Background to this inspection
Updated
10 May 2021
Dr Parmod Luthra (also known as Spring Grove Medical Practice) is situated at Thornbury Road Centre for Health, Thornbury Road, Isleworth, Middlesex, TW7 4HQ. The location is shared with another GP practice.
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, treatment of disease, disorder and injury, surgical procedures, family planning and maternity and midwifery services.
Dr Parmod Luthra is situated within the Hounslow City Clinical Commissioning Group (CCG) and provides services to 7,450 patients under the terms of a General Medical Services (GMS) contract. This is a contract between general practices and NHS England for delivering services to the local community.
There is one principal GP, three salaried GPs, a trainee GP and a long term locum GP. Three GPs are male and three female, who work a total of 33 sessions (plus 6 trainee GP sessions) per week. The practice employs a practice nurse and a health care assistant. The practice manager is supported by a team of administrative and reception staff.
This is a training practice, where a doctor who is training to be qualified as a GP has access to a senior GP throughout the day for support. There is a full-time GP registrar.
The practice does not have a dedicated website but online services can be accessed through online Patient Access and NHS choices website.
Out of hours (OOH) service is provided by Care UK.
The practice population of patients aged between 5 to 18 years old is higher than the national average and there is a lower number of patients aged above 65 years old compared to the national average.
Ethnicity based on demographics collected in the 2011 census shows the patient population is ethnically diverse and 58% of the population is composed of patients with an Asian, Black, mixed or other non-white backgrounds.
Information published by Public Health England, rates the level of deprivation within the practice population group as six, on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest. Male life expectancy is 81 years compared to the national average of 79 years. Female life expectancy is 85 years compared to the national average of 83 years.
Updated
10 May 2021
We carried out a review of Dr Parmod Luthra (Spring Grove Medical Practice) on 29 April 2021. Overall, the practice is rated as Good.
Set out the ratings for each key question
Safe - Good
Effective - Good
Caring - Good
Responsive - Good
Well-led - Good
Following our previous inspection on 5 February 2020 the practice was rated Good overall and for the key questions effective, caring, responsive and well-led. The practice was rated requires improvement for providing safe services and issued a requirement notice for Regulation 17 Good governance.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Parmod Luthra (Spring Grove Medical Practice) on our website at www.cqc.org.uk.
Why we carried out this review
This was a focused review of information without undertaking a site visit inspection to follow up on breaches of Regulation 17 Good governance. At the last inspection we found;
- Staff had not always had the appropriate authorisations such as Patient Specific Directions (PSDs) to administer flu injections.
We also followed up on ‘should’ actions identified at the last inspection. Specifically;
- Review the system in place to ensure uncollected prescriptions are monitored effectively.
- Improve the record keeping system to ensure a premises risk assessment is readily available.
- Take appropriate actions to provide sepsis awareness training.
- Continue to encourage and monitor the cervical and bowel cancer screening and childhood immunisation uptake.
How we carried out the review
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our reviews differently.
This review was carried out without visiting the location by requesting documentary evidence from the provider.
Our findings
We have rated this practice as Good overall and Good for providing safe services because:
We found that:
- The practice had made the necessary improvements to the delivery of care to ensure patients were kept safe.
- The practice informed us they had reviewed their protocol and only the practice nurse and the doctor had administered flu injections since the previous Care Quality Commission (CQC) visit in February 2020.
- The practice informed us that the Healthcare Assistant (HCA) had not administered any vaccine since the previous CQC visit. However, they had provided a signed document by the HCA confirming they understood that they were only allowed to administer vaccines when they had the appropriate authorisations such as Patient Specific Directions (PSDs) in place.
In addition;
- The practice had shared an uncollected repeat prescriptions policy which was reviewed on 20 December 2020. The practice had implemented monthly uncollected repeat prescriptions checks. We saw the records maintained by the practice and the last check was carried out on 30 March 2021.
- The practice had provided the documented premises risk assessment carried out in August 2020 and informed us that it was accessible to all staff members.
- We found that all staff members had received Sepsis Awareness training.
- The practice had provided us with the recent unverified data from the electronic clinical system which demonstrated improvements and childhood immunisations rates of children aged 2 had increased to 90% (for quarter 1 October 2020).
- The practice had provided current unverified data for cervical screening which was not comparable with the Public Health England published data (dated 30/09/2020). However, following national guidelines we have taken into account that cervical cancer screenings had been adversely affected during the Covid19 pandemic. We were also provided with evidence that the practice had plans in place to improve the call / recall system for eligible patients. The practice was offering additional clinics on weekends and weekday evenings for cervical cytology and immunisations.
Whilst we found no breaches of regulations, the provider should:
- Improve cervical screening uptake to bring in line with the England average.
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