Archived: Dr Srinivas Dharmana Also known as Dharmana's Family & General Practice

Updated 8 October 2015

Dr Dharmana’s practice is run by Dr Srinivas Dharmana who operates as a sole GP practitioner. Dr Dharmana has not delivered services personally since September 2013. GP services have been delivered by long term locum GPs. Services are delivered under a General Medical Services (GMS) contract.

The practice is registered with the Care Quality Commission to deliver five regulated activities:

• Treatment of disease, disorder or injury
• Diagnostic and screening services
• Maternity and midwifery services
• Surgical procedures
• Family planning.

Surgical procedures have not been delivered by the practice since September 2013. Some family planning services were not being delivered, for example contraceptive implants. Patients were referred to another provider to receive these services.

The practice is located in a former residential property that has been modified over time for use as a general practice. The layout of the property provides a ground floor consulting room, treatment room, a patient waiting room and reception area. The upper floor provides an office for the practice manager, administrative space and records storage. Toilet facilities are also on the upper floor.

There are approximately 2,400 patients registered with the practice.

The practice retained the services of a male and female locum to meet the needs of the practice population. A practice nurse was working at the practice for 18 hours each week to support patients with the management of long term conditions such as asthma, COPD, diabetes and hypertension (high blood pressure). The lead GP had been working as a practice manager since our inspection of October 2014. The practice had four administrative and reception staff who supported the running of the practice.

The practice is open between 8.00am and 6.30pm, Monday to Friday. The practice does not offer any extended hours surgeries.

Out of hours services were not provided by the practice. These were provided by Urgent Care 24. Patients who called the practice during the out of hours period were diverted by phone to this service.

This was a follow up to our inspection of 1 October 2014, when we found the practice was not delivering safe, effective and well-led care that was caring and responsive to patients’ needs. The practice was rated as ‘Inadequate’, and placed into Special Measures by the Care Quality Commission following the October 2014 inspection. The provider was required to submit an action plan detailing how improvements would be made. Special Measures is for a period of six months. During this time, support from NHS England and the local Clinical Commissioning Group had been available to make the improvements required.

Updated 8 October 2015

Letter from the Chief Inspector of General Practice

We carried out an announced follow-up inspection of Dr Srinivas Dharmana, also known as Dharmana’s Family and General Practice, on 30 July 2015. This inspection was a follow-up to our inspection of 1 October 2014 when the practice was rated as ‘Inadequate’, placed into Special Measures and required to make significant improvements.

Whilst we found there were some minor improvements in the responsiveness of the practice to patients’ needs, overall we found the practice had not made sufficient improvement in three of the five key domains. The practice is rated as Inadequate for providing safe, effective and well-led care, treatment and services. The practice is rated as Requires Improvement for providing responsive and caring services. The practice has failed to meet any of the regulatory requirements prescribed after the last inspection in October 2014 and no improvement in meeting the fundamental standards has been made.

Following this latest inspection, the provider has submitted an application to cancel their registration with CQC and the practice will close in December 2015. CQC has agreed to cancel the registration. The practice will remain in Special Measures.

In the meantime, NHS England and Liverpool Clinical Commissioning Group continue to support the practice and are taking steps to arrange the transfer of patients to alternative GP services in the local area.

Our key findings were as follows:

• The practice did not have an effective system in place for dealing with incoming patient related correspondence. We found a significant amount of correspondence that had not been read coded or annotated by the GPs working at the practice. No effective plan to address this backlog had been executed by the provider.
• The practice nurse had received some training on the management of patients with long term conditions. However, the nurse had not been booked onto essential update training on the delivery of immunisations and vaccinations, leaving the practice unprepared to manage responsibility for all childhood immunisations and vaccinations, which will be passed back to practices from Liverpool Community Health in September 2015.
• Insufficient records were held in relation to clinical staff and key background checks required had not been completed. Systems set up to promote quality checks on record keeping in relation to patient records were not upheld or effectively applied.
• Management and leadership were inadequate; improvements required in relation to infection control had not been made. Key records in relation to buildings maintenance could not be produced. Key parts to the improvement plan submitted to CQC following the inspection of 1 October 2014 had still not been achieved.

Importantly, the provider must:

• Provide care and treatment that meets the needs of patients. Patients seen by accident and emergency departments had not received appropriate intervention and support from their practice GP or nurse. The practice failed to respond in a timely manner to advice from hospital staff on patients’ conditions and medication.
• Have suitably qualified, competent, skilled and experienced persons deployed to cover both the emergency and routine work of the service.
• Hold, and have available, information in relation to each person employed for the purposes of delivery of regulated activities. Have records in place that are accessible to authorised people internally and externally, and as necessary to deliver care and treatment in a way that meets patient needs and keeps them safe.
• Address infection prevention and control concerns to ensure that they comply with the ‘Code of Practice for health and social care on the prevention and control of infection and related guidance’.
• Maintain records relating to the care and treatment of each person using the service that are fit for purpose.
• Do all that is reasonably practical to mitigate risks. Conduct and evaluate significant event analysis to establish how clerical or clinical errors had occurred.

Insufficient improvements have been made such that there remains a rating of Inadequate overall for this practice. The domains of Well-led, Effective, and Safe remain rated as inadequate and the Responsive and Caring domains are rated as requires improvement. As a result of this overall rating of Inadequate, all population group ratings remain as Inadequate.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 8 October 2015

The ratings of inadequate for the domains of safe, effective and well-led impacted on all patient groups. Since our inspection of October 2014, a nurse had received some training in the care and management of those patients with long term, chronic conditions. The nurse had completed an accredited course in the management of asthma. However more training was needed. Specifically, the nurse had not received formal training in the review of patients with diabetes, or in the review of patients requiring travel health advice. The nurse had not been trained in the read coding of patients consultations. The provider could not evidence any plans in place to facilitate the required training.

Updated 8 October 2015

The ratings of inadequate for the domains of safe, effective and well-led impacted on all patient groups. We found that the practice nurse had completed a foundation course on immunisation, which provided a theoretical update in line with the national minimum standards for immunisation training. The nurse was responsible for delivering immunisations and vaccinations at the practice. The provider could show no plans in place to facilitate updated learning required on childhood immunisations and vaccinations, which will be the responsibility of GP practices from September 2015. Of particular concern was the fact that the new meningitis, two stage vaccine for children will be delivered by practices from September 2015 and the nurse had not received the training required for this.

Updated 8 October 2015

The ratings of inadequate for the domains of safe, effective and well-led impacted on all patient groups. Multi-disciplinary team meetings had been put in place following our October 2014 inspection, to facilitate the care of those patients receiving palliative or end of life care in the community. Some continuity of service to patients had been provided by the retention of two long term locum GPs who were delivering services at the time our inspection.

Updated 8 October 2015

The ratings of inadequate for the domains of safe, effective and well-led impacted on all patient groups. We saw how the failure to deal with hospital correspondence effectively had resulted in patients’ conditions not being adequately reviewed by a GP, and how gaps in the duties of the practice nurse and the work of the GPs had impacted on patient health and well-being.

Updated 8 October 2015

The ratings of inadequate for the domains of safe, effective and well-led impacted on all patient groups. We were unable to find systems in place to improve the care and treatment of patients in this group. We reviewed records in relation to treatment of patients, which showed very poor care and a lack of responsiveness to the needs of vulnerable patients. These incidents were not reviewed by the practice staff to see if anything could have been done differently, and the practice did not make efforts to see these patients and address their health concerns.

Updated 8 October 2015

The ratings of inadequate for the domains of safe, effective and well-led impacted on all patient groups. When we made checks on the safeguarding register at the practice, we found it required further work to ensure it was up to date and accessible to all that needed to refer to this document. When asked, we found the full time locum GP at the practice could not access the register as it was on a drive on the computer that he did not have access to. When we reviewed some records of vulnerable patients subject to protection plans, we found information had not been uploaded to their patient records. Some patient records did not have the correct read code applied. This meant other providers of care and treatment, such as paramedics and hospital staff would not have access to significant information relating to these patients.