Archived: Dr Sivasailam Subramony

This practice is rated as Inadequate overall.

The key questions at this inspection are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Requires Improvement

Are services responsive? – Requires Improvement

Are services well-led? - Inadequate

We carried out a comprehensive inspection of Dr Sivasailam Subramony on 24 August, 4 September and 20 September 2018. The practice received an overall rating of inadequate and a decision was made 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.

We carried out an announced focused inspection at Dr Sivasailam Subramony, on 7 March 2019. Following this inspection, 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 remained regarding this provider CQC are imposed conditions on their registration as a service provider in respect of the regulated activities.

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

We carried out an announced comprehensive inspection at Dr Sivasailam Subramony on 8 July 2019. This inspection was planned to check whether improvements had been made and the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

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 rated the practice as Inadequate for providing safe services because:

• Appropriate measures had not been taken to safeguard patients.
• Staff immunity records were incomplete.
• The recruitment policy did not reference the need to check the professional registration of clinicians other than GPs.
• Identified actions had not been completed following the health and safety and premises risk assessments.
• Identified actions had not been completed following the infection prevention and control audit.
• Care plans were not in place for patients who were experiencing poor mental health.
• Codes were not used correctly to identify patients who required a review of their condition.
• There had been no multi-disciplinary team meetings held in the practice since the end of the provider’s suspension.
• Patients prescribed high risk medicines had not received appropriate blood monitoring to detect potential side effects.

We rated the practice as Inadequate for providing effective services because:

• Systems and processes were not in place to keep clinicians up to date with current evidence-based practice.
• There was a lack of clinical oversight of clinicians working in the practice.
• Systems were not in place to identify patients who needed a structured annual review of the health and medicine needs.
• The practice did not have arrangements for following up failed attendance of children’s appointments following an appointment in secondary care or for immunisation.
• Uptake for cervical screening, and breast and bowel cancer screening were below targets and national averages.
• Multi-disciplinary team meetings were not taking place.
• Care plans were not in place for patients experiencing poor mental health.

We rated the practice as Requires Improvement for providing caring services because:

• Actions had not been taken relation to the GP patient survey scores.
• We were informed there was a carers champion. However, only 12 patients had been identified as carers.

We rated the practice as Requires Improvement for providing responsive services because:

• There had been no meetings held with the local community teams to manage the needs of patients with long-term conditions, vulnerable children and adults.
• There were no systems in place to follow up children who had not attended hospital or practice appointments.
• The new website with up to date information was not clearly visible. The old website with out of date information was still active. There was no information to direct patients to the new website.
• Care plans were not used for patients experiencing poor mental health.

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

• There remained concerns with the practice management and leadership.
• There was a lack of plans in place to make continued improvements to the practice.
• Some policies did not contain practice specific information.
• There was a lack of clinical oversight.
• There had been no review of the clinical systems to monitor performance.

Due to the level of concerns regarding this provider CQC are imposing urgent conditions on their registration as a service provider in respect of the regulated activities. In addition, as insufficient improvements have been made and there remains an overall rating of inadequate, we are taking action in line with our enforcement procedures to prevent the provider from operating the service. A notice of proposal has been issued to cancel the providers registration with CQC.

The Provider handed in their NHS Contract to the Clinical Commissioning Group on 31.08.19. The Provider’s contract to provide services from location Medina Medical Centre, 3 Medina Road, Luton, Bedfordshire, LU4 8BD was duly terminated on 30.09.19.

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.

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.

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.