This practice is rated as requires improvement overall. The practice was previously inspected on 4 May 2016. At that inspection the rating for the practice was Inadequate overall. This rating applied to the effective, well led domains and all six population groups. Safe, caring and responsive were rated as requires improvement. At that time the practice was placed into special measures. A further inspection was held on 31 January 2017. At that time the practice was removed from special measures and the practice was rated as requires improvement in all areas except responsiveness where it was rated as good.

The report stated where the practice must make improvements:

• Ensure that vaccines are stored in line with guidance.
• Ensure that patient outcomes are continually reviewed throughout the year.
• Ensure that consent for cervical smear tests are adequately recorded.
• Seek and act on the views of people who use the service.

In addition, the provider should:

• Consider sharing the outcomes of serious untoward incident investigations with all staff.
• Consider adding contact details of all staff and providers with whom the service works to the business continuity plan.
• Ensure that meetings are held with the local mental health team.
• Consider reviewing recall systems for cervical smears and bowel and breast screening.
• Consider improving identification of carers on the patient list.
• Consider minuting all staff meetings.

A comprehensive follow up inspection was carried out on 10 May 2018. This was in follow up the inspection in which the practice was rated as requires improvement overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Requires improvement

Are services caring? – Requires improvement

Are services responsive? – Good

Are services well-led? – Requires improvement

At this inspection we found:

• The practice had clear 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.
• The practice had implemented defined and embedded systems to minimise risks to patient safety.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• The provider had improved the management of all patients with long term conditions with the exception of diabetes.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• The practice had not implemented an action plan in response to national patient survey results which were in several areas significantly lower than the national average.
• Information about services and how to complain was available.
• Patients said that the practice was responsive to their needs.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

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

• Ensure that systems and processes are in place to ensure good governance. This should include reviewing and taking action to address patient feedback, to ensure that patients with diabetes are well managed, and to improve the practice’s cervical smear uptake.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Letter from the Chief Inspector of General Practice

The practice was previously inspected by the CQC on 4 May 2016. At that stage the overall rating for the practice was inadequate. This rating applied to effective, well led and all six population groups. Safe, caring and responsive were rated as requires improvement. Following the inspection the practice was placed into special measures for six months and warning notices were issued. The report stated that the practice must do the following:

• Ensure that safe systems were in place, including completion of mandatory training, following cold chain guidance and maintenance of all all clinical equipment is up to date.

• Ensure that govenance systems were in place, including practice’s recall systems, appointments systems, acting on the views of people who use the service and ensure staffing is adequate, including performance monitoring.

We carried out an announced comprehensive inspection at Dr P Arumugaraasah's & Partners on 31 January 2017. We found that the practice had made improvements following the last inspection, and it is now rated as requires improvement.

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

• There was an open and transparent approach to safety and a system in place for reporting and recording significant events, although learning from events was not formally shared with non-clinical staff.
• The practice had mostly defined and embedded systems to minimise risks to patient safety, but vaccines were not stored in line with guidance.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• Patient outcomes were lower than the national average in most areas, and cervical smears were not recorded in line with guidance in the patient record.
• Results from the national GP patient survey and patients that we spoke to on the day of the inspection showed patients were less satisfied with the service provided than the national average.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The practice reported that it proactively sought feedback from staff and patients, but could not provide evidence of changes instigated by such feedback.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider must make improvements are:

• Assess the risks to the health and safety of service users of receiving the care or treatment in respect of

• The proper and safe management of medicines.

• Follow-up of patients with complex and long term conditions.

• Cervical smear procedures and recording

• Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.

In addition the provider should:

• Consider sharing the outcomes of serious events investigations with all staff.

• Consider adding contact details of all staff and providers with whom the service works to the business continuity plan.

• Ensure that meetings are held with the local mental health team.

• Review cervical smear and bowel and breast screening in order to improve outcomes for patients.

• Review and improve how patients with caring responsibilities are identified and recorded on the clinical system to ensure that information, advice and support is made available to them.

• Consider minuting all staff meetings.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

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 P Arumugaraasah's and Partners on 4 May 2016. Overall the practice is rated as inadequate.

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

• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, staff had not had training which was required for their role.

• The practice had a serious untoward event procedure, but the number of issues recorded was relatively low and the practice did not have robust systems in place to ensure that all events were being identified.

• Patient outcomes from QOF were below the national average. There was 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 were positive about their interactions with staff and said they were treated with compassion and dignity.

• Urgent appointments were not always available, and the nurse undertook triage for the practice. She was not qualified for this role..

• The practice had no clear leadership structure, insufficient leadership capacity and limited formal governance arrangements. This impacted on the practice’s ability to deliver safe, effective, caring and responsive services.

The areas where the provider must make improvements are:

• All staff receive mandatory training and that a record of this training is retained.

• Ensure cold chain guidance is followed when the temperatures at which vaccines can be safely stored are not met.

• Ensure calibration of all clinical equipment is up to date.

• Ensure the practice’s recall systems are reviewed and that patient outcomes are continually reviewed throughout the year.

• Ensure that the appointments system meets the needs of ptients meets the needs of patients who need to be seen both routinely and in an emergency.

• Seek and act on the views of people who use the service.

• Ensure that staffing requirements for the practice are adequate.

• Ensure all staff are appraised on a yearly basis.

The areas where the provider should make improvement are:

• Should ensure that the practice formally discusses serious untoward incidents.

• The practice should consider ensuring that protocols are in place detailing support available to carers and bereaved patients.

• The practice should ensure that its business continuity plan is available and up to date.

• The practice should ensure that all notifications from NICE, MHRA and the GMC from the period when the practice had no access are re-requested and reviewed The practice should also ensure that all clinical staff are aware of how to access best practice guidelines.

• The practice should ensure all clinical staff know how to use translation services.

• The practice should ensure that meetings are held with the local palliative care and mental health teams

• The practice should consider improving identification of carers on the patient list.

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