This practice is rated as Good overall. (Previous inspection July 2017, rated Good overall with Requires improvement for providing caring services).

The key questions at this inspection are rated as:

Are services caring? – Good

We carried out an announced focused inspection at Dr Kanjana Paramanathan, on 19 September 2018. This inspection was in response to a previous focused inspection at the practice in July 2017, where we identified that the practice needed to improve the service using patient feedback, particularly in relation to consultations with clinical staff.You can read the report from our last focused inspection on 4 July 2017; by selecting the 'all reports' link for Dr Kanjana Paramanathan on our website at www.cqc.org.uk.

At this inspection we found:

• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients feedback relating to their experience of consultations with clinicians had improved.

The areas where the provider should make improvements are:

• Continue to review and improve patient satisfaction in relation to the service.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Kanjana Paramanathan on 6 September 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the September 2016 inspection can be found by selecting the ‘all reports’ link for Dr Kanjana Paramanathan on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 4 July 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 6 September 2016. This report covers our findings in relation to these improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

• During our previous inspection the practice did not have adequate systems in place for the timely management of safety alerts. At this inspection we saw that processes were in place to receive alerts such as from the Medicines and Healthcare products Regulatory Agency (MHRA) as well as the Central Alerting System (CAS). Evidence we looked at showed that appropriate actions were being taken following receipt of relevant alerts.

• We found that the system in place for the prescribing of high risk medicines was not always effective, specifically with regards to recommended blood monitoring when we inspected the practice previously. At this inspection we saw evidence that improvements had been made and anonymised patient records we looked at demonstrated that patients on high risk medicines were being managed appropriately.

• When we inspected the practice in September 2016, the practice was unable to demonstrate that all clinical staff had appropriate indemnity cover in place. At this follow up inspection we saw evidence of indemnity cover for all relevant staff.

• At our previous inspection the national GP patient survey result we looked at showed patients rated the practice lower than others for some aspects of care, particularly in relation to quality of consultation and the practice could not demonstrate any formal plans for improvement. At this follow up inspection we saw evidence that the practice had developed and implemented plans to improve. However, the latest results showed achievement for some aspects of care below local and national averages

The areas of practice where the provider should make improvements are:

• Continue to explore ways to improve service using patient feedback, particularly in relation to quality of consultation with all clinical staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Kanjana Paramanathan on 6 September 2016. Overall the practice is rated as requires improvement.

• The practice was previously inspected by CQC in March 2015 and the practice was rated as requires improvement. Specifically we found improvements were needed in respect of the following; :

• Premises and equipment needed improving. An assessment of the building was required to ensure reasonable adjustments were considered so that people with a disability were able to access the service.

• Improvements were required to the systems for handing complaints as they were not effective and the complaints procedure was not easily accessible to patients.

• Effective systems were required to identify, assess and manage risks relating to the health, welfare and safety of service users and others who may be at risk from them carrying on of the regulated activity. For example legionella, fire and medicine management.

• An effective recruitment procedure was required to ensure appropriate checks were always completed prior to staff commencing their post. This included proof of identity and evidence of good character being obtained for staff prior to recruitment.

At this inspection we noted that most of the issues we had identified previously had been actioned and improvements made.

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.

• The practice had not registered to receive patient safety alerts directly; however they demonstrated that they had responded to medicine safety alerts received via the CCG.
• Arrangements were in place for emergency medicines to be provided by the adjoining pharmacy, however this arrangement was informal and assurance of availability had not been considered.
• The practice had not considered the risk to not having access to a defibrillator in the event of an emergency.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. However, we saw an example of where the practice had prescribed high risk medicines without confirming appropriate monitoring of bloods had taken place.
• 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 and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• The practice was aware of areas needing further improvement as highlighted by the national GP patient survey. However, no formal plans had been developed outlining how improvements would be achieved.
• There was a clear leadership structure and staff felt supported by management. However, the providers did not have effective systems and processes in place to enable them to identify and mitigate risks to patients or others and governance and oversight needed significant strengthening.

The areas where the provider must make improvement are:

• The provider must have effective systems to enable them to assess and monitor the quality of the service. For example by having clear communication, systems and policies which are understood and followed in order to identify, assess and mitigate risks. For example the timely receipt of safety alerts, ensuring clinical staff have the appropriate indemnity insurance and use feedback from patients to drive improvements in the service, such as in relation to national patient survey feedback.

• Take all practicable steps to identify and mitigate risks to patients of receiving unsafe care and treatment, for example the management of high risk medicines and the arrangements for emergency medicines and equipment.

The areas where the provider should make improvement are:

• All staff should be aware of the policy to allow people with no fixed address to register or be seen at the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Kanjana Paramanathan on 17 March 2015. Overall the practice is rated as requires improvement.

Specifically, we found the practice to require improvement for providing safe, caring, responsive and well-led services. We found the service to be good for providing effective services.

The areas for improvements that led to these ratings also applied to all of the six population groups that we inspected and which are also rated as requires improvement. These were, people with long term conditions, families, children and young people, working age people, older people, people in vulnerable groups and people experiencing poor mental health.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, not all risks were assessed and managed, such as legionella, fire, recruitment and medicine management.

• There were effective arrangements in place to identify, review and monitor patients with long term conditions. Patients’ needs were assessed and care was planned and delivered following best practice guidance.

• The majority of patients said they were treated with dignity and respect and they were involved in their care and decisions about their treatment. Data from the 2014-2015 national GP survey showed that patients rated the practice lower than others for some aspects of care and some of these areas had not been acted on.

• There were services aimed at specific patient groups for example, there were vaccination clinics for babies, children and those in high risk groups. The practice had not fully recognised the needs of different groups in the planning of its services. For example, people who were homeless and patients with a physical disability.

• There was visible leadership with defined roles and responsibilities and staff felt supported by the management team. Staff had received performance reviews and attended staff meetings and events. However, the governance arrangements at the practice was not robust as not all essential risks had not been assessed and managed.

The areas where the provider must make improvements are:

• Have robust governance systems in place for the management of risks to patients and others against inappropriate or unsafe care. This must include assessing and managing risks in areas such as legionella, fire and medicine management.

• Operate effective recruitment procedures and ensure that the information required under current legislation is available in respect of all staff employed to work at the practice.

• Take appropriate actions to ensure that reasonable adjustments are made to enable people with a physical disability to access the service.

• Establish robust systems for the management and handling of complaints and make information on raising complaints easily accessible to patients and others.

In addition the provider should:

• Ensure non clinical staff receive infection prevention and control training so that they are up to date with good practice.

• Proactively undertake dementia screening for patients to ensure early identification and intervention.

• Ensure clinical audits complete their full cycle in order to demonstrate improvements made to patient outcomes.

• Ensure that all areas of feedback from the 2014-2015 national GP patient survey is reviewed and acted on to improve patients experience of the service.

• Have clear processes in place for staff to follow so that patients with no fixed address or those requiring temporary registration can be seen or be registered at the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice