Dr Mannath Ramachandran’s practice have previously been inspected in December 2014, November 2015 and August 2016. They were rated as requires improvement during their first two inspections (the safe domain being rated as inadequate during their first inspection and then requires improvement on their second inspection) and were rated as good overall at their last inspection in 2016.

We carried out an unannounced focused inspection at Dr Mannath Ramachandran on 24 April 2018. We carried out a focused inspection in response to concerns received as part of our inspection programme under Section 60 of the Health and Social Care Act 2008. The inspection focused on particular aspects within the safe, effective, responsive and well-led domains.

Ratings were not given at this inspection therefore the key questions are:

Are services safe? – Not rated

Are services effective? – Not rated

Are services responsive? – Not rated

Are services well-led? – Not rated

At this inspection we found:

• The practice had reviewed and monitored their patients with diabetes, we were satisfied all relevant patients were receiving appropriate care.
• The practice had ineffective systems to monitor and assess emergency medicines.
• Policies and procedures were not regularly reviewed and updated.
• We found vaccinations had been ordered, stored and checked in accordance to national guidelines however legal authorisation for staff to administer vaccines had not been completed by all staff.
• We found inconsistencies in the management of the cold chain procedure. Staff who had responsibility for checking fridge temperatures did not fully understand the process. The practice had a cold chain policy however it had not been followed by the practice and did not outline important information.
• There had been no infection prevention control policy or audit completed since 2015. The practice did not have a designated lead to ensure these duties were carried out.
• Complaints and significant events had been documented and investigated appropriately but were not being shared with staff.
• Locum staff that were employed by the practice were not given adequate supervision or support.
• There was a lack of clinical oversight and support leading to increased areas of risk and ineffective procedures.

The areas where the provider must make improvements are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure care and treatment is provided in a safe way to patients.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 18 November 2015.

The practice was rated as requires improvement for providing safe and effective services and requires improvement overall. We issued the provider with a requirement notice for improvement.

After the comprehensive inspection, the practice wrote to us outlining what they would do to meet legal requirements in relation to: the monitoring and responding to national patient safety alert and medicines alerts; monitoring of patients prescribed medicines that require regular review. We had also identified a need for improvement with the proactive identification of children who might be at risk and with the clinical performance with regards to patients with a long term condition.

We undertook this focused inspection to ensure that the practice had made the necessary improvements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Dr Mannath Ramachandran on our website at www.cqc.org.uk

We carried out a desk based review of Dr Mannath Ramachandran on 10 August 2016. This means we asked the practice to provide us with evidence that they were meeting the legal requirements, but we did not visit the premises. Overall the practice is rated as good.

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

• There was a system in place to monitor and review patients prescribed high risk medicines.
• There was a system in place to review and action any patient safety or medicines alerts received by the practice.
• There was a system to identify and support children who may be at risk.
• The practice had improved their performance in relation to the management and monitoring of patients with a long term condition.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Mannath Ramachandran on 18 November 2015. Overall the practice is rated as requires improvement.

We found that many improvements had been made since the previous inspection in December 2014. At that time the practice had been rated as requires improvement overall with a rating of inadequate for safe, requires improvement for effective, responsive and well-led and good for caring.

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

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. They were analysed and areas for improvement identified and learning cascaded at team meetings where minutes were recorded.

• The practice had an effective recruitment process and staff were suitably qualified and experienced. All staff had received disclosure and barring service checks. Staff carrying out chaperone duties had received formal training.

• The monitoring of medicines for use in a medical emergency was effective and all items stored were of the recommended type and in date. Medicines and equipment were readily accessible.

• Medicines and vaccinations stored in fridges were all in date and kept at the required temperature with records being kept.

• The practice monitored patient and staff safety and a health and safety, legionella and infection control audits were in place. Risks to patients and staff were regularly reviewed.

• Staff had been trained in basic life support and knew the location of the emergency medicines. They were aware of how to use the defibrillator and oxygen.

• All staff had received training in safeguarding and whistle blowing and were supported with written protocols and policies.

• Staff were aware of relevant legislation in relation to consent including the Mental Capacity Act 2005 and Gillick competence.

• Clinical performance was monitored regularly and performance against targets was improving. The practice was aware of improvement areas and had plans in place to achieve objectives. All staff understood their roles and worked towards achieving the targets and objectives that had been set.
• Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
• The practice was aware of the needs of their patient population group and tailored their services accordingly. Information about how to complain was available and easy to understand.
• Data available to us and feedback on CQC comment cards reflected that patients were general satisfied with the services provided.
• The practice had a clear vision and had identified the objectives of the practice. This was monitored, regularly reviewed and discussed with staff.
• Regular team meetings took place which were recorded. Learning was cascaded to all staff. There was an audit trail that reflected where improvements had been implemented.

However there were areas of practice where the provider must make improvements:

• Ensure that the systems in place for responding to and monitoring of national patient safety and medicines alerts is effective to ensure that patients affected by the alerts have their medicines reviewed and changes made if necessary.

• Ensure there are systems in place to monitor patients on high risk medicines through regular reviews of their medicines in line with published guidance.

There were also areas of practice where the provider should make improvements:

• Monitor a variety of sources to identify where children might be at risk of safeguarding concerns.

• Implement a system to ensure that patients requiring repeat prescriptions for blood thinning medicines are receiving appropriate monitoring of their blood levels.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

On 11 December 2014 we carried out an announced inspection of the surgery known as Dr Mannath Ramachandran, at Medic House, Ottawa Road, Tilbury, Essex under our new approach of inspection of primary medical services. The practice also has a branch surgery situated at the Appledore Centre, East Tilbury, Essex but we did not visit this as part of our inspection.

Specifically, we found the practice to be inadequate for providing safe services and required improvement for effective, responsive and well-led. It also required improvement for providing services for all of the population groups we looked at. It was good for providing a caring service.

Where, as in this instance, a provider is rated as inadequate for one or more of the five key questions or one or more of the six population groups it will be inspected no longer than six months after the initial rating is confirmed. If, after re-inspection, it has failed to make sufficient improvement, and is still rated as inadequate for a key question or population group, we will place it into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

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

• Practice staff were kind, caring and dedicated to providing high quality care and treatment.
• Patient’s privacy and dignity was maintained.
• The system in place to manage medical emergencies in relation to medicines, equipment and training put patients at risk of unsafe care and treatment.
• Staff were unsure of whistleblowing and safeguarding procedures.
• Staff acting as chaperones had not received formal training and were unsure of the correct procedures to follow.
• Emergency medicines were not readily available and some were out of date. There was no oxygen available in the event of an emergency.
• Learning from incidents and complaints was not routinely cascaded to staff.
• Effective consultations took place in line with published guidance.
• An effective recruitment policy and procedure was not in place or being followed.
• Governance arrangements were not robust and the services provided were not regularly monitored and assessed.
• Performance against key health objectives was being monitored and targets achieved.
• There was an ineffective leadership structure and the role of the practice manager was unclear.

There were areas of practice where the provider needs to make improvements.

Importantly, the provider must:

• Ensure there are accessible and sufficient quantities of emergency medicines and equipment, in line with published guidance, at the main and branch surgery. Ensure that appropriate levels of staff are trained in its use. This includes a robust system for monitoring stocks and expiry dates of such medicines and equipment.

• Regularly assess and monitor the services provided and maintain records by undertaking clinical and non-clinical audits of the services they provide. This includes an infection control and health and safety audit.

• Identify, manage and assess risks to patients and others by carrying out a health and safety and legionella risk assessment.

• Review governance procedures to ensure oversight of clinical and non-clinical matters.

In addition the provider should;

• Include in their recruitment policy the job specific roles that require a Disclosure and Barring Service check and to risk assess those where a decision is made not to undertake one.

• Seek the views of patients about the services provided.

• Ensure that learning from safety incidents are cascaded to staff.

• Ensure that a system is in place to ensure that staff can display sufficient knowledge in relation to safeguarding, whistle blowing and Gillick competence (in relation to consent from children under the age of 16).

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice