Dr Thavapalan is a provider registered with CQC. The practice was previously rated requires improvement after our inspection in August 2015 and was then found to be good in all areas following a follow up inspection in May 2016.

We carried out an inspection of the provider on 29 March 2019 as part of our inspection programme.

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 requires improvement overall and requires improvement for all population groups.

We rated the practice as inadequate for providing safe services because:

• Patients taking high risk medicines were not consistently being monitored in line with current guidance and legislation.
• The professional registrations of clinical staff were not being checked on an annual basis.
• There were not clear systems and processes in place for the management of significant events.
• Risks associated with infection control, fire and legionella were not regularly assessed.
• The practice did not have diclofenac, furosemide or bumetanide and dexamethasone within their emergency medicine storage and there was no risk assessment to consider the need or not for these medicines. The defibrillator pads attached to the practice defibrillator had expired.

We rated the practice as requires improvement for providing well-led services because:

• Governance was lacking in key areas including safeguarding, significant event management and the management of medicines.
• The provider did not have adequate systems in place to assess, monitor and address risks associated with the premises including those associated with fire, legionella and detection and prevention of infection.
• The provider did not have an active patient participation group and there was limited structured feedback and engagement mechanisms for patients.
• There was limited evidence of continuous improvement or innovation.

However

• Staff provided positive feedback about working at the service which indicated a good working culture.
• The practice had taken action to ensure the sustainability of the service and responded well to challenges associated with the dispersal of the patient list from a nearby service which closed.

We rated the practice as requires improvement for providing effective services because:

• There was a lack of quality improvement activity.
• Staff were not receiving regular appraisals.
• Monitor the level of exception reporting for patients with long term conditions to ensure that this is appropriate.

However, we did see:

• Effective joint working was in place. The practice held monthly multidisciplinary meetings and detailed records of discussions and action points were retained.
• With the exception of high risk medicines; patients were receiving regular reviews and the treatment provided was in line with current guidelines this was reflected in high levels of achievement against local and national targets.

We rated the practice as good for responsive services because:

• The practice had worked to accommodate an influx of patients from a nearby surgery which had recently closed. Care had been taken to optimise the care and treatment of these patients.
• Complaints were managed in a timely fashion and detailed responses were provided.
• Feedback from both the patient survey and comment cards received by CQC indicated that it was easy to access care and treatment at the practice. The practice was continually reviewing and adjusting the appointment system to cater to the needs of patients.

We rated the practice as good for providing caring services because:

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

The areas where the provider must make improvements are:

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

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Include details of the organisations patients can escalate complaints to in complaint response letters.
• Work to improve the identification of those patients with caring responsibilities.
• Retain records related to staff induction.
• Consider ways to provide health promotion information to patients who do not speak English as a first language.
• Consider ways to improve the premises to make them more accessible for people with mobility needs.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

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

Letter from the Chief Inspector of General Practice

We undertook an announced focused inspection of Dr Thavapalan on 5 May 2016. We found the practice to be good for providing safe, effective and well-led services and it is rated as good overall.

We had previously conducted an announced comprehensive inspection of Dr Thavapalan on 25 August 2015. As a result of our findings during that visit, the practice was rated as good for being responsive and caring, and requires improvement for being safe, effective, and well-led, which resulted in a rating of requires improvement overall. We found that the provider had breached four regulations of the Health and Social Care Act 2008; Regulation 12 (2)(h) safe care and treatment, Regulation 17 (1)(2)(a)(b)(e) good governance, Regulation 18 (2)(a) staffing, and Regulation 19 (1)(2)(a) fit and proper persons employed.

The practice wrote to us to tell us what they would do to make improvements and meet the legal requirements. We undertook this focused inspection to check that the practice had followed their plan, and to confirm that they had met the legal requirements.

This report only covers our findings in relation to those areas where requirements had not been met. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Dr Thavapalan on our website at http://www.cqc.org.uk/location/1-493944585/reports.

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

• The provider had implemented a system to share, monitor and review information about incidents, significant events and safety alerts.
• The provider had implemented an effective process to assess the risk of the spread of infections.
• All staff were up to date with mandatory training.
• The provider was able to demonstrate further evidence of quality improvements from a completed audit.
• The provider had sufficient stocks of emergency medicines.
• The provider took action to ensure all staff were aware of how to access the practice’s business continuity plan for non-medical emergencies.
• The practice had conducted background checks on all staff who acted as chaperones.

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 Thavapalan & Partners on 25 August 2015. Overall the practice is rated as requires improvement.

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. However there was limited use of systems to share, monitor, review information about safety.

• Risks to patients were not always assessed and well managed in relation to recruitment checks and infection control.

• Patients’ needs were assessed and care was planned and delivered following best practice guidance, however not all staff had received mandatory training appropriate to their roles.

• 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 with a named GP 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 governance arrangements needed to be strengthened to ensure there was a focus on ongoing learning from significant events and safeguarding concerns.

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

The areas where the provider must make improvements are:

• Ensure there are systems in place to assess the risk of the spread of infections by carrying out annual infection control audits.

• Ensure that all staff are up to date with mandatory infection control training.

• Ensure adequate recruitment checks are carried out including criminal records checking prior to commencing employment and that comprehensive records of recruitment checks are kept.

• Ensure there are systems in place to assess, monitor and mitigate risks and improve the quality and safety of services provided, for example, ensure staff are aware how to report incidents and there is a clear process to show that learning points identified from significant events and safeguarding concerns are routinely shared amongst all practice staff and clinical audit cycles are completed.

• Ensure there is a formal mechanism in place to obtain feedback from patients.

In addition the provider should:

• Keep a stock of the emergency drug Glucagon on the practice premises for the treatment of diabetes.

• Ensure all staff are aware of the practices’ business continuity plan.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice