The Care Quality Commission
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  • GP practice

Nutgrove Villa Surgery

Overall: Good read more about inspection ratings

Nutgrove Villa, Westmorland Road, Huyton, Liverpool, Merseyside, L36 6GA (0151) 489 2276

Provided and run by:
Dr R Kulandaisamy & Dr S R Maddipati Practice

All Inspections

During an assessment under our new approach

Nutgrove Villa Surgery is a GP practice which provides a range of primary medical services from its location at Westmorland Road, Huyton, Liverpool, Merseyside, L36 6GA. The practice is provided and run by Dr R Kulandaisamy & Dr S R Maddipati Practice. The service is registered with the Care Quality Commission under the Health and Social Care Act 2008 to provide the regulated activities, diagnostic and screening procedures, midwifery and maternity services, and treatment of disease, disorder or injury. We carried out an announced focused on-site assessment on 23 October 2024. We looked at three quality statements which included the assessment of learning culture, safe systems, pathways and transitions and safeguarding. We found there was a culture of safety and learning, this was based on openness, transparency and learning from events that may have put people and staff at risk of harm. We looked at the processes in place to ensure that safety and continuity of care was a priority throughout people’s care journey. We found safe systems were in place to ensure this. We identified improvements were needed to the safeguarding arrangements at the practice and prompt actions were taken at the time of assessment by the provider.

25 May 2021

During an inspection looking at part of the service

Following our previous inspection on 21 March 2019, the practice was rated Requires Improvement overall and for safe, effective and well led key questions and good for caring and responsive.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Nutgrove Villa Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focused inspection looking at safe, effective and well led, with the previous ratings for caring and responsive carried forward.

We reviewed the breaches identified at the last inspection:

Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment. The regulation was not being met because:

  • The provider had failed to ensure the proper and safe management of medicines: Adrenaline was not available in the rooms in which babies were immunised.
  • The provider had not carried out a risk assessment in relation to the emergency medicines which were not stocked.
  • The provider had not risk assessed the systems in place to ensure baby immunisations were conducted in keeping with best practice guidance.
  • Systems were not in place to comprehensively monitor prescribing and the provider did not audit the prescribing of controlled medicines.
  • The provider did not have a documented approach for the management of requesting tests and the process for how to handle test results was not made familiar to all members of the practice team.
  • The provider did not have safe systems in place for referrals to secondary medical care.
  • The timeliness and take-up of routine referrals was not monitored.
  • Audits that had been completed did not provide information about the safety of the service provided or the outcomes for patients.
  • Sample takers had not audited their results.

Regulation 17 HSCA (RA) Regulations 2014 Good governance How the regulation was not being met:

  • There was a lack of systems and processes established and operated effectively to ensure compliance with requirements to demonstrate good governance. There was failure to ensure the audit and governance systems were effective.
  • The provider did not have an audit program to review the care and treatment provided by clinicians.
  • There was no clinical oversight relating to outcomes for patients.
  • The provider did not have an audit program in place to review the effectiveness and staff compliance with the policies and procedures in place.

We also reviewed the areas where the previous inspection identified that the provider should make an improvement by:

  • Audit whether consent to treatment is always legally obtained.
  • Review system or policies to manage uncollected prescriptions.

How we carried out the inspection/review

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
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short 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 key questions and population groups.

We found that:

  • The breaches of Regulation 12 Safe care and treatment had been addressed and changes had been made to policies and procedures. Patients received effective care and treatment that met their needs.
  • The breaches of Regulation 17 Good governance had been addressed by revising the governance structure, processes and procedures. The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.

Whilst we found no breaches of regulations, the provider should:

  • Obtain up to date references and DBS checks for new members of staff.
  • Audit patient records to check information is recorded accurately.
  • Record mental capacity assessment for DNACPR in electronic record as well as the required paper record.
  • Continue to improve breast screening uptake.

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

21/03/2019

During a routine inspection

We carried out an announced comprehensive inspection at Nutgrove Villa Surgery on 21 March 2019.

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 requires improvement overall.

We rated the practice as requires improvement for providing safe services because:

  • The practice did not have appropriate systems in place for the safe management of medicines.
  • Adrenaline was not available in the rooms in which babies were immunised.
  • Systems in place did not ensure that test and laboratory results were always dealt with appropriately.
  • The practice did not always learn and make service-wide changes when things went wrong.

We rated the practice as requires improvement for providing effective services because:

  • There was limited monitoring of the outcomes of care and treatment.
  • Limited clinical audits had been completed and the provider had not initiated a program of ongoing and comprehensive clinical audits which could trigger change and improvements.

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

  • While the practice had a clear vision, that vision was not supported by a credible strategy.
  • Systems were not in place to monitor the overall governance arrangements in place.
  • The practice had clear processes for managing risks, issues and performance, however this was not monitored for effectiveness.
  • Systems and processes for learning, continuous improvement and innovation were not always used appropriately.

These areas affected all population groups so we rated all population groups as requires improvement.

We rated the practice as good for providing caring and responsive services because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The areas where the provider must make improvements are:

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

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements is:

  • Audit whether consent to treatment is always legally obtained.
  • Review system or policies to manage uncollected prescriptions

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

4 February 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

This is the report from our inspection of Nutgrove Villa Surgery. Nutgrove Villa Surgery is registered with the Care Quality Commission to provide primary care services.

We undertook a planned, comprehensive inspection on the 4 February 2015 at Nutgrove Villa Surgery. We reviewed information we held about the services and spoke with patients, GPs, and staff.

The practice was rated as good overall.

Our key findings were as follows:

  • There were systems in place to mitigate safety risks. The premises were clean and tidy. Systems were in place to ensure medication including vaccines were appropriately stored and in date.
  • Patients had their needs assessed in line with current guidance and the practice promoted health education to empower patients to live healthier lives.
  • Feedback from patients and observations throughout our inspection highlighted the staff were kind, caring and helpful.
  • The practice was responsive and acted on patient complaints and feedback.
  • The practice was well led. The staff worked well together as a team and had regular staff meetings and training.

However there were some areas for improvement.

The provider should:

  • Resource additional training and ensure all members of staff receive training in adult safeguarding.
  • Carry out risk assessments to ensure staff are suitable to act as chaperones.
  • Ensure that the clinical governance policy is revised to reflect the current practice protocols and responsibilities and make all staff aware of this.
  • Make better use of the website for patient information and capturing patients’ feedback especially with regards to the younger population.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice