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Primecare - Dr S & N Ratneswaren Good

Inspection Summary


Overall summary & rating

Good

Updated 30 August 2018

We previously carried out an announced comprehensive inspection at Primecare - Dr S & N Ratneswaren on 14 August 2017.Overall the practice was rated as good.

The full comprehensive report on the 14 August 2017 inspection can be found by selecting the ‘all reports’ link for Primecare - Dr S & N Ratneswaren on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 25 July 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 14 August 2017.

At our previous inspection on 14 August 2017, we rated the practice as requires improvement for providing safe services as care and treatment was not provided in a safe way to patients.

In addition, there were areas identified at the last inspection where the provider should have made improvements:

  • Maintaining up to date and accurate records of staff training and appraisals.

  • Reviewing how staff code immunisations in patient records so accurate data is maintained.

  • Review the provision of appointments to determine if patient needs are being met.

  • Take into consideration the outcomes of the national patient survey.

  • Review how verbal complaints are recorded; and how easy the complaints procedure is to navigate for patients.

This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

At this inspection we found that services were provided to patients in a safe way. The practice is now rated as good for providing safe services.

Our key findings were as follows:

  • The provider had addressed all the issues that led to the breaches of regulations at their last inspection.

  • The practice maintained up to date and accurate records of staff training and appraisals.
  • Staff appropriately coded immunisations in patient records to maintain accurate data.
  • The practice conducted a patient survey to review the provision of the service provided.
  • Improvements were made in response to the outcomes of the national patient survey.
  • The practice reviewed how verbal complaints are recorded.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 30 August 2018

At our previous inspection on 14 August 2017, we rated the practice as requires improvement for providing safe services as the arrangements in respect providing safe services for patients were not adequate.

These arrangements had significantly improved when we undertook a follow up inspection on 25 July 2018. The practice is now rated as good for providing safe services.

Safety systems and processes

  • Staff interviewed demonstrated they understood their responsibilities regarding safeguarding. At the inspection on 14 August 2017 the training record provided by the practice did not state the dates safeguarding training had been carried out for three staff. In addition, it did not give the level of safeguarding children training undertaken by the health care assistant. At this inspection, the training record was updated to show that all staff had undertaken the appropriate safeguarding training relevant to their role and the date the training had been undertaken.
  • Policies were in place covering safeguarding adults and children. They were reviewed annually and accessible to all staff. One of the GPs was the safeguarding lead within the practice.
  • Cleaning schedules and monitoring systems were maintained. At the previous inspection we saw that some of the practice’s cleaning products were stored in unlocked cupboards. At this inspection we were told that cleaning was carried out by external contractors who removed all cleaning products from the premises at the end of each shift.
  • During the last inspection blank prescription forms and pads were not securely stored. At this inspection we saw that the blank prescription forms and pads were stored in a locked cupboard in the reception area. Additionally, we saw evidence that that there was a system in place to monitor the use of prescriptions, and that records of serial numbers were maintained.
  • Vaccines were stored appropriately; the cold chain was being maintained and the temperature of the refrigerator checked and recorded daily.
  • At the last inspection six personnel files were reviewed, not all of the appropriate recruitment checks had been undertaken prior to employment. At this inspection, all personnel files contained, proof of identification, references, qualifications, registration with the appropriate professional body and the appropriate DBS checks (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.)
  • At the last inspection we found that patient information leaflets placed on windowsills were very dusty; and a number of seats on the chairs in the waiting room were torn. At this inspection, the practice demonstrated an appropriate standard of cleanliness. The chairs in the practice we plastic and in good condition.

Risks to patients

  • At this inspection we found that staff were following the fire safety policy and procedure by keeping accurate records. The practice had created a spreadsheet to include the start and end time of fire drill, result and assessment and the names of staff that were present. There was a designated fire marshal within the practice.
  • At the last inspection, we found that not all staff were aware of the need for smart card security, and did not know they should remove their card if they left their computer unattended. During this inspection, we spoke to two staff members, both demonstrated a thorough understanding of how to maintain data security for patients, including the removal of smartcards when leaving their computers.
  • The last inspection revealed that boxes of needles and syringes were being stored in unlocked cupboards in the waiting area of the practice. At this inspection, we saw that the cupboards had been fitted with locks to keep the content secure.
  • All staff received annual basic life support training and there were emergency medicines available in the treatment room.

Track record on safety

  • At the inspection carried out on 14 August 2017 we were informed that the oxygen cylinder within the practice was checked daily to ensure that it contained the appropriate amount of oxygen. However, the checks were not being recorded. At this inspection, we reviewed the practice’s oxygen log book and saw evidence that daily checks had been carried out.
  • The staff we spoke to were aware of the location of the first aid kit and accident book.

Lessons learned and improvements made

  • A small number of CQC comment cards reviewed at the last inspection commented on the difficulty patients experienced in obtaining an appointment. At this inspection, we were informed that 50% of appointments were bookable on the day, routine appointments could be booked four weeks ahead. Patients could also be booked into one of the local hub practices.
  • During December 2017, two meetings were held at the practice to review the results of the GP patient survey with staff and members of the patient participation group. We reviewed the minutes of both meetings and saw evidence that the discussions shaped the content of the practice’s patient survey carried out on 21 February 2018.
  • At the last inspection we did not see that verbal complaints had been recorded. At this inspection, we saw that the practice had implemented a system for managing verbal complaints. They were recorded in a complaints log book which outlined the time and date the complaint was made and how the complaint was managed. We saw evidence that complaints and significant events were discussed during team meetings.

At the last inspection the practice informed us that they were unable to appropriately code immunisation patients due to the closure of a local practice causing the influx of new patients whose records were unobtainable from the practice that had closed. The records were eventually obtained from the NHS’s document and information sharing service. At this inspection we saw that staff appropriately coded immunisations in patient records.

Effective

Good

Caring

Good

Responsive

Good

Well-led

Good
Checks on specific services

People with long term conditions

Good

Updated 12 September 2017

The practice is rated as good for the care of people with long-term conditions.

  • The practice maintained registers of patients with various long term conditions such as COPD, diabetes, asthma, heart disease, hypertension, cancer, thyroid disease, rheumatoid arthritis, stroke and peripheral heart disease and Mental Health. Patients on these registers were invited to attend the practice for review.
  • Diabetes outcomes were comparable to local and national averages. For example, the percentage of patients with diabetes, on the register, in whom the last IFCCHbA1c was 64 mmol/mol or less in the preceding 12 months (01/04/2015 to 31/03/2016) was 65% compared to the CCG average of 71% and England average of 78%.
  • The percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) is 140/80 mmHg or less (01/04/2015 to 31/03/2016) was 76% compared to the CCG average of 72% and England average of 78%.
  • For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.
  • Home visits were provided for people who are unable to attend the practice.
  • The practice provided what it termed a ‘one stop shop’ offering patients, for example, diabetic care, foot care monitoring, phlebotomy and blood pressure monitoring.

Families, children and young people

Good

Updated 12 September 2017

The practice is rated as good for the care of families, children and young people.

  • From the sample of documented examples we reviewed we found there were systems to identify and follow up children living in disadvantaged circumstances and who were at risk.
  • Immunisation rates were below average. There are four areas where childhood immunisations are measured; each has a target of 90%. The practice achieved the target in one out of four areas. These measures can be aggregated and scored out of 10, with the practice scoring 8.8 (compared to the national average of 9.1). For example, the percentage of children aged 2 with pneumococcal conjugate booster was 84% compared to 90% national target. The practice felt this was predominantly due to coding errors.
  • Appointments were available outside of school hours and the premises were suitable for children and babies.
  • The practice worked with midwives, health visitors and school nurses to support this population group. For example, in the provision of ante-natal, post-natal and child health surveillance clinics.
  • Patients aged 15 - 24 years were encouraged to have chlamydia testing as appropriate.

Older people

Good

Updated 12 September 2017

The practice is rated as good for the care of older people.

  • Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns.
  • The practice offered proactive, personalised care to meet the needs of the older patients in its population. Patients over 75 had a named GP.
  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs.
  • The practice identified at an early stage older patients who may need palliative care as they were approaching the end of life. It involved older patients in planning and making decisions about their care, including their end of life care.
  • The practice followed up on older patients discharged from hospital and ensured that their care plans were updated to reflect any extra needs.
  • Where older patients had complex needs, the practice shared summary care records with local care services. Quarterly multi-disciplinary meetings were held with, for example, the palliative care team and the district nurses.
  • Older patients were provided with health promotional advice and support to help them to maintain their health and independence for as long as possible. For example they were encouraged to attend for shingle vaccination and pneumococcal vaccinations.
  • Yearly flu vaccinations were provided for housebound patients.
  • The waiting room had various information posters with information on Carer advice services for the older community.

Working age people (including those recently retired and students)

Good

Updated 12 September 2017

The practice is rated as good for the care of working age people (including those recently retired and students).

  • The needs of these populations had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care, for example, extended opening hours.
  • The practice was proactive in offering online services as well as a full range of health promotion and screening that reflected the needs for this age group.
  • The practice provided a service to students at the University of Greenwich campus and provided a catch up programme for students for relevant vaccinations.
  • Telephone consultations were provided during the day for patients that might not be able to access the surgery during normal hours.
  • Online appointments and electronic prescribing were provided.
  • NHS Health Check Plus for patients aged 40 -74 were offered.

People experiencing poor mental health (including people with dementia)

Good

Updated 12 September 2017

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia).

  • 91% of patients diagnosed with dementia who had their care reviewed in a face to face meeting in the last 12 months, which was comparable to the CCG average of 87% and the national average of 84%.
  • The practice specifically considered the physical health needs of patients with poor mental health and dementia. They maintained a register of patients with mental ill health. There were 45 patients on this register, 36 of whom had a documented care plan in 2016-17.
  • The practice had a system for monitoring repeat prescribing for patients receiving medicines for mental health needs.
  • Mental health outcomes were comparable to local and national averages. For example, the percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who had a comprehensive, agreed care plan documented in the record, in the preceding 12 months (01/04/2015 to 31/03/2016) was 93% compared to the CCG average of 82% and England average of 89%.
  • The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses whose alcohol consumption has been recorded in the preceding 12 months (01/04/2015 to 31/03/2016) was 92% compared to the CCG average of 82% and England average of 89%.
  • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those living with dementia.
  • Patients at risk of dementia were identified and offered an assessment.
  • The practice had information available for patients experiencing poor mental health about how they could access various support groups and voluntary organisations, such as the local ‘time to talk’ service.
  • The practice had a system to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.
  • Staff interviewed had a good understanding of how to support patients with mental health needs and dementia. Clinical staff had held a meeting with the primary care plus lead and consultant psychiatrist to gain a better understanding of the Mental Capacity Act.

People whose circumstances may make them vulnerable

Good

Updated 12 September 2017

The practice is rated as good for the care of people whose circumstances may make them vulnerable.

  • The practice held a register of patients living in vulnerable circumstances including homeless people, asylum seekers, refugees and those with a learning disability. There were 14 patients on the learning disability register, 50% of whom had had an annual review to date in the 2017/18 business year.
  • End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.
  • The practice offered longer appointments for patients with a learning disability.
  • The practice regularly worked with other health care professionals in the case management of vulnerable patients. For example, they liaised with the medical foundation for torture victims and provided medical reports for patients suffering from post-traumatic stress disorders.
  • The practice had information available for vulnerable patients about how to access various support groups and voluntary organisations.
  • Staff interviewed knew how to recognise signs of abuse in children, young people and adults whose circumstances may make them vulnerable. They were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.