Dr Kumudini Khare Also known as Dr Khare Medical Practice

We carried out an announced comprehensive inspection at Dr Kumudini Khare on 31 October 2023. Overall, the practice is rated as requires improvement.

Safe - requires improvement

Effective - requires improvement

Caring- good

Responsive - requires improvement

Well-led - requires improvement

Our last inspection took place on 21 December 2015 and the practice was rated good overall and for all key questions. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Kumudini Khare on our website at www.cqc.org.uk.

Why we carried out this inspection.

We carried out this inspection in line with our inspection priorities.

The focus of inspection included:

• The safe, effective, caring, responsive and well led domains.
• Areas followed up on the ‘shoulds’ identified in previous inspection.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A site visit.
• Staff questionnaires.
• Information provided to the Care Quality Commission by other stakeholders, such as patient feedback, Healthwatch and the local Integrated Care Board.

Our findings

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 found that:

• Safeguarding systems were in place and staff demonstrated a clear understanding of the reporting and recording processes. However, not all staff had completed training at the appropriate level for their role.
• Not all staff recruitment checks, in particular locums, had been carried out in accordance with regulations.
• Most health and safety risk assessments had been carried out and appropriate actions taken to mitigate identified safety risks for patients and staff.
• Not all staff were up to date with essential training requirements according to the staff training matrix.
• The practice had a good uptake rate for most child immunisations with the exception of those aged 5 for measles mumps and rubella.
• Staff dealt with patients with kindness and respect and communicated in a way that helped patients to understand their care, treatment and condition.
• Four of the national GP patient survey finding indicators were below the England averages in respect of; ease to get through to the practice by phone, overall experience of making an appointment, satisfaction with the appointment times and by the appointment offered by the practice.
• Staff felt valued and supported in their work and found leaders approachable, supportive and visible.

We found breaches of regulations. The provider must:

• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.
• Ensure care and treatment is provided in a safe way to patients.

The provider should:

• Implement a strategy to improve childhood immunisations for those aged 5 years.
• Consider a strategy to improve the uptake of cervical screening.
• Evaluate the National GP patient survey results for the practice and implement an improvement strategy.
• Implement measures to encourage a patient participation group.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care