We carried out an announced follow-up comprehensive inspection at Dr Manickam Murugan on 12 March 2019.

We previously carried out an announced comprehensive inspection at Dr Manickam Murugan on 11 January 2018. Overall the practice was rated overall as requires improvement. Breaches of legal requirements were found and requirement notices were served in relation to good governance and fit and proper persons employed. We also made five good practice recommendations. The full comprehensive report on the January 2018 inspection can be found by selecting the ‘all reports’ link for Dr Manickam Murugan on our website at .

At the last inspection in January 2018, we rated the practice and all of the population groups as requires improvement for providing safe services because:

• The practice had not obtained all of the required staff checks when recruiting new staff .
• The practice had not assessed the impact of reduced reception staff hours on the service.
• Reception staff did not have access to ‘red flag’ alerts to assist them on how to respond to symptoms that might be reported by patients.
• It was not clear if there were any designated fire marshals within the practice and not all staff were up to date with their fire training.

At this inspection, we found that the provider had satisfactorily addressed these areas.

We previously rated the practice and all of the population groups as requires improvement for providing effective services because:

• The practice did not have a structured system to keep clinicians up to date with current evidence-based practice.
• The programme of quality improvement activity and reviews of the effectiveness and appropriateness of the care provided needed to be further developed.

At this inspection, we found that the provider had satisfactorily addressed most of these areas.

We previously rated the practice and all of the population groups as requires improvement for providing caring services because:

• The deterioration in the results of the National GP Survey published in July 2017.
• The lack of any clear action taken by the practice to address the worsening GP Survey results.

At this inspection, we found that the provider had satisfactorily addressed these areas.

We previously rated the practice and all of the population groups as requires improvement for providing responsive services because:

• The deterioration in the results of the National GP Survey published in July 2017.

At this inspection, we found that the provider had not satisfactorily addressed these areas.

We previously rated the practice and all of the population groups as requires improvement for providing well-led services because:

• Clinical leadership and capacity and governance arrangements needed to be further developed.
• Effective processes to identify, understand, monitor and address current and future risks including risks to patient safety needed to be further developed and implemented.
• Arrangements were not in place to review and take effective action in response to the clinical performance of the practice.
• Limited arrangements were in place to explore and address the deterioration in the National GP Survey scores.

At this inspection, we found that the provider had satisfactorily addressed most of these areas.

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 for safe and responsive services and good for effective, caring and well-led services. The overall rating of requires improvement affected all population groups.

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

• The systems, processes and practice that helped to keep patients safe and safeguarded from abuse at the time of the inspection were insufficient. Not all staff were up to date with safeguarding and essential training and safeguarding policies did not reflect current national updates.
• The practice did not hold a register of children at risk or hold meetings with health visitors to discuss these children or frequent attenders at A&E.
• The practice had not implemented a system to monitor and follow up children who did not attend their appointment following referral to secondary care.
• The practice did not have a child pulse oximeter in place.
• The management of medicine reviews required greater oversight.

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

• Results from the national GP survey showed that patient’s satisfaction with how they could access care and treatment continued to be lower than local and national averages.

We rated the practice good for providing effective, caring and well-led services because:

• There was a positive culture for reporting, recording and learning from significant events.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
• The practice conducted safety risk assessments and had a suite of safety policies which were regularly reviewed and communicated to staff.
• The practice worked with other agencies to improve patient care.
• Although the practice did not have a formal proactive audit plan in place, some improvements had been made to quality improvement activity.
• The arrangements for clinical leadership and overall governance structures had been reviewed, further developed and changes implemented.
• Processes to identity, understand, monitor and address current and future risks, including risks to patient safety, had improved.
• Staff were supported in their roles and with their professional development.
• Regular meetings were held with staff to communicate to share information and practice performance.

The areas where the provider must make improvements as they are in breach of regulations are:

• Care and treatment must be provided in a safe way for service users

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

The areas where the provider should make improvements are:

• Improve telephone access to the practice.
• Undertake a review of staffing levels to help improve patient access.
• Ensure all staff complete outstanding training.
• Develop a structured programme of quality improvement activity.
• Provide the fire marshal with a high visibility vest in the event of a fire evacuation.
• Update the practice website to reflect the changes in staffing.
• Ensure reception staff are able to use the hearing loop.
• Improve the awareness and uptake of the patient participation group.

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

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Manickam Murugan on 17 May 2017. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months.

We found three breaches of legal requirements and as a result we issued requirement notices in relation to:

• Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 – Good Governance
• Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 – Fit and Proper Persons Employed

In addition we issued a warning notice in relation to:

• Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 – Safe Care and Treatment.

This inspection was an announced focused inspection carried out on 2 October 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in Regulation 12 that we identified in our previous inspection on 17 May 2017. This report only covers our findings in relation to those requirements. The full comprehensive report on the May 2017 inspection can be found by selecting the ‘all reports’ link for Dr Murugan Manickam on our website at www.cqc.org.uk.

Our key findings are as follows:

• We found that the practice had addressed the issues identified in the warning notice.
• A clinical monitoring policy and monitoring form had been developed to be used when supervising clinical staff.
• There were no staff working in an advanced clinical capacity currently employed so we were unable to check the effectiveness for the policy and monitoring form in practice.
• We saw records that demonstrated the provider had supervised the newly appointed practice nurse and reviewed a random sample of the electronic records to ensure that adequate information had been recorded and the practice nurse had covered all aspects during the consultation as required.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Dr Manickam Murugan on 25 August 2016. The overall rating for the practice was Requires Improvement. We found one breach of a legal requirement and as a result we issued a requirement notice in relation to:

• Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 – Good Governance.

The full comprehensive report from the inspection on the 25 August 2016 can be found by selecting the ‘all reports’ link for Dr Manickam Murugan on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection on 16 May 2017. Overall the practice is now rated as inadequate.

Following the inspection we sent a letter to the provider, which required them to provide the Care Quality Commission with information under Section 64 of the Health and Social Care Act 2008 and Regulation 10 Care Quality Commission (Registration) Regulations 2009. This related to the use of the message / triage book and whether appropriate action had been taken and recorded by clinicians in relation to patient care.

Our key findings were as follows:

• There was a lack of clinical leadership and governance within the practice.
• Patients were at risk of harm because there was no clinical oversight of the message / triage book to ensure clinical staff working in advanced roles were taking appropriate action or recording information in patient notes.
• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, the practice had not carried out appropriate recruitment checks on staff before employing them, store vaccines in line with manufacturers’ guidelines, or check all blood results in a timely manner.
• There was a lack of formalised systems in place to provide assurance that the Advanced Nurse Practitioner or the Advanced Clinical Pharmacist had the necessary skills and competency to carry out their advanced roles.
• There practice did not have a systematic approach for the receipt, sharing, monitoring and implementation of National Institute of Health and Social Care Excellence (NICE) best practice updates and guidelines.
• Patient outcomes were hard to identify as little or no reference was made to audits or quality improvement and there was no evidence that the practice was comparing its performance to others; either locally or nationally.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Patients told us they were usually able to get appointments when they needed them, although it was more difficult to book an appointment with the GP. Not all patients were aware that pre-bookable appointments were available.

There were areas of practice where the provider needs to make improvements.

Importantly, the provider must:

• Ensure that all Patient Group Directives are signed by both the GP and the practice nurse.
• Ensure vaccines are always stored in line with manufacturers’ guidelines.
• Ensure that blood results are reviewed and actioned in a timely manner.
• Ensure recruitment arrangements include all necessary legislative employment checks for all staff.
• Have a systematic approach for the receipt, sharing, monitoring and implementation of National Institute of Health and Social Care Excellence (NICE) best practice updates and guidelines.
• Introduce a system that supports the medicines used to treat systems of shock (anaphylaxis) have been checked.
• Have systems in place to support that the provider had assured themselves that clinical staff, especially those working in advanced roles have the necessary skills and competency to carry out those roles.
• Have systems in place to demonstrate clinical oversight of the message / triage book to ensure clinical staff working in advanced roles were taking appropriate action or recording information in patient notes.
• Have in place sufficient clinical leadership capacity and formal governance arrangements.

In addition the provider should:

• Carry out a risk assessment to support the rationale for not stocking injectable medicines to treat nausea and vomiting or severe pain.
• Assure themselves that the defibrillator is in good working order.
• Share the mission statement and vision with staff.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

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 of Dr Manickam Murugan on 7 January 2016. A total of three breaches of legal requirements were found. After the comprehensive inspection, the practice was rated as requires improvement overall.

We issued requirement notices in relation to:

• Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) 2014. Safe care and treatment.
• Regulation 17 HSCA (RA) Regulations 2014 Good governance.
• Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) 2014. Fit and proper persons employed.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Dr Manickam Murugan on our website at www.cqc.org.uk.

We undertook an announced comprehensive inspection on 25 August 2016 to check that the practice now met legal requirements.

Our key findings were as follows:

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• The practice had made improvements to the process for recording, investigating and learning from incidents that may affect patient safety. An effective system had been introduced for reporting and recording significant events.
• Improvements had been made to the governance arrangements in place, including the management of recruitment and effective system for handling complaints and concerns.
• Risks to patients were not always assessed and well managed. This included the management of patients who took high risk medicines and evidence to support that appropriate action had been taken following receipt of medicines and equipment alerts and the emergency medicines, oxygen and defibrillator had been checked.
• Systems to monitor the use of prescription pads and blank computer prescription forms had been introduced although a number of improvements were still required. These were addressed during the inspection.
• The appointment system was not working for patients. They told us they found it difficult to book an appointment, because they were unable to get through on the telephone and appointments could only be booked on the day and not in advance.
• There was a lack of evidence to support clear leadership within the practice. For example, there was no established clear vision or direction to influence staff in the activities required toward achievement of safe patient care.

The areas the provider must make improvements are:

• Introduce a system which demonstrates that medicines and equipment alerts issued by external agencies are acted upon.
• Introduce effective systems to monitor patients who are prescribed high risk medicines.
• Carry out risk assessments for the areas of the building used by the practice.
• Introduce a system that supports that the emergency medicines, oxygen and defibrillator have been checked.
• Develop a clear leadership structure, with a clear vision or direction to influence staff in activities towards achievement.

In addition the provider should:

• Ensure that all children on the child protection register have an alert on their computerised record.
• Identify the infection control lead for the practice and share this information with staff.
• Ensure that all staff complete the e-learning training modules, including infection prevention and control.
• Ensure that clinical audit cycles are completed in order to prompt improvement in patient outcomes and consider other clinical quality improvement initiatives.
• Adopt a more proactive approach to identifying and meeting the needs of carers.
• Improve the quality of services provided for patients contacting the practice by telephone and access to appointments.
• Ensure that all patient contact is recorded in on the electronic patient record.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Dr Manickam Murugan on 16 May 2017. The overall rating for the practice was Inadequate and the practice was placed into special measures. This was because of the lack of clinical and management oversight within the practice which did not keep patients safe.

We undertook an announced focused inspection on 2 October 2017 to follow up on the warning notice. We found that the provider had developed a clinical supervision policy and a monitoring form, and the practice nurse was receiving regular supervision.

Both the full comprehensive report on the May 2017 inspection and the focused report on the October 2017 inspection can be found by selecting the ‘all reports’ link for Dr Manickam Murugan on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 11 January 2018 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 comprehensive inspection on 16 May 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

This practice is rated as requires improvement overall. (The practice was rated inadequate at our previous inspection on 16 May 2017)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Requires Improvement

Are services responsive? – Requires Improvement

Are services well-led? – Requires Improvement

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Requires Improvement

People with long-term conditions – Requires Improvement

Families, children and young people – Requires Improvement

Working age people (including those retired and students – Requires Improvement

People whose circumstances may make them vulnerable – Requires Improvement

People experiencing poor mental health (including people with dementia) - Requires Improvement

Our key findings were as follows:

• We saw that the improvements seen during our previous inspection had been maintained.
• There had been an improvement in clinical leadership and capacity following the recent appointment of a salaried GP.
• The practice had some systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• There were areas where the practice did not have appropriate safety arrangements in place.
• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
• The practice had a recruitment policy that set out the standards to be followed when recruiting clinical and non-clinical staff. However, there were exceptions, for example, a Disclosure and Barring Service check had not been obtained for one newly recruited member of staff.
• The practice did not have a structured system to keep clinicians up to date with current evidence-based practice or review the effectiveness and appropriateness of the care it provided.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Patients found the appointment system easy to use and reported that they were generally able to access care when they needed it. However, some patients made reference to the challenges getting through on the telephone to make an appointment, particularly in the morning.
• We found that the majority of the scores in the National GP Patient Survey published in July 2017 were lower than the scores in the July 2016 survey. The practice had since carried out its own patient satisfaction survey and developed an action plan to address identified issues.

However, there were also areas of practice where the provider needs to make improvements.

Importantly, the provider must:

• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition the provider should:

• Ensure a review is undertaken to include a risk assessment of the availability of medicines to manage emergency situations.
• Review the storage arrangements and labelling of emergency medicines to ensure these can be easily identified in the case of an emergency.
• Review the process in place to ensure the identification of significant events through complaints received where appropriate.
• Review the reason for lower than average referral rates using the urgent two week wait referral pathway.
• Review the process in place to ensure all staff have read and signed minutes of meetings in line with practice policy.

I confirm that this practice has improved sufficiently to be rated Requires Improvement overall.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice