Dr Srinivas Rao Dasari and Dr Raveendra …...Dateofpublication:05/10/2016 1Dr Srinivas Rao Dasari...

This report describes our judgement of the quality of care at this service. It is based on a combination of what we foundwhen we inspected, information from our ongoing monitoring of data about services and information given to us fromthe provider, patients, the public and other organisations.

Ratings

Overall rating for this service Requires improvement –––

Are services safe? Requires improvement –––

Are services effective? Good –––

Are services caring? Good –––

Are services responsive to people’s needs? Good –––

Are services well-led? Requires improvement –––

DrDr SrinivSrinivasas RRaoao DasariDasari andand DrDrRRaveendraveendraa KatKatamaneniamaneniQuality Report

15 Rowlands RoadYardleyBirminghamB26 1ATTel: 0121 7066623Website: www.rowlandsroadsurgery.co.uk

Date of inspection visit: 3 August 2016Date of publication: 05/10/2016

1 Dr Srinivas Rao Dasari and Dr Raveendra Katamaneni Quality Report 05/10/2016

Contents

PageSummary of this inspectionOverall summary 2

The five questions we ask and what we found 4

The six population groups and what we found 7

What people who use the service say 11

Detailed findings from this inspectionOur inspection team 12

Background to Dr Srinivas Rao Dasari and Dr Raveendra Katamaneni 12

Why we carried out this inspection 12

How we carried out this inspection 12

Detailed findings 14

Action we have told the provider to take 26

Overall summaryLetter from the Chief Inspector of GeneralPracticeWe carried out an announced comprehensive inspectionat Dr Srinivas Rao Dasari and Dr Raveendra Katamaneni’spractice on 3 August 2016. Overall the practice is rated asrequires improvement.

Our key findings across all the areas we inspected were asfollows

• Staff understood their responsibilities to raiseconcerns, and to report incidents and near misses.However, the practice was not proactive in utilisingopportunities from incidents to support learning andservice improvement.

• We found systems were well implemented tosafeguard vulnerable patients, for the management ofmedicines and for managing medical emergencies.

• Although risks to patients who used services wereassessed, the systems and processes to address theserisks were not always sufficient to ensure patientswere kept safe. For example, risks relating to infectioncontrol, health and safety, disaster recovery,recruitment and staffing.

• There was limited capacity for the practice managerand practice nurse which reflected on some of thegovernance arrangements of the practice andperformance data.

• Data showed patient outcomes were in line with thenational average in most areas.

• Staff assessed patients’ needs and delivered care inline with current evidence based guidance. Staff hadbeen trained to provide them with the skills,knowledge and experience to deliver effective careand treatment.

• Patients said they were treated with compassion,dignity and respect and they were involved in theircare and decisions about their treatment.

• Patients said they found it easy to make anappointment and did not have to wait too long toobtain one, urgent appointments were available thesame day.

• The practice had good facilities and was well equippedto treat patients and meet their needs.

• Information about services and how to complain wasavailable and easy to understand. The practice hadreceived few formal complaints.

Summary of findings


• There was a clear leadership structure and staff feltsupported by management. However, there waslimited evidence that the practice was proactive inseeking feedback from patients to deliver serviceimprovements.

• The practice had a number of policies and proceduresto govern activity, but some of these were not practicespecific.

The areas where the provider must make improvementsare:

• Review systems for the identification andmanagement of risks within the service. Includingstaffing, recruitment checks, those relating to healthand safety of the premises, infection control andbusiness continuity.

In addition the provider should:

• Review system for reporting incidents and verbalcomplaints to identify how these could be moreeffectively used to support learning and serviceimprovement. Ensure the complaints process isavailable to patients.

• Introduce an alert system onto the patient record sothat those at risk of harm may be more easilyidentified.

• Review the coding of dementia patients to ensure allrelevant patients are correctly identified and receiveappropriate care and treatment.

• Reinstigate formal arrangements to ensure the needsof those with end of life or complex care are discussedregularly.

• Review and improve systems for obtaining patientfeedback so that patients’ views may be taken intoaccount when delivering services.

• Maintain accurate staff training records to ensuretraining is up to date.

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

Summary of findings


The five questions we ask and what we foundWe always ask the following five questions of services.

Are services safe?The practice is rated as requires improvement for providing safeservices.

• Staff understood their responsibilities to raise concerns, and toreport incidents and near misses. However, the practice wasnot proactive in utilising opportunities from incidents tosupport learning and service improvement.

• We found systems were well implemented to safeguardvulnerable patients, for the management of medicines and formanaging medical emergencies.

• Although risks to patients who used services were assessed, thesystems and processes to address these risks were not alwayssufficiently effective to ensure patients were kept safe. Forexample, risks relating to infection control, health and safety,disaster recovery, recruitment and staffing.

• There was limited capacity for the practice manager andpractice nurse which reflected on some of the governancearrangements of the practice and performance data.

Requires improvement –––

Are services effective?The practice is rated as good for providing effective services.

• Data from the Quality and Outcomes Framework (QOF) showedpatient outcomes were at or above average compared to thenational average in most areas.

• Staff assessed needs and delivered care in line with currentevidence based guidance.

• Clinical audits were used to support quality improvement.• Staff had the skills, knowledge and experience to deliver

effective care and treatment.• There was evidence of appraisals and personal development

plans for staff.• Staff worked with other health care professionals to understand

and meet the range and complexity of patients’ needs,although multidisciplinary meetings to discuss those with endof life care needs did not routinely take place.

Good –––

Are services caring?The practice is rated as good for providing caring services.

Good –––

Summary of findings


• Data from the national GP patient survey showed patientsrating of the practice was similar to others in the CCG area andnationally. The exception being the latest data on patientinvolvement in care and treatment although this was notconsistent with other feedback received.

• Patients said they were treated with compassion, dignity andrespect and they were involved in decisions about their careand treatment.

• Information for patients about the services available was easyto understand and accessible.

• We saw staff treated patients with kindness and respect, andmaintained patient and information confidentiality.

Are services responsive to people’s needs?The practice is rated as good for providing responsive services.

• Practice staff reviewed the needs of its local population andengaged with the NHS England Area Team and ClinicalCommissioning Group to secure improvements to serviceswhere these were identified. The practice participated in theCCG led Aspiring for Clinical Excellence to help deliver serviceimprovements and innovation.

• Patients said they found it easy to make an appointment anddid not have to wait too long to obtain one, urgentappointments were available the same day.

• The practice had good facilities and was well equipped to treatpatients and meet their needs.

• Information about how to complain was available and easy tounderstand and evidence showed the practice respondedquickly to issues raised. Evidence of learning from complaintswas limited, few formal complaints had been received andthere were no specific systems for recording verbal complaintsso that any themes or trends might be identified.

Good –––

Are services well-led?The practice is rated as requires improvement for being well-led.

• Although the practice had set out its values for the practice wedid not see any formal vision or strategy for the future of thepractice.

• The practice had a clear leadership structure and staff feltsupported by management and the partners.


Summary of findings


• Capacity was a significant issue in that the practice receivedonly one and half days management cover. This resulted insome weaknesses in relation to the arrangements for managingrisks, and for maximising opportunities for learning fromincidents, verbal complaints and general patient feedback.

• The practice had a number of policies and procedures togovern activity, but some of these were not practice specific ordid not contain sufficient detail to support staff in their roles.

Summary of findings


The six population groups and what we foundWe always inspect the quality of care for these six population groups.

Older peopleThe practice is rated as requires improvement for the care of olderpeople.

The provider is rated as requires improvement for safety and forwell-led. The issues identified as requiring improvement overallaffected all patients including this population group.

• We saw evidence of personalised care plans in place to meetthe needs of the older people in its population with complexcare needs.

• The practice was responsive to the needs of older people, andoffered home visits and urgent appointments for those withenhanced needs.

• The practice was accessible to patients with mobility difficultiesand included ramp access, automatic doors and disabled toiletfacilities. Consulting and treatment rooms were located on theground floor and the low reception desk enabled patients whoused a wheelchair to speak more easily with staff.

• The practice had systems in place to review the needs of thosewho experienced unplanned admissions to hospital.

• The practice did not routinely hold multidisciplinary meetingsto support patients with end of life care needs. However, healthprofessionals we spoke with said they found cliniciansresponsive when needed.


People with long term conditionsThe practice is rated as requires improvement for the care of peoplewith long-term conditions.


• The GPs took the lead in chronic disease management andpatients at risk of hospital admission were identified as apriority.

• Practice performance for diabetes related indicators overall was98% which was higher than the CCG and national average of89%. Exception reporting for diabetes related indicators wascomparable to CCG and national averages.

• Diabetic patients were referred to structured educationprogramme to support self-management.


Summary of findings


• Patients with blood test results indicating a pre-diabetescondition were called for review, and provided healtheducation and follow-up plan.

• Patients with a long term condition had a named GP and astructured annual review to check their health and medicinesneeds were being met.

• For the convenience of patients the practice provided in houseservices such as electrocardiogram (ECG), ambulatory bloodpressure monitoring, insulin initiation and phlebotomy (bloodtaking) to support the diagnosis and management of patientswith long term conditions.

• Patients with asthma and COPD patients received apersonalised care plan and were provided with rescue packsshould their condition worsen.

Families, children and young peopleThe practice is rated as requires improvement for the care offamilies, children and young people.


• There were systems in place to identify and follow up childrenliving in disadvantaged circumstances and who were at risk, forexample, children and young people who had a high number ofA&E attendances.

• Uptake of immunisation rates (2014/2015) were lower than CCGfor all standard childhood immunisations for two year olds andfive year olds.

• The premises was accessible to push chairs, with ramp accessand automatic doors. Baby changing facilities were alsoavailable.

• The practice’s uptake for the cervical screening programme(2014/15) was 68%, which was below the CCG average of 78%and the national average of 82%.

• Antenatal clinics with the midwife ran at the practice on aweekly basis.

• Clinics available for this population group included new bornbaby checks and postnatal checks for mothers.


Working age people (including those recently retired andstudents)The practice is rated as requires improvement for the care ofworking-age people (including those recently retired and students).


Summary of findings


The provider is rated as requires improvement for safety and forwell-led. The issues identified as requiring improvement overallaffected all patients including this population group

• The needs of the working age population, those recently retiredand students had been identified and the practice had adjustedthe services it offered to ensure these were accessible, flexibleand offered continuity of care. Extended opening hours wereavailable on a Monday and Friday evening.

• The practice was proactive in offering online services forbooking appointments and ordering repeat prescriptions aswell as a range of health promotion and screening that reflectsthe needs for this age group. This includes NHS health checksand smoking cessation support.

• Texting was used to remind patients of their appointments.• The practice offered travel vaccinations under the NHS and

signposted patients to other services as appropriate forvaccinations that are not available through the practice.

• Minor surgery clinics were offered from the practice.

People whose circumstances may make them vulnerableThe practice is rated as requires improvement for the care of peoplewhose circumstances may make them vulnerable.


• The practice held registers of patients living in vulnerablecircumstances such as those with a learning disability.

• The practice informed vulnerable patients about how to accessvarious support groups and voluntary organisations.

• Staff knew how to recognise signs of abuse in vulnerable adultsand children. Staff were aware of their responsibilities regardinginformation sharing, documentation of safeguarding concernsand how to contact relevant agencies.

• The practice worked with health visitors to support children atrisk of harm.

• GPs able to speak some of the languages spoken in the localcommunity.

• Practice told us that they had seen patients from the travellingcommunity who had been temporarily resident in the area.They also offered temporary registration for people of no fixedabode.


Summary of findings


People experiencing poor mental health (including peoplewith dementia)The practice is rated as requires improvement for the care of peopleexperiencing poor mental health (including people with dementia).


• National reported data for 2014/15 showed 70% of patientsdiagnosed with dementia had their care reviewed in a face toface meeting in the last 12 months, which was lower than theCCG average 82% and national average 84%. Exceptionreporting was also higher than CCG and national averages.Practice data showed there had been some improvement with75% of patients reviewed in 2015/16.

• National reported data for mental health outcomes (2014/15)was 96% which was comparable to the CCG average 92% andnational average 93%. Exception reporting was comparable tothe CCG and national averages.

• The practice signposted patients (both adults and youngerpeople) experiencing poor mental health about how to accessvarious support groups and voluntary organisations.

• Practice staff told us that they had a flexible approach toappointments so that patient assessments could be carried outwithout time constraints.


Summary of findings


What people who use the service sayThe national GP patient survey results were published inJuly 2016. The results showed the practice was mostlyperforming in line with and in some areas above localand national averages. 325 survey forms were distributedand 101 (31%) were returned. This representedapproximately 5% of the practice’s patient list.

• 91% of patients found it easy to get through to thispractice by phone compared to the CCG average of60% and national average of 73%.

• 83% of patients were able to get an appointment tosee or speak to someone the last time they triedcompared to the CCG average of 81% and nationalaverage of 85%.

• 88% of patients described the overall experience ofthis GP practice as good compared to the CCG averageof 83% and national average of 85%.

• 77% of patients said they would recommend this GPpractice to someone who has just moved to the localarea compared to the CCG average of 74% andnational average of 78%.

As part of our inspection we also asked for CQC commentcards to be completed by patients prior to our inspection.We received 41 comment cards, these were very positiveabout the standard of care received. Staff were describedas helpful and caring. A small proportion of patients(three) said they had difficulty obtaining an appointment.

We spoke with seven patients in person as part of theinspection, including two members of the practice’spatient participation group. All but one patient said theywere satisfied with the care they received. Most patientsfound it easy to get an appointment and found all staffhelpful and caring.

The practice told us that 89% of patients in the lastquarter who had responded to the friends and family testsaid they were likely or extremely likely to recommendthe practice to others.

Summary of findings


Our inspection teamOur inspection team was led by:

Our inspection team consisted of a CQC Lead Inspectorand a GP specialist advisor.

Background to Dr Srinivas RaoDasari and Dr RaveendraKatamaneniDr Srinivas Rao Dasari and Dr Raveendra Katamaneni’spractice, also known as Rowlands Road Surgery, is part ofthe NHS Birmingham Cross City Clinical CommissioningGroup (CCG).

Dr Srinivas Rao Dasari and Dr Raveendra Katamaneni’spractice, is registered with the Care Quality Commission toprovide primary medical services. The practice has ageneral medical service (GMS) contract with NHS England.Under the GMS contract the practice is required to provideessential services to patients who are ill and includeschronic disease management and end of life care. The twoGP partners took over the practice from the previousprovider in 2012.

The practice is located in a converted house which at thetime of the inspection was undergoing refurbishment.Based on data available from Public Health England,deprivation in the area served is slightly higher than thenational average. The practice has a registered list size ofapproximately 2100 patients.

The practice is open 8.30am to 1.30pm and 3.30pm to6.30pm on Monday, Tuesday Wednesday and Friday and8.30am to 1pm on a Thursday. Appointment times areusually available between 9.30am and 12pm ( and from9am on a Monday) and between 4pm and 6pm with theexception of Thursday afternoon. The practice hasextended opening hours on a Monday and Friday between6.30pm and 7pm. When the practice is closed during corehours (8am to 6.30pm) calls are taken by another provider,Birmingham and District General Practitioner EmergencyRoom Group (BADGER) and passed to the GP partners tomanage. In the out of hours period (6.30pm to 8am)patients also receive primary medical services throughBADGER.

The practice has two GP partners (both male) and a longterm locum GP (female), each GP works three clinicalsessions each. Other practice staff include a practice nursewho works two sessions each week, there is also a practicemanager who works one and a half days each week and isresponsible for the daily running of the practice and a teamof four administrative staff. A phlebotomist (employed bythe local hospital) attends the practice twice a week.

The practice has not previously been inspected by CQC.

Why we carried out thisinspectionWe carried out a comprehensive inspection of this serviceunder Section 60 of the Health and Social Care Act 2008 aspart of our regulatory functions. The inspection wasplanned to check whether the provider is meeting the legal

DrDr SrinivSrinivasas RRaoao DasariDasari andand DrDrRRaveendraveendraa KatKatamaneniamaneniDetailed findings


requirements and regulations associated with the Healthand Social Care Act 2008, to look at the overall quality ofthe service, and to provide a rating for the service under theCare Act 2014.

How we carried out thisinspectionBefore visiting, we reviewed a range of information we holdabout the practice and asked other organisations to sharewhat they knew. We carried out an announced visit on 3August 2016.

During our visit we:

• Spoke with a range of clinical and non-clinical staff(including the GPs, practice nurse, the practice managerand administrative staff).

• Observed how people were being cared for.• Reviewed how treatment was provided.• Spoke with health and care professionals who worked

closely with the practice.• Spoke with patients, including members of the

practice’s patient participation group.• Reviewed comment cards where patients and members

of the public shared their views and experiences of theservice.

• Reviewed documentation made available to us for therunning of the practice.

To get to the heart of patients’ experiences of care andtreatment, we always ask the following five questions:

• Is it safe?• Is it effective?• Is it caring?• Is it responsive to people’s needs?• Is it well-led?

We also looked at how well services were provided forspecific groups of people and what good care looked likefor them. The population groups are:

• Older people• People with long-term conditions• Families, children and young people• Working age people (including those recently retired

and students)• People whose circumstances may make them

vulnerable• People experiencing poor mental health (including

people with dementia).

Please note that when referring to information throughoutthis report, for example any reference to the Quality andOutcomes Framework data, this relates to the most recentinformation available to the CQC at that time.

Detailed findings


Our findingsSafe track record and learning

There was a system in place for reporting and recordingsignificant events.

• There was an incident recording form available to staffon the practice’s computer system. The incidentrecording form supported the recording of notifiableincidents under the duty of candour. (The duty ofcandour is a set of specific legal requirements thatproviders of services must follow when things go wrongwith care and treatment).

• Staff told us that they were encouraged to report anyconcerns and bring them to the attention of the GP orpractice manager.

It was not clear from evidence seen that the practice wasproactive in using incidents (positive and negative) tosupport learning and service improvement. The practicetold us that they had only three reported significant eventswithin the last 12 months. The reports did not consistentlydemonstrate what the learning was from these and howthis was shared, although staff we spoke with were awareof them. Two out of the three reports related to challengingand aggressive patients, the other highlighted the absenceof a NHS number when needed which had led to a reviewof the record system to identify any others that may bemissing. The practice told us that significant events wereshared with other practices in the local clinical networkmeetings.

The practice routinely received safety alerts and we sawseveral examples that had been acted on. These werecirculated by the practice manager to clinical staffincluding the locum GP. The practice nurse told us that theyreceived regular updates on immunisations.

Overview of safety systems and processes

The practice had systems, processes and practices in placeto keep patients safe and safeguarded from abuse. In mostareas these were well embedded but there were someareas for improvement.

• Arrangements were in place to safeguard children andvulnerable adults from abuse. These arrangementsreflected relevant legislation and local requirements.Policies were accessible to all staff. There were lead GPsfor both adult and child safeguarding and staff we spoke

with knew who they were if they had any concerns. TheGPs provided reports where necessary for otheragencies and we saw evidence of this. We receivedpositive feedback from the health visiting team aboutthe practice support for children at risk. Staff hadreceived training on safeguarding children andvulnerable adults relevant to their role. GPs were trainedto child protection or child safeguarding level 3. Thepatient record system did not immediately alert staff topatients that were vulnerable, for example childrensubject to child protection plans. Staff would have toreview patient records to find this information and sothere was a potential that this relevant informationcould be missed during a consultation.

• Notices advising patients that chaperones wereavailable if required were displayed throughout thepractice. All staff who acted as chaperones were trainedfor the role and had received a Disclosure and BarringService (DBS) check. (DBS checks identify whether aperson has a criminal record or is on an official list ofpeople barred from working in roles where they mayhave contact with children or adults who may bevulnerable).

• The practice maintained appropriate standards ofcleanliness and hygiene. We observed the premises tobe clean and tidy. Staff had access to appropriate handwashing facilities and personal protective equipmentsuch as gloves and aprons. Records were maintained forthe cleaning of clinical equipment. Cleaning of thepractice was contracted out and there were cleaningschedules which set out the areas to be cleaned. Thepractice nurse was the infection control clinical leadwho liaised with the local infection prevention teams tokeep up to date with best practice. The practice showedus two infection control audits that had beenundertaken in 2015 and 2016 in which scores hadimproved from 75% to 95% during this time the practicehad been undergoing refurbishment. The practicemanager told us that they had an agreement for theremoval of clinical waste with a local hospital but didnot have any formal documentation in relation to this.

• Reception staff told us that they sometimes handledspecimens and in the absence of the nurse may berequired to clean spills of bodily fluids. We were unableto verify what infection control training reception staffhad received as the practice manager was unable toopen the online training system records. There werealso no immunisation records for non-clinical staff. The

Are services safe?



infection control policy seen stated that all personnelwho work with or may handle blood or pathologicalspecimens were to be vaccinated against hepatitis b. Wealso found no immunisation records for the practicenurse, locum GP or one of the partners. Followinginspection the practice forwarded evidence that theywere in the process of checking and updating staffimmunisation status.

• The arrangements for managing medicines, includingemergency medicines and vaccines, in the practice keptpatients safe (including obtaining, prescribing,recording, handling, storing, security and disposal).Processes were in place for handling repeatprescriptions which included the review of high riskmedicines. The practice carried out regular medicinesaudits, with the support of the local CCG pharmacyteams, to ensure prescribing was in line with bestpractice guidelines for safe prescribing. Blankprescription forms and pads were securely stored andthere were systems in place to monitor their use. Wesaw vaccinations were appropriately stored and thosewe checked at random were in date. Patient GroupDirections had been adopted by the practice to allownurses to administer medicines in line with legislation.We checked a random sample and saw that these weresigned and in date.

• We reviewed four personnel files, for two non-clinicaland two clinical members of staff. Although we sawevidence of some recruitment checks having beenundertaken prior to employment we identified somegaps. The two non-clinical staff had been recruited sinceCQC registration. We noticed there was no proof ofidentification for the staff and in one of the files the DBScheck had been taken from a previous employer. Therewas no risk assessment in place to identify whether theroles of the member of staff required a current DBScheck. We did not see any interview records and wereadvised by the practice manager that these weredestroyed for confidentiality reasons.

• Both the clinical staff files we reviewed were for staffthat had been with the practice prior to CQCregistration. However we found no evidence of a DBScheck for one of the members of staff. In both files wesaw no proof of identification and where appropriateevidence that they were on the performers list. Theperformers list provides additional assurance to thepublic that GPs practicing in the NHS are fit to practice.

Monitoring risks to patients

We found the management of risks to patients was notconsistently clear.

• The practice was undergoing refurbishment which wasnearly complete at the time of the inspection. Patientsand staff commented on the significant improvementthis had made to the premises. However we foundarrangements for managing health and safety at thepractice were unclear. There was a health and safetypolicy available which identified the local health andsafety representative. When we spoke with this memberof staff they advised us that they were just the lead forfire safety. The practice had risk assessments in placeincluding control of substances hazardous to health andinfection control and legionella (Legionella is a term fora particular bacterium which can contaminate watersystems in buildings). We saw risk assessments werealso in place in relation to the premises but had notbeen personalised to the practice and were undated toidentify when they required review.

• The practice had a fire risk assessment in place. As partof the refurbishment the practice had installed a newfire alarm system. The fire evacuation procedure wasdisplayed throughout the practice. Staff confirmed thatthey had undertaken a fire drill since installation so thatthey would know what to do in the event of a fire. Thefire alarm was also checked on a weekly basis. Logswere maintained of these checks but did not distinguishbetween alarm checks and fire drills.

• Records showed that electrical equipment was checkedto ensure the equipment was safe to use and clinicalequipment was checked to ensure it was workingproperly. These checks had been undertaken within thelast 12 months.

• Practice staff including GPs and administrative staff toldus that they would cover for each other during absencesto ensure there were sufficient staff to meet patients’needs as they all worked part time at the practice. Thepractice nurse during recent leave had been covered bya locum nurse. However we were concerned that therewas insufficient nurse and practice manager capacity tomeet the needs of service. The practice nurse wascurrently working one morning a week followingmaternity leave and the practice manager worked oneand a half days at the practice. Although there wereplans to increase nursing hours and employ a health

Are services safe?



care assistant these had yet to be put in place. Theseconcerns were supported by lower than average uptakeof child immunisation and cervical screening and inrelation to the robustness of governance arrangements.

Arrangements to deal with emergencies and majorincidents

The practice had arrangements in place to respond toemergencies and major incidents.

• There was an instant messaging system on thecomputers in all the consultation and treatment roomswhich alerted staff to any emergency.

• Records seen showed that staff received basic lifesupport training, although we saw that annual trainingwas now overdue for one of the GP partners.

• The practice had a defibrillator available on thepremises and oxygen with adult and children’s masks.These were checked regularly to ensure they were inworking order.

• Emergency medicines were easily accessible to staff in asecure area of the practice and staff knew of theirlocation. All the medicines we checked were in date andstored securely.

The practice had a business continuity plan in place formajor incidents such as power failure or building damage.The plan included emergency contact numbers for seniorstaff. However we found the plan contained little detail asto what staff should do in the event of an incident andthere were no contacts included for various services thatmight be required.

Are services safe?



Our findingsEffective needs assessment

The practice assessed needs and delivered care in line withrelevant and current evidence based guidance andstandards, including National Institute for Health and CareExcellence (NICE) best practice guidelines.

• The GP we spoke with told us that they accessed NICEguidance from their computers.

• We saw evidence of audit undertaken in relation to themanagement of women with gestational diabetesagainst NICE guidance.

Management, monitoring and improving outcomes forpeople

The practice used the information collected for the QualityOutcomes Framework (QOF) and performance againstnational screening programmes to monitor outcomes forpatients. (QOF is a system intended to improve the qualityof general practice and reward good practice). The mostrecent published results were for 2014/15. This showed thepractice had achieved 95% of the total number of pointsavailable, which was comparable to the CCG average of94% and national average of 95%. Exception reporting bythe practice was 9% which was the same as the CCG andnational averages (also 9%). Exception reporting is used toensure that practices are not penalised where, for example,when patients do not attend for review, or where amedication cannot be prescribed due to a contraindicationor side-effect. Data from 2014/15 showed;

• Performance for diabetes related indicators was 98%which was higher than the CCG average and nationalaverage of 89%. Exception reporting for diabetes relatedindicators was similar to the CCG and national averageof 9%.

• Performance for mental health related indicators was96% which was comparable to the CCG average 92%and national average 93%. Exception reporting wascomparable to the CCG and national averages at 12%.

This practice was an outlier for uptake of cervical screening.They were also below CCG and national average fordementia reviews, uptake of childhood immunisations andhad high exception reporting for chronic heart disease,dementia and depression.

We looked at some of the practice’s data relating todementia reviews. This showed a slight improvement fromthe previous published data with 75% of patients reviewedin 2015/16 compared to 70% reviewed in 2014/15. Of thefour excepted patients that had not received a dementiareview one was an automatic exception due to recentdiagnosis, two patients had not been coded correctly andone patient did not have evidence of a dementia diagnosis.

There was some evidence of quality improvementincluding clinical audit.

• A CCG report on antibiotic prescribing (2015/16 data)showed the practice was making improvements inantibiotic prescribing although was higher than the CCGaverage overall. Data seen showed the practice hadmade significant improvements in the prescribing ofbroad spectrum antibiotics and was significantly lowerthan other practices within the CCG in relation to this.The GP we spoke with told us they had attended atraining event on antibiotic prescribing.

• The practice told us of four clinical audits that had beenundertaken over the last 12 months. We saw three ofthese as one was unavailable due to the absence of theGP who had conducted this audit on the day of theinspection. One of the audits was a two cycle auditwhere improvements made were implemented andmonitored. This related to the use of high dose inhaledcorticosteroids in asthma patients undertaken inconjunction with the CCG pharmacist in December 2015and June 2016. Although the re-audit showed evidenceof some improvements this was not consistently so. Wealso saw evidence of a minor surgery audit 2015/16which looked at areas such as consent, histology andinfection. This did not raise any concerns. Another auditundertaken in March 2016 was a one cycle auditinvolving a patients with gestational diabetes andidentified the need for lifestyle advice and follow up inthe management of such patients.

Effective staffing

Staff had the skills, knowledge and experience to delivereffective care and treatment.

• The practice manager advised us that induction trainingfor newly appointed staff was usually undertaken by oneof the more experienced members of staff. They also

Are services effective?(for example, treatment is effective)

Good –––


had access to mandatory training via e-learning whichcovered such topics as safeguarding, infectionprevention and control, fire safety, health and safety andconfidentiality.

• The practice could demonstrate how they ensuredrole-specific training and updating for relevant staff. Forexample, for those reviewing patients with long-termconditions. We saw evidence of additional training inareas such as diabetes.

• Staff administering vaccines and taking samples for thecervical screening programme had received specifictraining which had included an assessment ofcompetence. Staff who administered vaccines coulddemonstrate how they stayed up to date with changesto the immunisation programmes, for example throughtraining updates and alerts received.

• The learning needs of staff were identified through asystem of appraisals. Staff we spoke with confirmed thatthey received these. The two GPs we spoke with wereable to demonstrate that they had undergonerevalidation. This is the mechanism by which doctorsdemonstrate their fitness to practice.

• Staff had access to and made use of e-learning trainingmodules which covered a range of topics. There were noformal systems in place for monitoring staff training toensure staff were up to date.

Coordinating patient care and information sharing

The information needed to plan and deliver care andtreatment was available to relevant staff in a timely andaccessible way through the practice’s patient record systemand their intranet system. All correspondence relating topatients for example hospital letters, investigations andtest results were reviewed by one of the GPs in a timelyway.

The GP we spoke with told us that they providedinformation to the out of hours service to advise them ofpatients who may need to contact the service for example,patients with end of life care needs, There was a standardform used for this.

We spoke with health professionals who worked closelywith the practice. They told us that they found the practicewas supportive to ensure patients received the care thatthey needed. The health visitor we spoke with confirmedsafeguarding meetings took place on a regular basis andthe last recorded minutes were dated May 2015. Howevermultidisciplinary meetings to discuss patients with end of

life care and complex needs had not taken place for sometime. Minutes seen indicated that the last recordedmultidisciplinary meeting for those with end of life careneeds was dated October 2015.

Consent to care and treatment

Staff sought patients’ consent to care and treatment in linewith legislation and guidance.

• Staff understood the relevant consent anddecision-making requirements of legislation andguidance, including the Mental Capacity Act 2005. Wesaw information displayed about the Mental CapacityAct displayed in the treatment rooms and some of theclinical staff had undertaken training in this area.

• Staff understood relevant guidance in relation tocapacity when providing care and treatment for childrenand young people.

• The practice offered minor surgery, we saw an auditundertaken which showed consent was obtained in allcases. We checked two records at random and foundthis was the case.

Supporting patients to live healthier lives

The practice identified patients who may be in need ofextra support. For example, those with or at risk ofdeveloping a long-term condition or in need of healthylifestyle advice.

There were follow up arrangements for patients who hadunplanned admissions to review their needs. Staff told usthat they could refer patients to health trainers to supportthem in leading healthier lifestyles. They also providedsmoking advice and support in-house or with a localservice.

The practice’s uptake for the cervical screening programme(2014/2015) was 69%, which was significantly lower thanthe CCG average of 78% and the national average of 82%.The practice nurse had been on leave for a few months andat the time of this data was working two days a week. Thesituation was unlikely to improve immediately as thepractice nurse was now only working one day each week.The practice nurse told us that they were planning toincrease their hours but this had not yet been formallyagreed. There were systems in place to ensure results werereceived for all samples sent for the cervical screeningprogramme.


Good –––


Uptake of other national screening programmes includingbreast and bowel cancer screening was similar to otherpractices within the local CCG and nationally.

Childhood immunisation rates (2014/15) for thevaccinations given were below CCG averages. For example,childhood immunisation rates for the vaccinations given tounder two year olds ranged from 67% to 86% compared tothe CCG range of 80% to 95% and five year olds from 71%to 82%. Compared to the CCG range of 86% to 96%.

The practice was participating in local scheme with the CCGto monitor tuberculosis in new patients registering fromoverseas.

Patients had access to appropriate health assessments andchecks. These included health checks for new patients andNHS health checks for patients aged 40–74. Appropriatefollow-ups with a GP were made for the outcomes of healthassessments and checks were made, where abnormalitiesor risk factors were identified.


Good –––


Our findingsKindness, dignity, respect and compassion

We observed members of staff were courteous and veryhelpful to patients and treated them with dignity andrespect.

• Curtains were provided in consulting rooms to maintainpatients’ privacy and dignity during examinations,investigations and treatments.

• We noted that consultation and treatment room doorswere closed during consultations; conversations takingplace in these rooms could not be overheard.

• Glass partitions at reception helped minimise the risk ofconversations being overheard.

• Practice staff told us that they would use a private roomif patients wanted to discuss sensitive issues orappeared distressed.

• The doors to consulting and treatment rooms wereaccessed via a keypad lock which helped minimise therisk of unauthorised access during consultations.

Feedback we received about the service from the 41patients who completed the Care Quality Commissioncomment cards and the seven patients we spoke with inperson as part of our inspection was very positive overall.Patients were complimentary about staff. They found thepractice welcoming and described staff as helpful, caringand treated them with dignity and respect.

Results from the national GP patient survey (published July2016) showed patients felt they were treated withcompassion, dignity and respect. The practice wascomparable to other practices for its satisfaction scores onconsultations with GPs and nurses. For example:

• 90% of patients said the GP was good at listening tothem compared to the clinical commissioning group(CCG) average of 88% and the national average of 89%.

• 88% of patients said the GP gave them enough timecompared to the CCG average of 86% and the nationalaverage of 87%.

• 95% of patients said they had confidence and trust inthe last GP they saw compared to the CCG average of96% and the national average of 95%.

• 80% of patients said the last GP they spoke to was goodat treating them with care and concern compared to theCCG average of 84% national average of 85%.

• 90% of patients said the last nurse they spoke to wasgood at treating them with care and concern comparedto the CCG average of 89% and national average of 91%.

• 87% of patients said they found the receptionists at thepractice helpful compared to the CCG average of 84%and the national average of 87%.

Care planning and involvement in decisions aboutcare and treatment

Patients we spoke with as part of our inspection told usthey felt involved in decision making about the care andtreatment they received. They also told us they felt listenedto and supported by staff and had sufficient time duringconsultations to make an informed decision about theircare. Patient feedback from the comment cards wereceived was also positive and aligned with these views.Personalised care plans were in place for those withcomplex needs and at high risk of unplanned hospitaladmissions. The practice made use of the choose and booksystem to provide patient choice as to where they receivedcare and treatment.

Results from the national GP patient survey (published July2016) showed patient responses to questions about theirinvolvement in planning and making decisions about theircare and treatment were lower than CCG and nationalaverages. For example:

• 79% of patients said the last GP they saw was good atexplaining tests and treatments compared to the CCGaverage of 86% and the national average of 86%.

• 73% of patients said the last GP they saw was good atinvolving them in decisions about their care comparedto the CCG average of 81% and national average of 82%.

• 77% of patients said the last nurse they saw was good atinvolving them in decisions about their care comparedto the CCG average of 83% and national average of 85%.

We spoke with the practice manager about these resultswhich had only just been published prior to our inspection.They were surprised by them and felt they were notconsistent with other feedback received and wondered ifthere had been a mix up with the data. We looked at theresults from the previous national GP patient surveypublished in January 2016 which were more in line with theCCG and national averages. For example,

• 82% of patients said the last GP they saw was good atexplaining tests and treatments compared to the CCGaverage of 85% and the national average of 86%.

Are services caring?

Good –––


• 85% of patients said the last GP they saw was good atinvolving them in decisions about their care comparedto the CCG average of 80% and national average of 82%.

• 94% of patients said the last nurse they saw was good atinvolving them in decisions about their care comparedto the CCG average of 83% and national average of 85%.The practice had not undertaken any specific action inrelation to this low score.

The practice provided facilities to help patients be involvedin decisions about their care:

• Staff told us that translation services were available forpatients who did not have English as a first language.Some of the staff also spoke second languages thatwere spoken in the community.

Patient and carer support to cope emotionally withcare and treatment

Patient information leaflets and notices were available inthe patient waiting area which told patients how to accessa number of support groups and organisations.Information about support groups was also available onthe practice website. This included support for patientswith poor mental health, dementia, the elderly and isolatedand for carers.

The practice held a carers register and had identified 26patients as carers (1.2% of the practice list). Informationabout various avenues of support available to carers wasavailable on the practice website. Patients were signpostedto a local carers hub and a carers’ club which was hostedby another local practice. Patients who were identified ascarers were offered flu vaccinations.

Staff told us that if families had suffered bereavement, theywould signpost them to local bereavement services if theyneeded support.

Are services caring?

Good –––


Our findingsResponding to and meeting people’s needs

The practice reviewed the needs of its local population andengaged with the NHS England Area Team and ClinicalCommissioning Group (CCG) to secure improvements toservices where these were identified. The practice wasparticipating in the CCG led Aspiring to Clinical Excellence(ACE) programme aimed at driving standards andconsistency in primary care and delivering innovation.

• The practice offered appointments during extendedopening hours on a Monday and Friday evening until7pm for working patients who could not attend duringnormal opening hours.

• Although the practice did not specifically offer longerappointments, staff told us they did not rush patientsand this was confirmed by patients we spoke with.Results from the latest national patient survey alsoshowed patients were not waiting too long from theirappointment time.

• Home visits were available for patients who had clinicalneeds which resulted in difficulty attending the practice.

• Same day appointments were available for childrenunder 5 years and elderly.

• The practice provided travel vaccinations on the NHS.They were able to signpost patients to other services forother vaccinations to meet their needs where notavailable.

• The practice was accessible to patients with mobilitydifficulties and included ramp access, automatic doorsand disabled toilet facilities. Consulting and treatmentrooms were located on the ground floor and the lowreception desk enabled patients who used a wheelchairto speak more easily with staff.

• The practice had a hearing loop and the receptionist wespoke with was able to explain how it worked. Thepractice did not have any notices displayed to highlightthe availability of this facility.

• Translation services were available for patients who didnot speak English. Some of the staff including GPs wereable to speak some of the languages spoken by patientsin the local community.

• The premises were also accessible for push chairs andbaby changing facilities were available. Practice stafftold us children under five would always be seen thesame day.

• For the convenience of patients, the practice provided inhouse services such as electrocardiograms (ECG),ambulatory blood pressure monitoring and insulininitiation to support the diagnosis and management ofpatients with long term conditions. One of the GPs hadrecently undertaken a Spirometry course so that thisservice could be brought in house. Phlebotomy (bloodtaking) services were also provided at the practice bythe local hospital twice a week.

• The practice was participating in an ambulance triagescheme led by the CCG in which GPs provide advice toparamedics and support patients as an alternative toaccident and emergency.

Access to the service

The practice was open 8.30am to 1.30pm and 3.30pm to6.30pm on Monday, Tuesday Wednesday and Friday and8.30am to 1pm on a Thursday. Appointment times areusually available between 9.30am and 12pm (and from9am on a Monday) and between 4pm and 6pm with theexception of Thursday afternoon. The practice hadextended opening hours on a Monday and Friday between6.30pm and 7pm. When the practice was closed duringcore hours (8am to 6.30pm) calls are taken by anotherprovider, Birmingham and District General PractitionerEmergency Room Group (BADGER) and passed to the GPpartners to manage. In the out of hours period (6.30pm to8am) patients also receive primary medical servicesthrough BADGER.

In addition to pre-bookable appointments that could bebooked up to six weeks in advance, some appointmentswere reserved for same day and urgent bookings. Sameday appointments were released in the morning andafternoon for greater flexibility for patients who may not beable to call first thing.

Feedback received from patients we spoke with on the dayof inspection and through the comment cards told us thatmost patients felt able to get appointments when theyneeded them. Reception staff told us that they aimed tooffer patients an appointment within two working days andif willing to wait with their preferred GP. We saw that thenext available routine GP appointment was for thefollowing day and the next nurse appointment within fourworking days.

Are services responsive to people’s needs?(for example, to feedback?)

Good –––


Results from the national GP patient survey showed thatpatient’s satisfaction with how they could access care andtreatment was above local and national averages.

• 76% of patients were satisfied with the practice’sopening hours compared to the CCG average of 74%and national average of 76%.

• 91% of patients said they could get through easily to thepractice by phone compared to the CCG average of 60%and national average of 73%.

The practice had a system in place to assess whether ahome visit was clinically necessary; and the urgency of theneed for medical attention. Requests received were passedto the GP for review.

Listening and learning from concerns and complaints

The practice had an effective system in place for handlingcomplaints and concerns.

• Its complaints policy and procedures were in line withrecognised guidance and contractual obligations forGPs in England.

• The practice manager was a designated responsibleperson who handled all complaints in the practice.

• We saw that information was available to help patientsunderstand the complaints system, there was acomplaints and comments leaflet for patients to takeaway on request and information in the practice leaflet.However there was no information displayed alertingpatients to the complaints system. The complaintsleaflet detailed how the patient could get support tomake a complaint and what to do if they were unhappywith the response received from the practice.

The practice told us that they received two formalcomplaint in the last 12 months. One had only just beenreceived prior to the inspection and had yet to be fullyaddressed. We reviewed the other complaint and found ithad been appropriately managed with the patient beinggiven an opportunity to discuss their concerns withpractice staff. Any verbal complaints were recorded directlyonto patient notes so were not formally used to look attrends. We did however see evidence of action taken inresponse to a verbal complaint.

Are services responsive to people’s needs?(for example, to feedback?)

Good –––


Our findingsVision and strategy

At the start of the inspection the practice manager and oneof the partners gave us a presentation which set out thepractice values and ethos. Practice staff we spoke withwere aware of this and told us that they aimed to give thebest possible service to all patients. Our findings on the daywere that staff demonstrated these values. However, therewas no formally documented vision or strategy for thefuture of the practice.

Governance arrangements

The practice had an overarching governance framework tosupport the delivery of the service.

• There was a clear staffing structure and staff were awareof their own roles and responsibilities.

• The practice performed well overall in terms of patientoutcomes and patient satisfaction.

• There was evidence of clinical and internal audit used tomonitor quality and to support improvements.

However,

• There was a lack of capacity in terms of practicemanagement, the practice manager was available forone and a half days a week. We found some weaknessesin the management of risks, and for maximisingopportunities for learning from incidents, verbalcomplaints and general patient feedback.

• Practice policies were accessible to staff from theircomputers. However, not all policies seen were practicespecific policies. For example, the infection controlpolicy contained information relating to anotherpractice and was undated. The business continuity planlacked detail on action required in the event of servicedisruption.

Leadership and culture

On the day of inspection the partners in the practice andpractice manager demonstrated they had the experienceand capability to run the practice and ensure high qualitycare. However, capacity was the main issue. All staff workedpart time and so there were limited opportunities for theclinical staff and practice managers to get together.

There was positive feedback from staff, other healthprofessionals and patients about the practice leadership.Staff told us that there was a good relationship betweenstaff, managers and GPs and that they were well supported.They found senior staff approachable when available.

The provider was aware of and had systems in place toensure compliance with the requirements of the duty ofcandour. (The duty of candour is a set of specific legalrequirements that providers of services must follow whenthings go wrong with care and treatment). There werehowever few incidents and complaints with which thiscould be demonstrated in practice. Staff told us that thepartners did encouraged a culture of openness andhonesty.

There was a clear leadership structure in place and staff feltsupported by management.

• Practice staff told us that regular meetings were heldwith all staff (including the locum GP), minutes seenshowed these occurred between one and threemonthly. The minutes of meetings were not alwaysdetailed and there was no set agenda to ensure thatspecific issues were always discussed for example,complaints, significant events, safety alerts.

• Staff told us there was an open culture within thepractice and said they would feel confident in raisingissues if needed.

Seeking and acting on feedback from patients, thepublic and staff

There was limited evidence that the practice had beenproactive in obtaining feedback from patients, the publicand staff.

• The practice had a patient participation group (PPG)however, there was little evidence as to how the PPGworked with the practice to help support serviceimprovement. There were no meeting minutes. We weretold the PPG meet twice yearly however, the twomembers of the PPG we spoke with told us they had lastmet in December 2015 and that this had been the firstmeeting since the previous provider had retired. Wewere advised there had been approximately fivepatients in attendance and the meeting had been takenup with identifying roles but that there had been a lackof clarity as to the role of the group. We did not see anyinformation displayed about the patient participationgroup.

Are services well-led?(for example, are they well-managed and do senior leaders listen, learnand take appropriate action)



• The practice had a suggestion box located in theentrance which was also the repeat prescription box.Staff told us this was emptied daily but rarely containedany comments or suggestions. We also saw the friendsand family box inviting patients to say whether theywould recommend the practice to others. The practicetold us that in the last quarter 89% of patients said theywould recommend the practice.

• Practice staff told us that they felt able to give feedbackand discuss issues with senior staff if they wanted to.The practice nurse told us that they had been discussingthe clinics run at the practice as part of their return towork following recent maternity leave.

Are services well-led?(for example, are they well-managed and do senior leaders listen, learnand take appropriate action)



Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

Regulated activityDiagnostic and screening procedures

Maternity and midwifery services

Surgical procedures

Treatment of disease, disorder or injury

Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

There were areas in which the practice did not haveeffective systems to assess, monitor and mitigate therisks relating to the health, safety and welfare of serviceusers. The practice was unable to demonstrate robustsystems for:

• Ensuring appropriate staffing to support governancearrangements and uptake of child immunisations andcervical screening.

• Completeness of recruitment checks.• Risks associated with the premises and environment.• Risks associated with infection control for example

specimen and bodily fluid handling, staff immunisationand clear arrangements for the disposal of clinicalwaste.

• Ensuring policies and procedures are practice specificand contain specific detail to support staff.

Regulation 17 (1) (2)(b) Health & Social Care Act 2008(Regulated Activities) Regulations 2014: GoodGovernance

Regulation

This section is primarily information for the provider

Requirement notices


Dr Srinivas Rao Dasari and Dr Raveendra …...Dateofpublication:05/10/2016 1Dr Srinivas Rao Dasari...

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