Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Ravindrasena Muthiah also known as Salisbury Surgery on 15 June 2016 and the overall rating for the practice was good. The practice was rated good for providing safe, caring, responsive and well-led services and requires improvement for providing effective services. This was in relation to aspects of quality monitoring and governance as there were some deficiencies in the arrangements for monitoring performance and improving quality. This specifically related to accuracy of clinical coding, QOF performance in some areas and absence of clinical audit to monitor and drive improvements.

We issued a requirement notice to the provider in respect of good governance. In response to the requirement notice issued, the provider sent us an action plan outlining the improvements that would be put in place to address the concerns identified at our previous inspection in order to meet the regulations.

The full comprehensive reports on the 15 June 2016 inspection can be found by selecting the ‘all reports’ link for Dr Ravindrasena Muthiah (Salisbury Surgery) on our website at www.cqc.org.uk.

This inspection, carried out on 20 February 2018, was an announced comprehensive inspection to review in detail the actions taken by the practice since our last inspection on 15 June 2016 to improve the quality of care and to confirm that the provider was now meeting legal requirements.

Overall the practice is rated as good.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) – Good

Our key findings were as follows:

The practice had made improvements since our previous inspection of 15 June 2016 and the concerns that we identified had been addressed.

• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
• There were systems, processes and practices to keep patients safe and to minimise most risks.
• Staff had the skills, knowledge and experience to carry out their roles.
• The practice demonstrated that it used information about its performance to monitor and improve the quality of care. Improvement in QOF performance had been made since the previous inspection. However there were areas that could be further improved.
• The practice carried out clinical audit and there was evidence of completed full cycle audits to show improved patient outcomes.
• The practice promoted good health and prevention and provided patients with advice and guidance.
• Data from the national GP Patient survey showed the practice was comparable with local and national averages for its satisfaction scores on consultations with GPs and for nurses.

• The practice had an effective system for proactively identifying patients who were carers to offer them additional support.

• There was an effective complaints system in place and those received were responded to appropriately to improve the quality of care.
• The practice had completed a review of their policies and procedures to ensure they were up to date and operating as intended.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

However, there were also areas of practice where the provider needs to make improvements.

The provider should:

• Review the arrangements for the documentation of emergency medicines and equipment checks and of all cleaning task schedules.
• Review the arrangements for acceptance of staff DBS checks undertaken by previous employers.
• Consider the installation of an independent fridge temperature thermometer.
• Review the arrangements for the documentation of multidisciplinary team meetings.
• Continue to monitor and further improve Quality and Outcomes Framework (QOF) performance.
• Continue to monitor and improve uptake of childhood immunisations and cervical screening programmes.

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 Salisbury Surgery on 15 June 2016. Overall the practice is rated as good.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.

• Risks to patients were assessed and well managed.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.

• Data showed some patient outcomes were low compared to the national average. Although some audits had been carried out, we saw no evidence that audits were driving improvements to patient outcomes.

• 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 said they found it easy to make an appointment and there was continuity of care, with urgent appointments available the same day.

• There was a clear leadership structure and staff felt supported by the lead GP.

• The practice proactively sought feedback from staff and patients, which it acted on.

• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvements are:

• Review the read-coding procedures to improve the practice performance for QOF and the services provided for patients, with particular focus on long term conditions.

• Review all practice policies and procedures to ensure these are up to date and practice-specific.

• Develop a practice programme of quality improvement including clinical audit and re-audit to drive improvements and monitor quality.

The areas where the provider should make improvements are:

• Provide regular performance reviews or appraisals for all staff.

• The provider should improve the childhood immunisation rates and cervical screening uptake in line with the national averages.

• The provider should ensure an infection control audit is undertaken annually and action is taken to address any improvements identified as a result.

• The provider should improve its identification of patients who are carers and the support offered to them by the practice.

• Consider improving communication with patients who have a hearing impairment.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

On our previous inspection in November 2013 we found that there was no working portable oxygen supply or defibrillator available in the practice which meant that appropriate emergency equipment was not available. We also found that paper records were being stored in a room that was accessible to patients and not actively supervised by staff.

On this inspection we found that a portable oxygen supply was now in place and there was a system in place to ensure that this was in good working order. In addition, the paper records had now been moved to secure filing cabinets within a staff office. However, it was noted that there was still no defibrillator in place (contrary to best practice guidance).

We spoke to people using the service and their family members. They told us that the doctor explained the health conditions people had "very well" and what treatments involved. They said that they were provided with leaflets as appropriate. They said that the doctor "takes an interest" and that they were "treated very well". The service was accessible to people using wheelchairs. Staff reported that most people who did not speak English attended with someone who could translate for them, but that they had access to a translation service if they needed it. If advance notice was given a female chaperone could be arranged for individual consultations.

Before people received care or treatment appropriate medical histories were taken and people were treated at the practice or referred to other services as appropriate. However, whilst the provider had emergency drugs, they did not have a working portable oxygen supply or a defibrillator which meant that appropriate equipment was not available for use in a medical emergency.

People who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and knew how to respond to situations where abuse was suspected.

Staff received appropriate professional development and the provider had a system in place for monitoring the quality of the service provided at the practice.

Clinical records were not always stored securely.