Archived: Dr Tirunelveli Ashok Kumar

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection at Dr Tirunelveli Ashok-Kumar’s Surgery also known as Highwoods Surgery on 29 July 2015. The practice was rated as requires improvement overall. Specifically they were rated as good for caring services, inadequate for safe, and requires improvement for effective, responsive, well-led services.

In particular, on 29 July 2015, we found the following breaches of the regulations at the practice;

• Medicines were not stored appropriately.

• Systems to identify or monitoring risks were ineffective and not mitigated.

• Staff were unaware how to report potential safety incidents or act when they occurred.

• The practice nurses and healthcare assistant were not authorised to administer some vaccinations nor had appropriate training and competency checks to administer them safely.

• Infection prevention and control procedures required strengthening; this included cleaning, environmental checks, and audit.

• Governance systems or processes insufficient to assess monitor and improve the quality and safety of the service.

• Staff lacked understanding regarding the reporting, and investigation of significant incidents. They did not share incident findings or learning with staff members.

• There was no system to processes, record, or investigate complaints and share findings and lessons learned with staff members.

• There was a lack of monitoring and assessing the quality services and patient outcomes at the practice, this included acting on patient feedback.

As a result of our findings at the inspection we issued the provider requirement notices and told the provider they must send a report to the CQC that stated what action they were g going to take to make the required improvements. This related specifically to the following regulations;

Regulation 12 – Safe care and treatment.

Regulation 16 – Receiving and acting on complaints.

Regulation 18 – Staffing.

Regulation 17 – Good Governance.

Regulation 19 – Fit and proper persons employed.

Following the inspection on 29 July 2015 the practice sent us an action plan that explained what actions they would take to meet the regulations in relation to the requirement notices we issued.

The report of the 29 July 2015 inspection was published in January 2016. When a provider is rated as inadequate for one of the five key domains or one of the six population groups it needs to be re-inspected no longer than six months after the initial rating was confirmed.

We therefore carried out a further comprehensive inspection at Dr Tirunelveli Ashok-Kumar’s Surgery on 24 May 2016 to check whether the practice had made the required improvements from the July 2015 inspection and those contained within the requirement notices. We found that the required improvements had been made.

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

• Medicines were stored securely and only accessible to authorised staff members. Medicines seen at the practice were within the expiry date for use. Records showed us that medicines requiring cold storage were kept in refrigerators that were maintained and monitored daily to ensure medicines was stored at their optimum temperature.

• There was a system in place to identify risks and rated to show priority, likelihood, action required and learning. The system to assess risks included those associated with; premises, equipment, medicines, and infection control.

• Staff members knew how to raise concerns, and report safety incidents. The policy showed the practice complied with the requirements of the duty of candour. Safety information was recorded and any issues identified were shared with staff members.

• The nurses and healthcare assistant could evidence authorisation to administer all vaccinations provided for patients at the practice through guidance directives. They had received appropriate training and competency checks to ensure patient safety.

• The practice maintained satisfactory standards of cleanliness and hygiene. The infection control lead had received specific training and the policy in place met national and local guidance and legal requirements.

• The practice performed an audit and an annual statement setting out standards stated within their policy of quality and safety at the practice.

• There was a system to process, record, or investigate complaints and share findings with any lessons learned with staff members. Information regarding how to complain was available at the practice and in an easy to read format.

• The quality services and patient outcomes were monitored in practice meetings, and they acted on patient feedback to improve services.

• Patient care was planned and provided to reflect best practice using recommended current clinical guidance.

• Patient comments were positive about the practice during the inspection and told us they were treated with dignity and respect. Members of the practice patient participation group told us they were involved with practice development.

• There were urgent appointments available on the day they were requested.
• The practice had suitable facilities and equipment to treat patients and meet their requirements.
• The leadership structure at the practice was clear and understood by all the staff members.

The areas where the provider should make improvements:

• Review all policies and procedures to ensure they are updated and meet current guidance and legislation.

• Increase efforts to identify patients that are carer’s, currently the number identified were 34 this equated to 0.5% of the practice patient population.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice