We carried out an announced focused inspection at Dr Sivasailam Subramony also known as Medina Medical Centre on 16 January 2019. This inspection was undertaken to follow up on the notice of decision to suspend the provider from carrying out regulated activities for a period of four months from 27 September 2018 to 27 January 2019.

The practice received an overall rating of inadequate at our inspection on 24 August, 4 September and 20 September 2018 and this will remain unchanged until we undertake a further full comprehensive inspection.

The full comprehensive report from the August/September 2018 inspection can be found by selecting the ‘all reports’ link for Dr Sivasailam Subramony on our website at .

Following the inspection, the provider was suspended from delivering regulated activities for a period of four months. During this time a caretaker provider held a temporary contract to deliver the regulated activities from Medina Medical Centre. The responsibility for the management of staff and the improvements required to be made remained with the provider. The provider had access to the premises in the evenings and weekends outside of the hours patients were present in the practice.

At this inspection we found:

• There remained a systematic lack of leadership and governance at the practice.
• The provider did not have a policy in place to ensure they had clinical oversight of the work being done by healthcare professionals in their employment. There was no effective process in place to assess and monitor the quality of the services provided.
• Risks to patients and staff were not being identified and acted on. Risk assessments had not been completed including those for fire safety, legionella, infection prevention and control and disability access.
• The practice had developed some policies and procedures. They did not contain up to date, relevant and practice specific information. There were some essential policies not available.
• Pre-employment checks had not been completed for staff members recruited since the previous inspection.
• Some improvements had been made to the practice in relation to infection, prevention and control. We found the policy in place to manage this did not contain sufficient information.
• There were no documented channels for staff to speak up and no information of external agencies they could approach. The practice had a whistle blowing policy that we reviewed and found it did not contain adequate information and was not specific to Medina Medical Centre.
• Clinical audits identified to be completed by the provider did not demonstrate quality improvement specific to the practice. There was no schedule or audit tool available for the completion of clinical audits.
• Some improvements had been made to the practice that included the installation of a fire alarm system, changes to the flooring, identification of a disabled parking bay and installation of a hearing loop. However, in the absence of risk assessments we were not assured that sufficient actions had been taken.

The areas where the provider must make improvements as they are in breach of regulations are:

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

As a result of insufficient improvements made to the breaches of the regulations and the risk this posed to patients, the Care Quality Commission decided to extend the suspension of the provider’s registration to carry out the regulated activities of diagnostic and screening procedures, maternity and midwifery services, surgical procedures, treatment of disease disorder or injury, under section 31 of the Health and Social Act 2008. This is because we believe that a person will or may be exposed to the risk of harm if we do not take this action.

Section 31 of The Health and Social Care Act 2008 allows the Commission to decide under section 18 to suspend the registration or extend a period of suspension. A Notice of Decision was served on the provider on Thursday 27 September 2018 and the providers registration was suspended from 2pm the same day. A further Notice of Decision was served on the provider on 22 January 2019 to extend the suspension.

The provider, who is a single-handed provider, is therefore unable to carry on the regulated activities for a further period of two months and two weeks at or from the following location, Dr Sivasailam Subramony (also known as Medina Medical Centre), 3 Medina Road, Luton, Bedfordshire LU4 8BD. The provider is no longer providing care or treatment from Dr Sivasailam Subramony (also known as Medina Medical Centre), 3 Medina Road, Luton, Bedfordshire LU4 8BD. Other arrangements have been put in place to provide services to patients at the surgery.

In addition we are taking action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within two months and two weeks if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within two months and two weeks, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

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

Please refer to the evidence table for further information.

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Medina Medical Centre on 7 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. It was also good for providing services for the population groups of older people, people with long term conditions, families and young people, working people, those patients whose circumstances make them vulnerable and those with mental health problems.

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.
• Risks to patients were assessed and well managed.
• 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 said they found it easy to make an appointment and that there was continuity of care, with urgent appointments 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.

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

Importantly the provider should:

• Ensure that issues identified from infection control audit have actions and are carried out in a timely way.
• Remove plugs from sinks in all rooms and install elbow taps in clinical rooms.
• Ensure that all policies are dated.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

During our inspection on 6 June 2013, we found the service to be welcoming with friendly staff. Information was clearly displayed for people using the service, including health promotion, and information about the practice. Within the practice leaflet, information informed people that language support was available in Urdu, Punjabi, Bengali, Hindi and Gujarati.

The service was predominantly used by a large Asian population, of which the majority of people did not speak English as their first language. We saw evidence throughout our inspection of staff effectively communicating with people in various languages during their visit.

We spoke with one person using the service, and the relatives of two others who had accompanied people to assist with interpretation as necessary. Those we spoke with told us they were happy with the service provided. One person said, “The staff are very helpful.”

We looked at the care management plans for people using the service and saw that care and treatment was planned to meet people’s needs.

We reviewed the staff training and support processes and saw that staff received training relevant for their role. We also spoke with five members of staff who said they enjoyed working in the practice and felt supported by the provider.

We looked at the quality monitoring systems used within the service and saw these to be effective, with evidence of learning from areas identified through audit and monitoring.

We carried out an announced focused inspection at Dr Sivasailam Subramony, also known as Medina Medical Centre, on 7 March 2019. We also carried out a desk based review on 9 April 2019. This inspection was undertaken to follow up on the notice of decision to suspend the provider from carrying out regulated activities for a period of four months from 27 September 2018 to 27 January 2019 with an extension of two months and two weeks until 11 April 2019, following a focused inspection on 16 January 2019.

The practice received an overall rating of inadequate at our inspection on 24 August, 4 September and 20 September 2018 and this will remain unchanged until we undertake a further full comprehensive inspection.

The full comprehensive report from the August/September 2018 inspection and the focused report for the January 2019 inspection can be found by selecting the ‘all reports’ link for Dr Sivasailam Subramony on our website at .

At this inspection we found:

• The provider had taken some actions in relation to concerns identified at previous inspections.
• We were not assured that the practice management was suitably qualified or experienced to lead and manage the practice in the future. However, during our inspection we were informed of the proposed management structure and intentions for the management staff to undertake training specific to primary care management.
• The practice had developed some new policies but it was unclear which policies would be used in the practice in the future. Not all of the policies contained practice specific, detailed information that was reflective of current guidance.
• Clinical audits identified to be completed by the provider did not demonstrate quality improvement specific to the practice. There was no schedule or audit tool available for the completion of clinical audits.
• The principal GP had not completed the recommended level of safeguarding training. Following the inspection, we were provided with evidence that they had booked to complete face to face safeguarding level three training.
• A legionella risk assessment had been completed. There was no action plan in place to address the identified actions.
• A comprehensive fire risk assessment was completed following the inspection. We were provided with evidence of proof of payment for completion of most of the required actions identified, with the exception of those relating to the air conditioning units.
• There had been no infection control audits completed and staff were unclear on how infection prevention and control would be managed in the future. Some improvements had been made to the practice in relation to infection prevention and control. For example, new wipeable flooring and chairs.
• There were no changes to the staff immunity records since the previous inspection. There was not a record of all the recommended immunisations for clinical and non-clinical staff and there was no record of blood tests taken to check for the antibody status of those staff who had received a hepatitis B vaccine.
• The practice whistle blowing policy did not contain adequate information to guide staff on how to raise concerns outside of the practice. We were informed by the provider that this would be addressed following our visit.

The areas where the provider must make improvements as they are in breach of regulations are:

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

The suspension of Dr Sivasailam Subramony to carry out regulated activities from Medina Medical Centre ended on 11 April 2019. As the provider had made some improvements CQC made the decision not to continue with the suspension. However, due to the level of concerns that remain regarding this provider CQC are imposing conditions on their registration as a service provider in respect of the regulated activities. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.