff had records of training for basic life support and sepsis awareness. Staff were aware of how to raise an alarm in the event of an emergency and could use the panic alarm system that was integrated into their clinical system. Staff were aware of the location of the emergency medicines and medical equipment, for example oxygen and the AED.

At our onsite assessment we observed the premises to be clean, accessible and appropriate for the activities being carried out. The practice had facilities documentation for fire maintenance records and the practice had completed a fire risk assessment internally. Fire safety was part of the mandatory training schedule, and the practice had fire marshals with the intention of ensuring that there was always a fire marshal onsite. We saw evidence of fire alarm testing and fire evacuation drills; the evacuation drills highlighted that staff had not been signing in and out. Some staff shared that they did not always know when clinicians were on home visits and there needed to be clearer guidance to keep everyone safe. During the assessment we looked over the sign-in-and-out sheet and could see this risk had continued. The sign-in-and-out sheet also needed updating to reflect current staffing, which the practice rectified immediately. There was evidence of portable appliance testing (PAT), calibration of medical equipment, a Gas Safety Certificate and an Electrical Fixed Installation Condition Report (EICR). The practice had an external risk assessment completed for Legionella, and an external risk assessment completed for Health and Safety. The external risk assessment for Legionella was undertaken in 2019 and the practice had completed the recommended actions. They had a person responsible who had completed Legionella training, and we saw logs for tap flushing on a weekly basis. The tap flushing logs highlighted that the hot water temperatures were frequently recorded below the required temperature and the practice had not actioned this. The practice agreed to action this and investigate the cause of the low temperatures. We saw that the practice had completed their own control of substances hazardous to health (COSHH) risk assessments in 2019 and the documentation we reviewed did not reflect the practice policy which advised that items were audited annually. In addition, they did not have risk assessments for all potential hazards within the practice, for example liquid-based cytology pots and spill kits had not been included. The practice advised that they would undertake a review of and update their risk assessments.

The practice had both an employment handbook and workforce handbook in place, and during the assessment we found that these required updating to reflect current guidance within the practice. We reviewed 1 clinical and 2 non-clinical recruitment files of staff that had been employed since the previous inspection. Within these files there were gaps in signed contracts and immunisations. For two members of staff the practice had not obtained references prior to the start date.The practice agreed to review their recruitment procedures to ensure all documentation is in place prior to staff commencement. The practice had policies and procedures for induction and appraisal including an induction checklist. During the assessment we reviewed some appraisal records and found that there were still ongoing areas of concern with the depth of supervision and support, particularly for non-medical prescribers. Some staff shared that they felt as though appraisals were rushed, inconsistent and lacked acknowledgement of positive work. We reviewed 3 clinical and 2 non-clinical recruitment files of staff alongside the training matrix and found that there were gaps in both mandatory training and role-specific activities. We also reviewed 2 clinical locum recruitment files and found that the practice did not always obtain evidence of competencies and training for role-specific activities. The practice was not utilising external occupational health services and providing these services internally, including workplace desk assessments, identifying which immunisations were appropriate and providing these immunisations internally. The practice did not provide the staff undertaking the occupational health role with any additional training and there had been risks raised regarding staff confidentiality. Some staff shared that they were not aware that external occupational health services, including health and wellbeing support, were available. Despite the practice not utilising occupational health services, we observed posters for both occupational health and wellbeing support onsite. Following the assessment the practice told us that wellbeing support was discussed in one-to-one meetings. Staff told us that staffing levels had impacted access to appointments, the practice had recruited 2 salaried GP’s and felt as though they were in a stronger position for staffing than in previous years.

The practice had a designated infection, prevention and control lead; however, the lead had not received any additional training to undertake this role. All other staff had relevant training. We saw an infection prevention and control audit with some required actions that had no dates and had been raised during previous inspections.The service did not always assess or manage the risk of infection. The practice did not request the required immunisations as outlined within the Immunisation of Healthcare and Laboratory Staff: The Green Book, Chapter 12. There were gaps for both existing staff and staff that had been employed since the previous inspection, and no risk assessments had been completed. The practice advised they would refer staff to an external occupational health service to identify and rectify gaps for the required immunisations.

The practice had policies and systems in place to check the stock levels of equipment and medicines, they also checked the expiry dates for medicines, including the emergency medicines, the doctor home visit boxes and vaccines. During the assessment, we looked at some Patient Group Directions (PGD) that there was 1 Patient Group Direction (PGD) that was missing a locum signature. All other documents had been completed as necessary. We reviewed Patient Specific Directions (PSDs), both the previous paper copies and the more recent electronic copies.The practice had effective systems to manage and respond to safety alerts and medicine recalls, they involved patients in the reviews of their medicines and helped them to manage medicines safely. As part of our assessment, a Care Quality Commission GP specialist advisor (SpA) conducted a series of remote clinical searches of patient records and found some concerns with the practice’s procedures. The practice responded to these concerns and acted to ensure patients prescribed medicines with specific risks, received recommended monitoring.