Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection for Dr Mathibalasingham Chandrakumar (also known as Sun Lane Surgery) on 07 April 2015. Overall the practice is rated as good. Specifically, we found the practice to be good for providing safe, well-led, effective, caring and responsive services. The practice was also good for providing services for older patients’, patients’ with long term conditions, families, children and young patients’, working age, those recently retired and students, patients’ who’s circumstances make them vulnerable and patients experiencing poor mental health.

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, monitored appropriately reviewed and addressed and learning was routinely shared with staff.
• Risks to patients were assessed and well managed.
• Patient outcomes were at or above average for the locality and good practice guidance was referenced and used routinely.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• Patients were able to book routine appointment s with the GP at a time that suited them. Urgent appointments were available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management.
• The practice proactively sought feedback from staff and patients, which it acted on.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Our last inspection in November 2013 identified some concerns that there was no system to effectively manage staff training to ensure their practice remained up to date. Effective systems were not in place to assess and monitor the quality of care.

We carried out this follow up inspection to check that improvements had been made.

We found that since our last inspection in November 2013, there had been changes in staff and the provider had appointed a new practice manager in May 2014 and a new deputy practice manager in August 2014.

We found that the improvements required following our previous inspection had not been fully completed in that training records were still being developed. However, both the practice manager and deputy were working hard to complete the work by December 2014.

We found that staff were supported to deliver care to an appropriate standard through training, development and supervision and that effective systems were in place to assess and monitor the quality of care.

We spoke with nine patients. We spoke with non-clinical staff, including the practice manager, nurses and a GP.

Patients felt that their privacy and confidentiality were respected. They were pleased with the quality of care that they received. “Ten out of ten” and “very well looked after” were comments we received.

People were protected against the risks of infection. The premises were clean. One patient said the practice was, “very fussy about hygiene”.

Staff were not supported to deliver care to an appropriate standard through training, development and supervision.

Effective systems were not in place to assess and monitor the quality of care.

We carried out an announced comprehensive inspection at Dr Mathibalasingham Chandrakumar on 18 March 2019 as part of our inspection programme.

At the last inspection in May 2018 we rated the practice as inadequate. The practice was placed in special measures because:

• The practice did not have clear systems to manage risk so that safety incidents were less likely to happen.

• The practice did not have an effective system to manage infection prevention and control.

• The practice did not have a systematic approach for health and safety audits.

• The practice did not have reliable systems for appropriate and safe handling of medicines.

• Clinical audits did not include measurable outcomes, nor were they effectively used to drive quality improvement.

• Not all leaders were visible in the practice and there was a lack of oversight in areas such as clinical governance, risk assessments recruitment and future planning.

At this inspection, we found that the provider had satisfactorily addressed these areas.

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 and

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

We have rated this practice as good overall. We rated it as good for its treatment of all the population groups, with the exception of people with long term conditions for which it is rated as requires improvement.

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.

• Patients received effective care and treatment that met their needs.

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.

• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

• Improve the identification of carers to enable this group of patients to access the care and support they need.

As a result of the improvements made the practice has been re rated and removed from special measures.

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