We carried out an announced comprehensive inspection at Dr Parmod Luthra (also known locally as Spring Grove Medical Practice) on 5 February 2020 as part of our inspection programme.
At the last inspection in January 2019, we rated the practice as good overall and specifically requires improvement for providing safe services because:
- Risks to patients were assessed and well managed in most areas, with the exception of those relating to the management of the spread of infections and the monitoring of fridge temperatures.
Previous reports on this practice can be found on our website at: www.cqc.org.uk/location/1-525624918.
We decided to undertake a comprehensive inspection of this practice following our annual regulatory review of the information available to us. At this inspection, we found that the practice had demonstrated improvements, however, we found additional risks and they were required to make further improvements and is rated as requires improvement for providing safe services.
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 good for all population groups, with the exception of working age people (including those recently retired and students) , which is rated as requires improvement.
We rated the practice as requires improvement for providing safe services because:
- Risks to patients were assessed and well managed in most areas, with the exception of those relating to the appropriate authorisations such as Patient Specific Directions (PSDs) to administer flu injections.
- Staff understood and fulfilled their responsibilities to raise concerns, and report incidents and near misses. When incidents did happen, the practice learned from them and improved their processes.
We rated the practice as good for providing effective, caring, responsive and well-led services because:
- Patients received effective care and treatment that met their needs.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
- The practice was encouraging patients to register for online services and 51% of patients were registered to use online Patient Access.
- The practice was aware of and complied with the requirements of the Duty of Candour.
- There was a clear leadership structure and staff felt supported by management.
We rated all population groups as good for providing responsive services. We rated all population groups as good for providing effective services, with the exception of working age people (including those recently retired and students), which is rated as requires improvement, because of low cervical screening.
The areas where the provider must make improvements as they are in breach of regulations are:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
The areas where the provider should make improvements are:
- Review the system in place to ensure uncollected prescriptions are monitored effectively.
- Continue to encourage and monitor the cervical and bowel cancer screening and childhood immunisation uptake.
- Improve the record keeping system to ensure a premises risk assessment is readily available.
- Take appropriate actions to provide sepsis awareness training.
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