We carried out an announced comprehensive inspection at Ramanathan Surgery on 19 July 2017. The overall rating for the practice was requires improvement. The full comprehensive report on the July 2017 inspection can be found by selecting the ‘all reports’ link for Ramanathan Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 7 February 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 inspection on 19 July 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

• There were systems in place to ensure that patients prescribed a high risk medicine in a secondary care setting were being monitored appropriately.
• Clinical staff had access to the latest guidance from National Institute for Clinical Excellence (NICE).
• Care and treatment was provided in a safe way to patients.
• The practice had considered ways to improve the level of patient involvement and satisfaction in their care.
• The practice had systems to keep clinicians up to date with current evidence-based practice. We saw clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

This inspection of Ramanathan Surgery was carried out on 19 July 2017 and was to check improvements had been made since our second inspection on 16 August 2016.

We initially inspected Ramanathan Surgery on 14 December 2015. At the December 2015 inspection the practice was rated as inadequate overall. Specifically they were rated as inadequate for safe and well-led, requires improvement for effective, caring and responsive.

We completed a second inspection on 16 August 2016 to review improvements made since the December 2015 inspection. Following our August 2016 inspection the practice was rated as requires improvement overall. Specifically they were rated as inadequate for caring, requires improvement for safe and well led and good for effective and responsive.

The practice was placed in special measures for an extended period. The full comprehensive reports on the inspections can be found by selecting the ‘all reports’ link for Ramanathan Practice on our website at www.cqc.org.uk.

As a result of our findings at the August 2016 inspection we took regulatory action against the provider and issued them with a warning notice and requirement notices for improvement.

Following the inspection on 16 August 2016 the practice sent us an action plan that explained what actions they would take to meet the regulations in relation to the breaches of regulations.

At this inspection we found that the majority of the improvements had been made and progress had been made across all areas of concern. However the practice is still rated as requires improvement overall.

Our key findings were as follows:

• Significant events were fully investigated; if patients were involved they would receive support, honest explanations and apologies in line with the duty of candour. The learning was shared with appropriate staff.
• Staff demonstrated that they understood their responsibilities and all had received training on safeguarding children and vulnerable adults relevant to their role.
• Risks relating to health and safety, fire, infection control and legionella were assessed and managed.
• There were systems in place to ensure safe medicines management.
• Patients prescribed high risk medicines by the practice received appropriate monitoring and review. However the practice did not have an effective system to monitor and review patients whose prescription was initiated in a secondary care setting. Following our inspection they initiated a system to ensure that no repeat medicines would be prescribed without appropriate monitoring taking place. They also implemented a process to review all patients prescribed a high risk medicine for whom they did not have evidence that the appropriate monitoring checks had taken place.
• The practice had a system in place to deal with any patient safety and medicines alerts.
• There was a clear recruitment process in place for permanent and locum staff. Clinical staff files contained evidence of vaccination and level of immunity against Hepatitis B.
• Staff received appropriate training to fulfil their roles.
• Staff did not have access to all the latest evidence based guidance from the National Institute for Health and Clinical Excellence (NICE), however during our inspection they signed up to electronic updates and told us that there would now be an agenda item on their clinical meetings to discuss latest guidelines to ensure that both GP and nursing staff were aware of the latest updates.
• Staff sought patients’ consent to care and treatment in line with legislation and guidance.
• Policies and procedures were up to date, practice specific and staff were aware of where to find them and their contents.
• Feedback from patients on the day about their care was consistently positive.
• Data from the GP survey, published in July 2017, was lower than compared to other practices locally and nationally in their scores around the level of patient involvement, however showed an improvement from the previous year’s data.
• The practice had a system for identifying and supporting the carers on their register.
• The complaints policy was clearly visible to patients. Complaints were fully investigated and there was a clear audit trail of actions taken by the practice.
• There were processes in place to gather and act on patient feedback including a patient participation group (PPG).
• Staff had worked as a team to act on the feedback from the previous inspection and involved the PPG in identifying changes needed relating to patients.

However, there were still areas of practice where the provider needed to make improvements.

Importantly, the provider must:

• Ensure where patients are prescribed a high risk medicine in the secondary setting, GPs are assured that appropriate monitoring checks have taken place and it is safe to prescribe a repeat for that medicine.
• Ensure care and treatment is provided in a safe way to patients.

The provider should:

• Review and improve systems relating to clinical governance. Including implementing a system to make sure that all clinical staff are aware of the latest available guidelines and the implications for the practice have been discussed. Where monitoring checks are completed, for example, for high risk medicines, ensure that appropriate documented action and follow up take place.
• Consider ways to further improve level of patient involvement and satisfaction in the services provided.

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

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

On 14 December 2015, we carried out a comprehensive announced inspection. We rated the practice as inadequate overall. The practice was rated as inadequate for providing safe, and well-led services and requires improvement for providing effective services, caring and responsive services. As a result of the inadequate rating overall the practice was placed into special measures for six months.

Practices placed into special measures receive another comprehensive inspection within six months of the publication of the report so we carried out an announced comprehensive inspection at Ramanathan Surgery on 16 August 2016 to check whether sufficient improvements had been made to take the practice out of special measures.

On the day of this inspection we rated the practice as requires improvement overall.

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

• There was a system in place for reporting and recording significant events. The practice had an open and transparent approach to dealing with incidents; however not all staff who were responsible for investigating when mistakes occurred were aware of the duty of candour.
• There was no effective system in place to ensure that patient safety and medicines alerts were received or actioned to protect patient safety.
• There was no effective system in place to review patients to ensure safe prescribing.
• Risks relating to health and safety, fire, infection control and legionella were assessed and well managed.
• The practice had emergency oxygen and medicines available.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Staff sought patients’ consent to care and treatment in line with legislation and guidance. One GP told us that they would not prescribe to patients under the age of 16, attending without a parent or guardian. Other staff were unaware of this GP’s views.
• Data showed patient outcomes were comparable to local and national averages. A programme of clinical audits had been commenced since our last inspection.

• Patients we spoke with said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment; however data from the national GP patient survey, published in July 2016, showed patients rated the practice lower than others for many aspects of care.

• 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.
• Patients said they were able to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice had only identified 0.3% of their patient list as carers; however there was information and support available for these patients.

The areas where the provider must make improvements are:

• Implement an effective system to ensure all safety and medicines alerts are received and actioned.
• Implement an effective patient review system to ensure patient’s health and medicines needs are being met
• Ensure that GPs understand the current guidance for assessing the competency of patients under the age of 16 attending without a parent or guardian.
• Ensure relevant staff are aware of the duty of candour.
• Respond to low levels of patient satisfaction as reflected in the national GP patient survey.

In addition the provider should:

• Implement change to improve patient feedback within the national GP patient survey
• Continue the newly implemented programme of clinical audit to drive improvement.
• Increase the identification of patients with caring responsibilities.

This service was placed in special measures in February 2016. Insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall. Therefore, we are taking 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 six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

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 Ramanathan Surgery on 14 December 2015. 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 emergency medicines and equipment were inadequate and recruitment checks were incomplete. The practice did not have an induction or recruitment pack for locum staff.

• Staff were not clear about reporting or recording incidents, near misses and concerns and there was no evidence of learning and communication with staff.

• Prescription pads were not being stored securely or monitored.

• Patient outcomes were hard to identify as very little reference was made to audits or quality improvement.

• There was no system in place for consistently read-coding patient information, therefore patient records were not fully auditable.

• Appointment systems were working and patients received timely care when they needed it.

• Patients were positive about their interactions with staff and said they were treated with compassion and dignity, although data from the GP patient survey published in July 2015 suggested this was not always the case.

• Complaints were not recorded in detail and verbal complaints were not recorded at all.

• The practice had a number of policies and procedures to govern activity, but not all were being implemented and not all staff knew how to access them.

• The practice had no clear leadership structure, insufficient leadership capacity and limited formal governance arrangements.

The areas where the provider must make improvements are:

• Introduce processes for reporting, recording, acting on and monitoring significant events, incidents and near misses.

• Take action to address identified concerns with emergency medicines and equipment.

• Ensure recruitment arrangements include all necessary employment checks for all staff.

• Carry out clinical audits including re-audits to ensure improvements in services have been achieved.

• Ensure prescription pads are stored securely and their use is monitored

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

• Ensure staff can access appropriate policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.

• Clarify the leadership structure in the practice and ensure there is leadership capacity to deliver all improvements.

The areas where the provider should make improvement are:

• Risk assess the need for a defibrillator to be located within the practice.
• Introduce a structured method of sharing information with all staff including learning from complaints and serious incidents to help drive improvement within the practice.

• Introduce an induction process and recruitment pack for locum staff.

• Promote the identification of carers within the practice in order they may be appropriately supported.

I am placing this practice in special measures. Practices 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 practice 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 vary the provider’s registration to remove this location or cancel the provider’s registration. Special measures will give people who use the practice the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice