During an assessment under our new approach
Date of Assessment: 25 July 2025 to 29 July 2025. Dr Kumudini Khare is a GP practice and delivers service to 2,581 people under a contract held with NHS England.
The National General Practice Profiles states that the ethnic make-up of the practice area is 95.6% White, 1.4% Asian, 1.85% Mixed, 0.85% Black and 0.3% other. The age distribution of the practice population indicates the practice had a higher number of 30–64-year-old people registered at the practice. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 4th decile (4 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
We carried out an assessment to follow up on the last inspection when the service was Requires Improvement overall.
We found 3 breaches in Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3) (as amended). These included, safe care and treatment, fit and proper persons employed and good governance. We have taken action in response to these breaches of regulation. During this assessment the service remains Requires Improvement overall.
We found a lack of depth and detail within the significant event documents we reviewed. We found a lack of recognition of an incident as a significant event.
The facilities and equipment met the needs of people, and the majority but not all risks had been mitigated.
We found gaps in some of the processes and procedures at the practice. For example, a lack of risk assessments in some areas such as emergency medicine not held, gaps in the infection prevention and control policy and audit, recruitment, and record keeping in relation to prescription stationary.
We found gaps in some of the processes and procedures; for example, in our clinical search findings, there were some deficiencies in the system of responding to patient medicine safety alerts.
There were systems to ensure staff received training and regular appraisals. People were involved in assessments of their needs. Staff took account of people’s communication, personal and health needs. Staff worked with agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people and took decisions in people’s best interests where they did not have capacity.
People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. Staff wellbeing was fully embedded within the working practices and ethos of the service.
The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback.
Leaders and staff had a shared vision and culture based on the care and treatment of patients in a safe and welcoming environment. Their values included being accountable, fair, professional, innovative and caring. Leaders were visible and supportive, helping staff develop in their roles.
Staff spoke positively about the leaders, felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities.
There were limited systems to support innovation, however staff were provided with opportunities for continuous learning.