Dr Krishnan

Updated 6 July 2017

Dr Krishnan is located in Kent Elms Health Centre just off the A127 in Leigh on Sea, Essex. The practice provides services for 4948 patients.

• The practice holds a General Medical Services (GMS) contract and provides GP services commissioned by NHS England and Southend Clinical Commissioning Group.
• The practice is managed by three GP partners who hold financial and managerial responsibility.
• The practice employs one salaried GP. In total three male and one female GPs work at the practice. In addition the practice employs one practice nurse, one practice nurse prescriber and health care assistant (HCA), a practice manager, and a team of reception and administrative staff.
• The practice is open between 8am and 6.30pm on Monday to Friday with late evening opening up to 8pm on Mondays and early morning appointments Tuesdays from 7am.
• The practice has opted out of providing GP out of hour’s services. Unscheduled out-of-hours care is provided by the NHS 111 service and patients who contact the surgery outside of opening hours are provided with information on how to contact the service.
• The practice has a comprehensive website providing details of services and support agencies patient may find useful to access.

Updated 6 July 2017

Letter from the Chief Inspector of General Practice

On 6 January 2016 we carried out a comprehensive inspection at Dr Krishnan. Overall the practice was rated as inadequate and placed in special measures. The practice was found to be inadequate in safe and well-led, requires improvement in effective and good in responsive and caring.

As a result of that inspection we issued the practice with a requirement notice in relation to risks to patient safety not been assessed and managed appropriately, the governance at the practice, staff training and recruitment. The issues of concern related to the lack of health and safety risk assessments in place and clinical equipment that had not been calibrated since 2013. There was no system for ensuring staff were registered with their professional body and a lack of system for reviewing test results and recording appropriately in patient records. Not all staff had undertaken training in respect of their roles and responsibilities and appropriate checks had not been carried out when employing staff.

The practice submitted further information following the inspection that assured us that the risks identified at the practice on the day of the inspection had been considerably reduced.

We then carried out an announced comprehensive inspection at Dr Krishnan on 1 June 2017. Overall the practice is rated as good.

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

• Risks to staff and patients had been assessed and managed appropriately. The practice had completed all actions from the inspection in January 2016.
• Staff had received training that was specific to their roles and the practice manager had a matrix that showed the training completed and when it was due for renewal.
• Appropriate checks were carried out as to the fitness of staff to practice and all staff had current and effective registrations with their professional body. All relevant staff had received a disclosure and barring service check prior to employment or had a risk assessment in place detailing the reasons why for the staff that had recently commenced employment.
• There was an effective system for assessing and monitoring the quality and safety of services provided.
• Staff carrying out chaperone duties had received training and a disclosure and barring service check was in place.
• There was sufficient and appropriate equipment for use in the treatment of patients, including in the event of a medical emergency and the equipment was calibrated to ensure it was working correctly.
• There was a comprehensive business continuity plan in place in the event of an emergency taking place that disrupted the services to patients.
• There was an ongoing programme of clinical audit that demonstrated quality improvement.
• Practice policies and procedures had been reviewed to ensure that they were up to date and practice specific.
• Prescriptions were stored securely however on the day of inspection were not tracked through the practice. The practice said that they would ensure this was completed.
• The practice held regular multi-disciplinary team meetings in addition to coordinated care through the patient record system.
• Data from the national GP patient survey showed patients reported high levels of satisfaction with the practice nursing team and had trust and confidence in their GPs.
• Carers were identified and supported to access services and receive appropriate vaccinations.
• The practice had an effective patient participation group and meetings showed how the practice had listened and responded to patient feedback.
• Staff were able to recognise and reported significant incidents. These were investigated and lessons learnt identified and shared during clinical and practice management meetings attended by all staff.

• The practice was clean and tidy and staff had reviewed infection prevention control and cleaning policies.

• The practice manager had a log of all risk assessments and other tasks such as calibration and electrical testing documented on a log. This was colour coded and as they approached the date due the colour changed from green, to amber, to red.

• Medicines were appropriately stored and monitored and we saw evidence to support this.
• Patient safety and medicine alerts were shared amongst the clinical team and consistently actioned and a record and log was maintained.

Actions the practice should take to improve:

• Ensure all blank prescriptions are handled in accordance with national guidance and tracked accordingly.
• Review process and methods for identification of carers and the system for recording this to enable support and advice to be offered to those that require it.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 6 July 2017

The practice is rated as good for the care of people with long-term conditions.

• Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.
• Longer appointments and home visits were available when needed.
• All patients had a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.
• Nursing staff performed diabetic foot checks, spirometry and peak flow assessments.

Updated 6 July 2017

The practice is rated as good for the care of families, children and young people.

• 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 followed up child missed appointments and flagged these for the reception staff to contact the patient and to the GP to follow up when they had any concerns.
• Immunisation rates were high for all standard childhood immunisations.
• The practice offered contraceptive advice for patients.
• The practice promoted the cervical screening programme. The practice’s uptake for the cervical screening programme was 82%, which was comparable with the CCG average and the national average of 81%.

Updated 6 July 2017

The practice is rated as good for the care of older people.

• The practice offered proactive, personalised care to meet the needs of the older people in its population.
• Longer appointments were available for older people if required.
• The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.
• The practice worked closely with their admission avoidance patients with a multi-disciplinary approach.
• Patients were referred to local services in the area. For example, the falls clinic and a day assessment unit.

Updated 6 July 2017

The practice is rated as good for the care of working-age people (including those recently retired and students).

• 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.
• The practice offered two extended hours surgeries per week, Tuesday morning and Monday evening.
• The practice offered online services as well as a full range of health promotion and screening that reflected the needs for this age group.
• Telephone appointments were available with the GP or nursing team.

Updated 6 July 2017

The provider was rated as good for the care of people experiencing poor mental health (including people with dementia).

• The practice’s data showed 91% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which was above the CCG average of 81% and national average of 84%.
• The practice was comparable to the CCG and national average for their management of patients with poor mental health. For example, 91% of their patients with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive care plan documented in their records within the last 12 months compared with the CCG average of 84% and the national average of 89%.
• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia. Staff had a good understanding of how to support patients with mental health needs and dementia.
• The practice carried out advance care planning for patients with dementia and provided home visits for those unable to attend.
• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.
• Carers were highlighted on their patient record and offered appropriate vaccinations and health checks.

Updated 6 July 2017

The practice is rated as good for the care of people whose circumstances may make them vulnerable.

• The practice held a register of patients living in vulnerable circumstances including those with a learning disability.
• The practice offered longer appointments for patients with a learning disability.
• The practice regularly worked with other health care professionals in the case management of vulnerable patients.
• The practice informed vulnerable patients about how to access various support groups and voluntary organisations.
• 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.