Archived: Dr Kodaganallur Subramanian

Updated 9 February 2018

Dr Kodaganallur Subramanian is a GP practice in the London Borough of Havering, to the east of London. The practice is part of the London Borough of Havering Clinical Commissioning Group (CCG) and provides primary medical services through a General Medical Services (GMS) contract with NHS England to around 1800 patients.

The practice is housed within a converted, two storey, semi-detached house in a residential area. The practice is easily accessible by local buses. It does not have a car park, however there is permit free parking on surrounding streets. The practice consists of two consulting rooms (one on each floor), reception and waiting area, a toilet and office.

The practice’s age distribution data shows a higher than average number of patients aged 75 to 85 years and above. At 78 years for men and 83 years for females the average life expectancy is similar to the national average of 79 years for males and 83 for females. The practice locality is in the fifth less deprived decile out of 10 on the deprivation scale.

Clinical services are provided by one GP (male, nine sessions) and one practice nurse (female, one session). At the time of our initial visit the practice did not have a permanent practice manager, although there was an interim practice manager in post. Administrative roles were shared between the GP, one full time and one part time receptionist/administrator.

The practice opens at 9am every week day and closes at 7pm on Monday and Wednesday, 6.30pm Tuesday and Friday and 1pm on Thursday. The practice does not open at weekends. Surgery times are from 9am to 12.30pm and then 2.30pm to 6.30pm every day except Thursday when there is no afternoon surgery. Extended hours operate on Monday and Wednesday from 6.30pm to 7pm. Outside of these hours services are provided by the practice’s out of hours provider.

The practice is registered to carry out the following regulated activities: Treatment of disease, disorder or injury and Diagnostic and screening procedures from 1 Harlow Road, Rainham, Essex RM13 7UP.

Updated 9 February 2018

Letter from the Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Kodaganallur Subramanian on 20 December 2016 and 24 January 2017. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. The full comprehensive report on the December 2016 and January 2017 inspections can be found by selecting the ‘all reports’ link for Dr Kodaganallur Subramanian on our website at www.cqc.org.uk.

This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 23 October 2017. Overall the practice is now rated as requires improvement.

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

• There was an effective system for reporting, recording, investigating and learning from significant events. However, two recent incidents had not been investigated in a timely manner.
• There was an ineffective system for reviewing and cascading safety alerts.
• Improvements to risk management had been made. However, some risks to patients, staff and visitors were not adequately assessed and well managed.
• There had been improvements in arrangements to deal with emergencies and major incidents.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• Data from the Quality and Outcomes Framework (QOF) demonstrated a positive change in patient outcomes. However, further improvements were still required to benefit patients.
• Some new staff members had not completed necessary training including Safeguarding, chaperoning and equality and diversity.
• The practice followed up patients recently discharged from hospital and had worked with other health care professionals when necessary to understand and meet the range and complexity of patients’ needs.
• 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. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients we spoke with said they found it easy to book appointments with a named GP and there was continuity of care, with urgent appointments available the same day.
• Improvements to governance arrangements at the practice had taken place. However, further improvements to risk assessment, governance and management were found to be required.
• There was a clear leadership structure and staff felt supported by management. The practice gathered feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvements are;

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

The areas where the provider should make improvements are;

• Record the daily visual checks of the cleanliness of the practice environment.
• Increase uptake of childhood immunisations.
• Consider installing a hearing loop for patients who are hearing aid users.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 9 February 2018

The practice is rated as requires improvement for the care of people with long-term conditions. The provider is rated as requires improvement for providing safe, effective and well-led services and good for providing caring and responsive services. The resulting overall rating applies to everyone using the practice, including this patient population group.

• Patients at risk of hospital admission were identified as a priority.
• Performance for diabetes related indicators was comparable to the local clinical commissioning group (CCG) average and national average. For example, 75% of the practice’s patients with diabetes, on the register, whose last IFCC-HbA1c was 64mmol/mol or less in the preceding 12 months compared with the local CCG average of 74% and national average of 80%. 77% of the practice’s patients with diabetes, on the register, had a last measured total cholesterol of 5mmol/l or less compared with the local CCG average of 74% and national average of 80%.
• The practice followed up on patients with long-term conditions discharged from hospital to help ensure that their care records were updated to reflect any additional needs.
• All these patients had a named GP and there was a system to recall patients for 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 when required.

Updated 9 February 2018

The practice is rated as requires improvement for the care of families, children and young people. The provider is rated as requires improvement for providing safe, effective and well-led services and good for providing caring and responsive services. The resulting overall rating applies to everyone using the practice, including this patient population group.

• There were systems to identify and follow up children living in disadvantaged circumstances and who were at risk. For example, children and young people who had a high number of accident and emergency attendances.
• Childhood immunisation rates for the vaccines given to children under two years of age were below the national averages.
• All the patient feedback we received indicated that children and young people were treated in an age-appropriate way and were recognised as individuals.
• The practice’s uptake for the cervical screening programme was 76%, which was comparable to the local CCG of 82% and national average of 81%.
• Appointments were available outside of school hours and the premises were suitable for children and babies.

Updated 9 February 2018

The practice is rated as requires improvement for the care of older people. The provider is rated as requires improvement for providing safe, effective and well-led services and good for providing caring and responsive services. The resulting overall rating applies to everyone using the practice, including this patient population group.

• Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns.
• The practice offered proactive, personalised care to meet the needs of the older people in its patient population.
• The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.
• The practice involved older patients in planning and making decisions about their care, including their end of life care.
• The practice followed up on older patients discharged from hospital to help ensure that their care records were updated to reflect any additional needs.
• Patients over the age of 75 years had a designated GP to oversee their care and treatment requirements.
• Practice staff visited patients who lived in local residential homes when required as well as annually to review their needs and provide annual influenza immunisations. 

Updated 9 February 2018

The practice is rated as requires improvement for the care of working-age people (including those recently retired and students). The provider is rated as requires improvement for providing safe, effective and well-led services and good for providing caring and responsive services. The resulting overall rating applies to everyone using the practice, including this patient population group.

• The needs of these populations had been identified and the practice had adjusted the services it offered to help ensure these were accessible, flexible and offered continuity of care.
• The practice was proactive in offering some online services, as well as a full range of health promotion and screening that reflects the needs for this age group.

Updated 9 February 2018

The practice is rated as requires improvement for the care of people experiencing poor mental health (including people with dementia). The provider is rated as requires improvement for providing safe, effective and well-led services and good for providing caring and responsive services. The resulting overall rating applies to everyone using the practice, including this patient population group.

• Performance for mental health related comparable to CCG and national scores. For example, 82% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which was comparable to both the local clinical commissioning group (CCG) average of 81% and national average of 80%. We looked at a random sample of these patients’ records which confirmed this. 100% the practice’s patients with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive, agreed care plan documented in their records in the preceding 12 months compared with the local CCG average of 91% and national average of 90%. This was an increase of 33% over the 2015/2016 figures. 100% of patients with schizophrenia, bipolar affective disorder and other psychoses had their alcohol consumption recorded, in the preceding 12 months compared to the local CCG average and national averages of 91%.
• The practice worked with multi-disciplinary teams when required in the case management of patients experiencing poor mental health, including those with dementia.
• The practice had information available for patients experiencing poor mental health about how to access various support groups and voluntary organisations.
• The practice had a system 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 February 2018

The practice is rated as requires improvement for the care of people whose circumstances may make them vulnerable. The provider is rated as requires improvement for providing safe, effective and well-led services and good for providing caring and responsive services. The resulting overall rating applies to everyone using the practice, including this patient population group.

• The practice held a register of patients with a learning disability.
• End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.
• Although patients with learning disabilities were not routinely offered longer appointments by the practice, staff confirmed that the clinicians always gave enough time to these patients, overrunning appointment times whenever necessary.
• The practice worked with other health care professionals when required in the case management of vulnerable patients.
• The practice had information available for vulnerable patients about how to access various support groups and voluntary organisations.
• Staff knew how to recognise signs of abuse in children, young people and adults whose circumstances may make them vulnerable. 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.
• The practice supported patients who were also carers and had identified 18 which represented 1% of the practice population.