Archived: Dr Thavapalan Also known as Dr Thavapalan & Partners

Dr Thavapalan is a provider registered with CQC. The practice was previously rated requires improvement after our inspection in August 2015 and was then found to be good in all areas following a follow up inspection in May 2016.

We carried out an inspection of the provider on 29 March 2019 as part of our inspection programme. At that inspection, we rated the practice requires improvement overall, safe was rated as inadequate, effective and well-led were rated requires improvement and caring and responsive were rated good. We issued a warning notice and a requirement notice in respect of breaches of regulations 12 (Safe care and treatment) and 17 (Good governance) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The concerns related to poor medicines management and insufficient systems and processes. You can read the findings from our last inspection by selecting the ‘all reports’ link for Dr Thavapalan on our website at .

At this inspection we followed up on breaches of regulations identified at our last comprehensive inspection on 29 March 2019. We carried out an announced comprehensive inspection at Dr Thavapalan on 18 November 2019 to check whether the provider was now meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014

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 good overall and requires improvement for safe. We rated this practice good for all population groups.

At this inspection we found:

• The practice was monitoring patients on high risk medicines in accordance with guidance and recommendations.
• The practice had all the recommended emergency medicines and equipment.
• Risks associated with fire, infection control and legionella were adequately assessed.
• The practice had clear systems and processes in place for handling significant events.
• There were systems in place to monitor the professional registrations of clinical staff.
• There was a system in place to ensure staff were regularly appraised.

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

• The system for monitoring test results was not effective to assure the safety of patients. However after the inspection the practice provided evidence to show they had discussed the system seen on the day of the inspection and had now changed the process for reviewing test results to assure the safety for patients.
• On the day of the inspection there was no process in place to monitor patients collecting prescriptions for controlled medicines.
• On the day of the inspection no premises/security risk assessment and health and safety risk had been undertaken.

We rated the practice as good for providing effective services because:

• Patients’ needs were assessed, and care and treatment were delivered in line with current legislation, standards and evidence-based guidance.
• There was evidence of quality improvement activity.
• Staff were receiving regular appraisals.

We rated the practice as good for providing caring services because:

• The practice respected patients’ privacy and dignity.
• Patients we spoke with during our inspection and those who completed comments cards, spoke favourably about the practice: that the staff treated them with respect, that they felt listened to and that they had observed improvements in the practice.
• Patient feedback from the GP patient survey results were in line with local and national averages.

We rated the practice as good for responsive services because:

• Complaints were managed in a timely fashion and detailed responses were provided.
• Feedback from the patient survey indicated that respondents’ ease of access care and treatment was in line with local area and national averages.
• The practice was continually reviewing and adjusting the appointment system to cater to the needs of patients.

We rated the practice as good for providing well-led services because:

• The practice had improved since our inspection 29 March 2019 and had addressed the concerns we found at our previous inspection.
• There were clear responsibilities, roles and systems of accountability to support good governance and management.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients.

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

The areas where the provider should make improvements are:

• Introduce a system for the collection of controlled medicine prescriptions.
• Allocate protected time to staff for training and admin duties.
• Take action so safeguarding training for staff is to the appropriate level.
• Record detail and action taken in meeting minutes.
• Continue to develop and support 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

We carried out an announced comprehensive inspection at Dr Thavapalan on 29 March 2019.

At that inspection, we found that:

• The practice was not monitoring high risk medicines in accordance with guidance and recommendations.
• The practice did not have all recommended emergency medicines and had not assessed the need for these.
• Defibrillator pads attached to the practice defibrillator had expired.
• Not all prescriptions were secured and monitored.
• Risks associated with fire, infection control and legionella were not adequately assessed.

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 rated the practice requires improvement overall and we rated them as inadequate for providing safe services. Because of the concerns found at that inspection, we served the provider with a warning notice for breaches of regulation 12 (Safe care and treatment) of the Health and

Social Care Act 2008 (Regulated Activities) Regulations 2014 which we asked them to have become complaint with by 31 May 2019.

We carried out this focussed follow up inspection on 26 July 2019. We carried out this inspection to check whether the provider had made enough improvements to become compliant with regulations 12. The practice was not rated on this occasion.

At this inspection, we found that:

• The provider had implemented improvements to address breaches of regulations 12.
• The practice had audit protocols in place for clinicians and reception staff to follow in relation to the management of patients on high risk medicines
• Legionella risk assessment had been undertaken and associated remedial actions completed.
• Infection prevention and control audit had been completed and remedial actions taken.
• Fire risk assessment had been completed and associated remedial works arranged.
• Appropriate emergency medicines and equipment were in stock and fit for use.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

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

Dr Thavapalan is a provider registered with CQC. The practice was previously rated requires improvement after our inspection in August 2015 and was then found to be good in all areas following a follow up inspection in May 2016.

We carried out an inspection of the provider on 29 March 2019 as part of our inspection programme.

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 overall and requires improvement for all population groups.

We rated the practice as inadequate for providing safe services because:

• Patients taking high risk medicines were not consistently being monitored in line with current guidance and legislation.
• The professional registrations of clinical staff were not being checked on an annual basis.
• There were not clear systems and processes in place for the management of significant events.
• Risks associated with infection control, fire and legionella were not regularly assessed.
• The practice did not have diclofenac, furosemide or bumetanide and dexamethasone within their emergency medicine storage and there was no risk assessment to consider the need or not for these medicines. The defibrillator pads attached to the practice defibrillator had expired.

We rated the practice as requires improvement for providing well-led services because:

• Governance was lacking in key areas including safeguarding, significant event management and the management of medicines.
• The provider did not have adequate systems in place to assess, monitor and address risks associated with the premises including those associated with fire, legionella and detection and prevention of infection.
• The provider did not have an active patient participation group and there was limited structured feedback and engagement mechanisms for patients.
• There was limited evidence of continuous improvement or innovation.

However

• Staff provided positive feedback about working at the service which indicated a good working culture.
• The practice had taken action to ensure the sustainability of the service and responded well to challenges associated with the dispersal of the patient list from a nearby service which closed.

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

• There was a lack of quality improvement activity.
• Staff were not receiving regular appraisals.
• Monitor the level of exception reporting for patients with long term conditions to ensure that this is appropriate.

However, we did see:

• Effective joint working was in place. The practice held monthly multidisciplinary meetings and detailed records of discussions and action points were retained.
• With the exception of high risk medicines; patients were receiving regular reviews and the treatment provided was in line with current guidelines this was reflected in high levels of achievement against local and national targets.

We rated the practice as good for responsive services because:

• The practice had worked to accommodate an influx of patients from a nearby surgery which had recently closed. Care had been taken to optimise the care and treatment of these patients.
• Complaints were managed in a timely fashion and detailed responses were provided.
• Feedback from both the patient survey and comment cards received by CQC indicated that it was easy to access care and treatment at the practice. The practice was continually reviewing and adjusting the appointment system to cater to the needs of patients.

We rated the practice as good for providing caring services because:

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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

The areas where the provider should make improvements are:

• Include details of the organisations patients can escalate complaints to in complaint response letters.
• Work to improve the identification of those patients with caring responsibilities.
• Retain records related to staff induction.
• Consider ways to provide health promotion information to patients who do not speak English as a first language.
• Consider ways to improve the premises to make them more accessible for people with mobility needs.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

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