Background to this inspection
Updated
20 September 2021
Dr Mahadeva Selvarajan is the registered individual and sole provider and offers primary care services to a registered list of 3,500 patients. The list is gradually increasing due to closure of a neighbouring practice. The practice delivers commissioned services under the General Medical Services (GMS) contract and is a member of NHS Bolton Commissioning Group (CCG).
The GMS contract is the contract between general practices and NHS England for delivering primary care services to local communities. The practice is registered with the Care Quality Commission (CQC) to provide the regulated activities of diagnostic and screening procedures; family planning; maternity and midwifery services; surgical procedures, and treatment of
disease, disorder and injury.
Regulated activities are delivered to the patient population from the following address:
Deane Clinic One Stop Health Centre
Horsfield Road
Bolton
BL3 4LU
The practice has a website that contains information about what they do to support their patient population and the in house and online services offered. However, the website was inactive for a long period of time and was only reactivated on 5 July 2019.
www.deaneclinic.co.uk
There is one GP, one advanced nurse practitioner and a practice nurse, supported by a practice manager and a small team of reception/administration staff.
The average life expectancy and age profile of the practice population is broadly in line with the CCG and national averages. Information taken from Public Health England placed the area in which the practice is located in the second most deprived decile (from a possible range of between 1 and 10). In general, people living in more deprived areas tend to have a greater need for health services.
Patients requiring a GP outside of normal working hours are advised to contact the surgery and they will be directed to the local out of hours service which is provided by Bolton GP Federation. Additionally, patients can access GP services in the evening and on Saturdays and Sundays through the hubs provided by Bolton GP Federation.
Updated
20 September 2021
We carried out an announced comprehensive inspection at Dr Mahadeva Selvarajan on 9 August 2021. The practice is rated Good overall.
The key questions at this inspection are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Good
Why we carried out this inspection
The practice was firstly rated Inadequate overall on 6 November 2018. They were inspected again on 6 July 2019 when the ratings improved to requires improvement overall. At that time they remained in special measures because the population group families and young children remained inadequate due to significantly lower than average child immunisation scores.
At an inspection on 8 January 2020 data outcomes remained lower than average for child immunisations and cervical screening. This affected the population groups families and young children and working age people (including those recently retired) which remained requires improvement. That resulted in an overall rating of requires improvement for the effective key question. In addition, patient satisfaction scores had decreased since the previous inspection resulting in the practice being rated requires improvement for caring. That impacted on the overall rating which remained requires improvement.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Mahadeva Selvarajan on our website at www.cqc.org.uk
This inspection was a full comprehensive inspection including an on-site visit and was not limited to the concerns mentioned above. We found the practice had maintained all the improvement it had embedded at the last inspection and further improvements were seen again.
How we carried out the inspection
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included
- Conducting staff interviews using video conferencing where possible.
- Reviewing patient records to identify issues and clarify actions taken by the provider
- Requesting evidence from the provider
- A full day’s site visit
Our findings
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 Good overall and Good for all population groups except for Working Age People (including those recently retired and students) which remains requires improvement.
We found that:
- The provider and the practice staff continued to engage with the Clinical Commissioning Group (CCG). We saw that the practice had taken every effort to improve data outcomes for immunisation and cervical screening. We saw continual improvement and we saw that the practice did not cease these efforts just because their inspection was over.
- The inspection team saw evidence of a collective response from all members of the practice team who demonstrated hard work and collaborative desires to continue with the improvements.
- GP and clinical cover were sufficient to manage long term conditions of patients safely and effectively. We saw that outcomes continued to improve in these population groups.
- Improvements previously demonstrated around systems and processes had been maintained and were yet further embedded to keep patients safe.
- Incident reporting, management of patient safety alerts, prescription protocols, emergency equipment, fridge monitoring and information sharing were all embedded within the practice.
- Staff were clear about reporting incidents, near misses and concerns and all staff reported continued improvement around formal communication, access to information and learning.
- The provider had produced audits and we saw evidence of a significant number of patient outcomes that had improved yet further since our last inspection. We saw that audits continued to be discussed at practice meetings.
- Complaints were sufficiently dealt with and the practice maintained a constructive approach with regard to verbal comments received from patients which were being logged and reviewed. We saw evidence of many positive comments from patients which were also kept to share with staff.
- Recruitment checks and personnel information were sufficiently maintained in accordance with requirements. Two new members of staff had started at the practice since the last inspection and we saw that all appropriate induction and mandatory training had been undertaken.
- Appointment systems were improved so that all patients had access to care when they needed it.
- There was improved practice leadership and evidence of a whole team approach.
We saw one area of outstanding practice:
- The practice carried out their own phlebotomy and blood tests at the practice. As there was only one collection of samples per day to the pathology department this was problematic to the practice. To address this problem a centrifugal machine was purchased at the practice’s expense so that patients’ blood tests could be taken throughout the day and would not be affected by being stored overnight.
Whilst we found no breaches the provider should continue to:
- Find ways to improve the uptake of immunisations and cervical screening.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care