Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Nagala Ramesh on 14 July 2015. Breaches of the legal requirements were found. Following the comprehensive inspection, the practice wrote to us to tell us what they would do to meet the legal requirements in relation to the breaches.

We undertook this focussed inspection on 28 June 2016, to check that the practice had followed their plan and to confirm that they now met the legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Dr Nagala Ramesh on our website at www.cqc.org.uk.

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 Nagala Ramesh on 14 July 2015. Overall the practice is rated as requires improvement.

Specifically, we found the practice to require improvement for providing safe and well led services. The concerns which led to these ratings applied to all population groups. We therefore found that the practice required improvement for providing services for older people, people with long-term conditions, families, children and young people, working age people (including those recently retired and students), as well as people whose circumstances may make them vulnerable and people experiencing poor mental health (including dementia). We found the practice was good for providing effective, caring and responsive services.

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 reported, recorded, and addressed, although analysis of incidents and events was not undertaken to identify any trends or re-occurring issues.
• Data showed that many patient outcomes were above average for the locality and there was evidence that the Quality and Outcomes Framework (QOF) was used by the practice to monitor performance and drive improvement.
• The practice undertook clinical audits to improve outcomes for patients.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
• Information about services and how to complain was available and easy to understand.
• The practice had a number of policies and procedures to govern activity, although there were some that required updating.
• The practice had not always undertaken audits to monitor the quality and safety of the services, including infection control, training, and audits of recruitment checks for the staff employed and working in the practice.
• A risk management process had not been fully developed and implemented to assess and record all risks, including those relating to equipment and the premises.

There were areas of practice where the provider needs to make improvements. Importantly, the provider must:

• Ensure the system used in relation to safety alerts received by the practice clearly identifies how issues are followed-up and the actions taken by staff.
• Ensure the practice has a system that reflects the hygiene code in relation to the prevention, control and spread of infection.
• Ensure that the recruitment procedures for the practice include the required employment checks for all staff, including locum GPs.
• Ensure the governance arrangements for the practice include a system of audits and safety checks to monitor and manage the quality and safety of the services provided, including the management of identified risks.

In addition the provider should:

• Review the arrangements for undertaking staff appraisals.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Our inspection on 31 October 2013 found that patients had not always been protected from the risks associated with the unsafe use and management of medicines. The provider did not have a system in place to ensure prescription pads were kept securely and no records were kept to log how many prescription pads were in use within the practice. Some stocks of medical equipment and medicines had not been stored safely and the fridge used to store medicines had been found unlocked and the key missing. The first aid box had contained out of date clinical equipment and medicines and checks had not been undertaken on a regular basis to monitor expiry dates of vaccines and medicines held at the practice.

We asked the provider to take action to address these concerns and they wrote to us confirming that all required actions had been taken to comply with the regulations regarding the safe management of medicines. A planned follow-up inspection was scheduled to check that the provider had achieved compliance.

At this inspection, we found that the provider was able to demonstrate that they had met the compliance actions set to address the areas of concern identified at our previous inspection.

We found that the service operated an appointment system that allowed people to book on the same day or in advance. People we spoke with said: “If I phone up in the morning, they always fit me in” and “We never have any problems with appointments”.

We read the patient information leaflet and saw posters and leaflets in the waiting areas with advice about many different health conditions. We saw that patient records were completed by the GP at the time people were seen and that these contained detailed information about diagnoses, treatments and advice.

Staff knew how to identify signs of possible abuse and how this should be reported.

The service was clean and tidy and there were some infection control systems in place.

Prescription pads were not being monitored or stored securely and we found that some medicines and dressings had passed their expiry date.

People’s opinions about the service had been sought in regular surveys and we saw evidence that action had been taken to make improvements as a result. Audits had been conducted to identify trends and monitor the service provided.

This practice is rated as Good overall.

The key questions at this inspection are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Dr Nagala Ramesh on 26 November 2018 under Section 60 of the Health and Social Care Act 2008, as part of our regulatory functions. The inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

At this inspection we found:

• There was an effective system for reporting and recording significant events.
• There was an effective system to manage infection prevention and control.
• The practice did not have an adequate range of emergency medicines available. This was rectified by the following day.
• The arrangements for managing medicines in the practice kept patients safe.
• The practice ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff treated patients with compassion, kindness, dignity and respect.
• Patients could access care and treatment from the practice within an acceptable timescale for their needs.
• Patients were satisfied with the ease with which they could contact the practice by phone.
• There were clear responsibilities, roles and systems of accountability to support good governance and management.
• The practice had systems and processes for learning, continuous improvement and innovation.

The areas where the provider Must make improvements are:

• Ensure that care and treatment is provided in a safe way for service users.

The areas where the provider should make improvements are:

• Continue to encourage patients to form a patient participation group.

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

Please refer to the detailed report and the evidence tables for further information.