Dr Sukumaran and Partners

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Sukumaran & Partners on 04 November 2015. Overall the practice is rated as inadequate.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded and monitored, but not appropriately reviewed and addressed.

• Risks to patients were assessed and well managed, with the exception of those relating to information governance and recruitment checks.

• Data showed patient outcomes were mostly comparable to the locality. Although some audits had been carried out, there was no evidence that audits were driving improvement in performance to improve patient outcomes.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• The appointment system met the needs of the patients who were able to book ahead and urgent appointments were usually available on the day they were requested. This system was also adaptable to allow for specific patient needs.

• The practice had a number of policies and procedures to govern activity, but these were not complete and lacked review dates. The practice did not hold regular governance meetings and issues were discussed with staff on an ad hoc basis only.

• The premises were visibly clean and tidy but in a poor state of repair with potential risks to staff and patients. Water was seen to be leaking from the ceiling of a consultation room used by one of the locum GP’s and in the communal walkways leading to treatment rooms, consulting rooms and the nurse’s room. There was considerable damage and staining to walls and ceilings to show this had been a problem for some time. This had been reported to the landlord for repairs but action had not been taken and no related risk assessments had been undertaken. Since the inspection we have been provided with written assurance that action is being taken, by the landlord, to improve the building and reduce risks to patient and staff safety.

Systems were in place to ensure medicines including vaccines were appropriately stored and in date.

• Feedback received from patients and observations throughout our inspection showed that staff were kind, caring and helpful. The practice had systems in place to respond to and act on patient complaints and feedback however these were not consistently applied.

• There were ineffective governance systems in place to monitor the safety and the quality of the services provided.

• The staff worked well together as a team.

The areas where the provider must make improvements are:

• Ensure recruitment arrangements include all necessary employment checks for all staff. Ensure chaperones have DBS checks in place or a risk assessment to detail why these are not required.

• Be able to demonstrate there are robust policies and procedures in place for infection control and that staff have a good understanding of these. Clinical waste must be stored safely and securely. Address safety issues that have arisen from the damage to the building, including leaks from the roof which affect the safety of patients and staff. Since the inspection visit we have been assured that work is underway to resolve this issue. Implement an effective system for dealing with significant events to ensure they are reported and analysed, and areas for improvement identified and learning shared with relevant staff members. Be able to demonstrate that staff have a sound understanding of information governance in order to protect confidential information. Ensure all staff have appropriate policies, procedures and guidance to carry out their role and that they are aware of their content.

• Ensure prescription pads are stored securely.

• Implement an effective leadership structure that monitors the level of service provided by the practice

• Implement a system to monitor and assess the services provided including a programme of clinical and non-clinical audit to identify where the practice might improve.

• The practice must produce a comprehensive business plan

• The practice must have an information governance policy and ensure staff understand and work in line with this policy.

• Have proper clinical governance policy and actions.

In addition the provider should:

• Review the system in place for complaint handling and investigation to ensure formal lessons learned and actions taken are clearly identified to practice staff and to the complainant.

• Hold regular multidisciplinary meetings and document care plans where appropriate.

• Ensure staff are appropriately trained on the computerised patient record system in relation to the Quality and Outcomes Framework.

• Implement a system to receive and act on feedback from patients.

• Implement a system to obtain feedback from staff and to share information and learning between all staff members.

• Ensure that the practice has a vision and strategy that is shared and discussed with staff.

Where a practice is rated as inadequate for one of the five key questions or one of the six population groups it will be re-inspected within six months after the report is published. If, after re-inspection, it has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we will place it into special measures. Being placed into special measures represents a decision by CQC that a practice has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice