Archived: Dr Surendra Kumar Dhariwal Also known as Manor Park Medical Centre

Updated 9 October 2017

Dr Surendra Kumar Dhariwal (also known as Manor Park Medical Centre) is situated within NHS Newham Clinical Commissioning Group (CCG). The practice provides services to approximately 1,350 patients under a Personal Medical Services (PMS) contract.

The practice was registered with the Care Quality Commission (CQC) to carry on the regulated activities of maternity and midwifery services, family planning services, treatment of disease, disorder or injury, surgical procedures, and diagnostic and screening procedures. In June 2016 the Lead GP told us minor surgery and family planning had not been undertaken for a long time and we asked the provider to update their registration. However, the practice had not applied to CQC to remove minor surgery or family planning as a regulated activity.

Staff include: the lead male GP working seven sessions per week, and two long term male locum GPs (one working two sessions per week and the other as and when in the event the Lead GP goes on holiday); one or two female practice nurses working seldom and ad hoc, a practice secretary working 25 hours per week (five hours every weekday), a receptionist working 20 hours per week, and a records summariser working ad hoc.

The practice premises are on the ground floor of a converted semi-detached house. Its core opening hours are between 8:00am to 6.30pm every weekday. GP appointments are from 9.00am to 11.00am and 4.00pm to 6.00pm, except on Thursday when there is no afternoon session but the doors of the practice remain open. The practice offers on-site extended hours GP appointments from 6.30pm until 7.00pm on Tuesdays and Fridays. Patients telephoning when the practice is closed are directed to the local Newham GP Co-op out-of-hours service provider. Appointments include pre-bookable appointments, home visits, telephone consultations and urgent appointments for patients who need them. GPs provide a visiting doctors round to residents at a 60 bedded local care home and related information is included in this report.

The Information published by Public Health England rates the level of deprivation within the practice population group as two on a scale of one to ten - level one representing the highest levels of deprivation. The practice has a relatively high population of older patients compared to the local CCG. Data showed 19% of its patients were over 65 years of age compared to 7% within the CCG and 17% nationally.

The practice was previously inspected on 29 June 2016 when it was rated inadequate overall and placed in special measures. There was a follow up inspection on 22 March 2017 when the practice was rated inadequate overall, and accordingly remained in special measures for a further six month period.

Updated 9 October 2017

Letter from the Chief Inspector of General Practice

This inspection was a follow up to earlier inspections carried out on 29 June 2016 and 22 March 2017.

Following the inspection on 29 June 2016 the practice was rated inadequate in the provision of safe, effective and well-led and requires improvement in caring and responsive services. It was rated inadequate overall and placed in special measures. There were breaches in relation to the following regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - Regulation 11 the Need for consent, Regulation 12 Safe care and treatment, Regulation 15 Premises and equipment, Regulation 17 Good governance, Regulation 18 Staffing, and Regulation 19 Fit and proper persons employed. After the inspection the provider submitted an action plan detailing how it would make improvements and when the practice would be meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

Following the inspection on 22 March 2017, which we carried out to consider whether sufficient improvements had been made and to identify if the provider was meeting legal requirements and associated regulations, the practice was rated inadequate in the provision of safe, effective and well-led, requires improvement in caring, good in responsive and inadequate overall and remained in special measures. The provider had made improvements; however there continued to be breaches of Regulation 12 Safe care and treatment, Regulation 17 Good governance, Regulation 18 Staffing, and Regulation 19 Fit and proper persons employed. After the inspection the provider submitted an action plan detailing how it would make further improvements and when the practice would be meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

This inspection was undertaken following the period of special measures and was an unannounced comprehensive inspection on 3 July 2017. Overall the practice remains rated as inadequate.

At our inspection on 3 July 2017 we found:

• Staffing arrangements were unclear and there were gaps in maintaining relevant staff checks or information such as Disclosure and Barring Service (DBS) and clinician’s medical indemnity insurance and immunity.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance but there were weaknesses in staff appraisal procedures and training.
• There were gaps in safety arrangements such as safety alerts follow up and managing unforeseen staff absence.
• Areas of the premises were dusty and some items were visibly dirty or out of date.
• A significant amount of medicines and equipment were not fit for use and there were no effective systems in place to address this.
• There was no evidence of clinical or other quality improvement activity.
• There was a system in place for reporting and recording significant events but it was ineffective. Significant events had not been captured to make improvements or monitor trends to take action to prevent future recurrence.
• The mission statement, vision and strategy were unclear and there were no business plans and operational structures had weaknesses.
• Staff were aware of current evidence based guidance and worked with other health care professionals to understand and meet the range and complexity of patients’ needs.
• Patients said they were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• There was no evidence of the duty of candour or that lessons were learned from individual concerns and complaints or analysis of trends and action taken as a result to improve the quality of care.

Importantly, the provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Ensure all premises and equipment used by the service provider is fit for use.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.
• Maintain all necessary employment checks for all staff.

In addition the provider should:

• Review arrangements for patient’s access to information and services online.
• Review systems for signposting carers and embed polices and guidance.
• Ensure the most recent CQC rating is clearly displayed and provide accurate information to the CQC as required.
• Review reception staffing and chaperoning cover arrangements.
• Review and improve arrangements for relevant staff safeguarding and administering vaccinations updates or training.

This service was placed in special measures on 3 November 2016. Insufficient improvements have been made such that there are ratings of inadequate for safe, effective, caring, responsive, well-led and overall. We took enforcement action and decided to cancel the providers’ registration and the provider appealed this decision. The case was heard in court at a First Tier Tribunal that decided it was not disproportionate for CQC to cancel the providers’ registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 9 October 2017

The provider is rated as inadequate for safe, effective, caring, responsive and for well-led. The issues identified as inadequate overall affected all patients including this population group.

• Performance for diabetes related indicators was similar to national averages. For example, the percentage of patients with diabetes, on the register, in whom the last IFCCHbA1c (blood sugar level) was 64 mmol/mol or less in the preceding 12 months was 84%, compared with the CCG average of 72% and national average of 78%.
• The percentage of patients with hypertension having regular blood pressure tests was 87%, which is similar to the CCG 82% average of and national average of 83%.
• The percentage of patients with COPD who had a review undertaken including an assessment of breathlessness using the Medical Research Council dyspnoea scale was 100% compared to 87% within the CCG and 90% nationally.
• Longer appointments and home visits were available when needed.

• All these patients had a named GP and a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Updated 9 October 2017

The provider is rated as inadequate for safe, effective, caring, responsive and for well-led. The issues identified as inadequate overall affected all patients including this population group.

• 87% of patients diagnosed with asthma, on the register had an asthma review in the last 12 months compared to 76% nationally.
• Childhood immunisation rates for under two year olds were 94%, (the national expected coverage of vaccinations is 90%); and the Measles, Mumps and Rubella (MMR) vaccine for five year olds was 100% for Dose 1 compared to 94% nationally; and 100% for Dose 2 compared to 88% nationally.

• Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.
• Data for female clinical care was below average and no effective action had been taken to understand or address this. The practice’s uptake for the cervical screening programme was 87%, which was comparable to the national average of 81%. However, exception reporting was relatively high at 26% compared to 11% within the CCG and 7% nationally.
• Females aged 50-70, screened for breast cancer in last 36 months was 51% compared to 59% within the CCG and 73% nationally. Females aged 50-70, screened for breast cancer within 6 months of invitation was 0% compared to 63% within the CCG and 74% nationally.
• Appointments were available outside of school hours and the premises were suitable for children and babies.
• We saw positive examples of joint working with midwives and health visitors.

Updated 9 October 2017

The provider is rated as inadequate for safe, effective, caring, responsive and for well-led. The issues identified as inadequate overall affected all patients including this population group.

• Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns.
• GPs provided a visiting doctors round to residents at a 60 bedded local care home. Feedback from the care home was not positive and indicated concerns including insufficient and delayed repeat prescribing for dressings and food supplements, and a lack of end of life and advance care planning, communication including with residents families in relation to medicines and practice manager cover.
• The practice offered home visits and urgent appointments for those with enhanced needs.
• The practice followed up on older patients discharged from hospital and ensured that their care plans were updated to reflect any extra needs.
• Where older patients had complex needs, the practice shared summary care records with local care services such as adult social care teams.

• The practice participated in an initiative to improve preventative medical care for frail older patients and avoid unnecessary admissions into hospital.

Updated 9 October 2017

The provider is rated as inadequate for safe, effective, caring, responsive and for well-led. The issues identified as inadequate overall affected all patients including this population group.

• The practice did not have a website or specific plans to create one but offered online appointment booking and prescription requests through the online national patient access system.
• The practice offered a range of health promotion and screening that reflects the needs for this age group.
• The practice offered extended hours from 6.30pm until 7.00pm on Tuesdays and Fridays for working patients who could not attend during normal opening hours.
• Telephone consultations with clinicians were available to meet the needs of this population group.

Updated 9 October 2017

The provider is rated as inadequate for safe, effective, caring, responsive and for well-led. The issues identified as inadequate overall affected all patients including this population group.

• 78% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which was comparable to national average of 84%.
• 94% of patients diagnosed with a mental health had a comprehensive documented agreed care plan which was comparable to national average of 89%.
• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia and carried out advance care planning for patients with dementia.
• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.
• The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.
• Staff had a good understanding of how to support patients with mental health needs and dementia.

Updated 9 October 2017

The provider is rated as inadequate for safe, effective, caring, responsive and for well-led. The issues identified as inadequate overall affected all patients including this population group.

• The practice held a register of patients living in vulnerable circumstances including those with a learning disability.
• The practice offered longer appointments for patients with a learning disability.
• The practice had five patients on the register with a learning disability, three (60%) of these patients had received an annual health check in the last 12 months.
• The practice regularly worked with other health care professionals in the case management of vulnerable patients.
• The practice informed vulnerable patients about how to access various support groups and voluntary organisations.
• Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.