Archived: Dr Arun Tangri Also known as Riverlyn Medical Centre

Updated 7 February 2017

Dr Arun Tangri provides primary medical services to approximately 3,000 patients through a personal medical services (PMS) contract at Riverlyn Medical Centre. This is a locally agreed contract with NHS England.

It is located in the centre of the Bulwell area of Nottingham, approximately four miles from the city centre. The practice was formed in 1992, and moved into purpose-built premises owned by the practice in 1997.

The practice deprivation scores indicate people living in the area were significantly more deprived than the local CCG and national average. Data shows the proportion of patients aged 18 years and below registered at the practice, is significantly higher than the local CCG and national average. The proportion of patients aged 65 years and above is marginally above the local CCG average but lower than the national average.

The medical team comprises of two GP partners and three long term GP locums (one female GP and four male GPs) and a practice nurse. They are supported by seven members of the administration team, some of whom have dual roles including health care assistant and phlebotomy duties. A practice manager has recently joined the team on an interim basis working approximately one day a week. It is a teaching practice, offering placements to second, third and fourth year medical students.

The practice is open between 8.30am and 6.30pm Monday to Friday. Appointment times start at 9am and the latest appointment offered at 5.50pm daily. The practice provides the extended hours service from 6.30pm to 7.30pm on Tuesdays, with the latest appointment offered at 7.15pm.

When the surgery is closed, patients are advised to dial NHS 111 and they will be put through to the out of hours service which is provided by Nottingham Emergency Medical Services.

Updated 7 February 2017

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection of Dr Arun Tangri on 4 January 2017. This inspection was undertaken to follow up on a warning notice we issued to the provider in respect of ensuring effective systems to enable the provider to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk. This included systems to ensure fire safety, the management of staff training, responding to complaints and making sure staff were safely recruited.

The practice received an overall rating of requires improvement at our inspection on 1 August 2016 and this will remain unchanged until we undertake a further full comprehensive inspection within six months of the publication date of the initial report.

You can read the report from our last comprehensive inspection, on our website at www.cqc.org.uk .

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

• The practice had complied with the warning notice we issued and had taken the action needed to comply with legal requirements.

• Significant improvements had been achieved in addressing the fire safety concerns identified at the comprehensive inspection on 1 August 2016. The practice had received advice from the local fire service who had assisted them in undertaking comprehensive risk assessments. An effective fire policy had been developed showing improvements made.

• Infection control arrangements were reviewed to ensure roles were clear and to confirm who was responsible for making sure actions were completed.

• Effective systems had been put in place to carry out recruitment checks making sure staff were suitable to work with patients.

• Staff training had been reviewed and an effective system was put in place to support the development of staff.

• An effective system had been implemented to manage complaints and significant events and analyse trends.

• The practice sought feedback from patients on appointments for the purposes of continually evaluating and improving such services. Results were shared with patients and there were plans to repeat the surveys and encourage the use of the patient suggestion box.

• There was evidence that the GPs and interim practice manager had responded to the actions required following the issue of the warning notice to ensure compliance with the regulations. They had demonstrated good leadership in the steps taken to address the issues of concern.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 16 December 2016

The issues identified as requiring improvement overall affected all patients including this population group. However, there were positive findings in respect of this population group.

• The practice had a recall system for patients with long term conditions, audited on a monthly basis to identify patients who are due for a review. All clinical staff had various roles in chronic disease management and patients at risk of hospital admission were identified as a priority.

• A structured annual review was offered to check their health and medicines needs were being met. For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

• There was evidence of coordinated care with multi-disciplinary teams to improve the outcomes for patients.

• QOF achievement on indicators for diabetes was consistently above with CCG averages. For example, the percentage of patients with diabetes on the register who had influenza immunisations in the preceding 12 months was 98%, compared to a CCG average of 93% and national average of 94%.

• Longer appointments and home visits were available and offered when needed.

• The practice provided weight management and lifestyle advice. There was a weighing machine and blood pressure monitor available in the waiting room for patients to use prior to their appointments if they wished to do so.

• There were a number of leaflets providing education and self-care advice.

Updated 16 December 2016

The issues identified as requiring improvement overall affected all patients including this population group. However, there were positive findings in respect of this population group.

• The practice worked closely with midwives, health visitors and family nurses attached to the practice. There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances.

• The practice held meetings every six weeks with the health visitor and midwife, and also reviewed any children on a child protection plan at their clinical meetings.

• The health visiting service held weekly drop in clinics on Monday afternoons from the practice. This was used as an opportunity to coordinate care with the GPs carrying out the 8-week postnatal checks for mothers at the same time. Feedback from the health visitor was positive about the working relationships and communications with practice staff.

• Immunisation rates were slightly below the CCG averages for standard childhood immunisations. Vaccination rates for children under two years ranged from 79% to 93%, compared against a CCG average ranging from 91% to 96%. GPs told us they were working closely with the health visitor to follow up non-attenders and offer opportunistic immunisations when patients attended appointments for other reasons.

• Flu and whooping cough vaccinations were offered to pregnant women.

• The premises were suitable for children and babies. Baby changing facilities were available and the practice accommodated mothers who wished to breastfeed.

• Appointments were available outside of school hours with urgent appointments available on the day for children and babies.

• Teenage patients were offered opportunities to be seen in confidence if they requested appointments without their parents.

• There was a full range of family planning services offered to patients of the practice and those registered elsewhere, which included fitting of intra-uterine devices (coil), contraceptive implant fitting and emergency contraception.

Updated 16 December 2016

The issues identified as requiring improvement overall affected all patients including this population group. However, there were positive findings in respect of this population group.

• The practice offered proactive, personalised care to meet the needs of the older people in its population. They offered same day telephone appointments and urgent appointments for those with enhanced needs.

• Home visits were offered to housebound patients. The practice liaised with the local acute visiting service for patients acutely unwell who could not attend the surgery.

• The GPs discussed elderly patients who may be at risk of being vulnerable with multi-disciplinary teams including district nurses, social workers and local care coordinators, to ensure patient needs were met and referrals to other services were made promptly.

• All patients aged over 75 years had a named GP for continuity of care. They were invited for annual health checks as part of the chronic disease management recall system. There were 150 patients aged 75 years and over on the practice register.

• Data from 2014/15 showed 71% of eligible patients over 65 years old had been given flu vaccinations, in line with the CCG average of 72%.

• Nationally reported data showed that outcomes for patients for conditions commonly found in older people, including heart failure were in line with or above local and national averages.

• The practice had good access for disabled patients and height adjustable couches for patients who may need them.

Updated 16 December 2016

The issues identified as requiring improvement overall affected all patients including this population group. However, there were positive findings in respect of this population group.

• The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care. This included access to appointments after 5pm every day and telephone appointments. The practice opened until 7.30pm on Tuesdays.

• Online appointment services included booking and cancelling appointments and ordering prescriptions. Additionally, there was a 24 hour automated telephone booking and cancelling of appointments service. Mobile phone text reminders were used for appointments, including the option to cancel an appointment via text.

• There was a full range of health promotion and screening information in the practice that reflects the needs for this population group. Services provided from the premises included in-house phlebotomy, sexual health and minor surgery, in addition to physiotherapy, and smoking cessation advice.

• The practice uptake for cervical screening for eligible patients was 86%, higher than the CCG average of 81% and the national average of 82%. Breast cancer screening was higher than the CCG and national averages. Bowel cancer screening data was marginally lower than the CCG and national averages. The practice was aware of their performance and offered more opportunistic testing to improve uptake rates.

• Spirometry (a test used to help diagnose and monitor certain lung conditions) was offered to patients over age 35 years as well as all patients recorded as smokers.

Updated 16 December 2016

The issues identified as requiring improvement overall affected all patients including this population group. However, there were positive findings in respect of this population group.

• Data showed in 2014/15 there were 90% of patients diagnosed with severe mental health condition who had a comprehensive agreed care plan documented in their records in the last 12 months, compared to the CCG average of 84% and national average of 88% in 2014/15.

• Patients were offered 30 minute appointments for their annual mental health check.

• In 2014/15, 94% of patients diagnosed with dementia had been reviewed in a face to face review in the preceding 12 months, compared to the CCG and national average of 84%.

• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia. The practice carried out advance care planning for patients with dementia.

• There were leaflets for mental health wellbeing support services available in the reception area.

• Staff had a good understanding of how to support people experiencing poor mental health. Patients were encouraged to self-refer to counselling services. Staff told us they routinely flagged patients who had experienced recent poor mental health episodes and contact them for support.

Updated 16 December 2016

The issues identified as requiring improvement overall affected all patients including this population group. However, there were positive findings in respect of this population group.

• Practice supplied data indicated there were 22 patients on the practice learning disabilities register in 2015/16, but only 11 were eligible for health checks under the enhanced service. Staff told us 10 of the eligible patients were reviewed in a face to face appointment.

• The practice liaised with a local learning disabilities specialist nurse in the identification of patients with learning disabilities, and had a named member of staff who organised appointments for patients. Feedback from the specialist nurse was positive about the engagement with the practice and adjustments made to support patient attendance in a timely manner to achieve positive clinical outcomes.

• The practice offered longer appointments for patients with a learning disability and for those who required it.

• The practice regularly worked with other health care professionals in the case management of vulnerable patients. Formal monthly multidisciplinary meetings were held to discuss patients at high risk of admission to hospital.

• Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.

• All staff had received training in domestic violence and offered cards informing patients how to identify themselves discreetly to staff as victims of domestic violence.

• The practice referred vulnerable patients who were likely to be socially excluded to a local social organisation which encouraged social interaction to reduce isolation and improve the wellbeing of their patients.

• Staff told us they were culturally sensitive and tailored their service to meet the needs of patients from different ethnic backgrounds.

• The practice’s computer system alerted GPs if a patient was also a carer. The practice had identified 80 patients as carers (2.5% of the practice list).