Dr Kumudini Khare Also known as Dr Khare Medical Practice

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm.

At our last inspection, we rated this key question as requires improvement. At this assessment, the service was rated inadequate.

We found breaches in Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3) (as amended). These included safe care and treatment, and fit and proper persons employed. We have action taken in response to these breaches of regulation.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We found that learning events had not been collated to enable analysis of trends and discussions at meetings. The new practice manager had recommenced the learning event system in April 2025. Records of events prior to April 2025 were not located. The processes for staff to report incidents, near misses and safety events were in place. However, these were not always effective, as there were gaps seen in reporting, and some documentation reviewed lacked details, such as a root cause analysis. This was also a reported concern and a breach of regulation during our inspection in October 2023. We found that opportunities to raise and investigate significant events had been missed. The practice did not always investigate incidents thoroughly.

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. We discussed with leaders the role and benefit of trend analysis for any verbal complaints.

Staff felt there was an open culture, and that safety was a top priority. Staff told us that managers encouraged them to raise concerns when things went wrong.

The service mostly worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. However, our clinical searches identified some gaps in respect of downloading monitoring blood results when completed in secondary care prior to repeat prescribing.

Local health care providers used the same electronic patient record system and could access information about people using the service.

There were systems in place for processing information relating to new patients.

The service worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately. Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures.

The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. However, this list was not verified with the local safeguarding team to ensure safeguarding information was accurate and up to date. This was also a reported concern and a breach of regulation during our inspection in October 2023.

Systems and processes were in place to identify and raise awareness of potentially vulnerable groups of people. Safeguarding concerns were discussed at the practice meetings. There were processes in place to follow up people who failed to attend appointments in primary and secondary care or were frequent attenders to the emergency department.

The service worked with people to understand and manage risks by thinking holistically.

Emergency equipment was available and maintained. However, there was no risk assessment in place for the emergency medicines not held, or for the shared

automated external defibrillator (AED). This was also a reported concern and a breach of regulation during our inspection in October 2023. This was shared between the practice and a co-located practice. The absence of a formal risk assessment for the shared arrangement may compromise the practice’s ability to respond effectively in emergency situations. The provider responded to these on-site findings and implemented risk assessments, and we were told that discussions had taken place regarding risk, between the co-located practice with whom the AED was shared

Effective systems were not in place for checking the expiry dates of consumables, as out of date syringes, blood bottles and needles were available in two rooms.

Patient triage systems were not working effectively enough to be assured that professional clinical boundaries were safeguarded in respect of staff roles and responsibilities. Most but not all reception staff had completed Care Navigation training to support nonclinical staff to signpost patients to the most appropriate clinician. There was no documented guidance in place at the time of the onsite inspection to support staff awareness on when to alert the GP regarding patients presenting symptoms.

Clinical staff advised patients on risks related to their condition and actions to take if their condition deteriorated. Staff we spoke with told us they would recognise a deteriorating patient and of the action to take. They had awareness of sepsis red flag symptoms.

Services were provided from a ground floor practice within a large health centre owned by the landlord Midlands Partnership NHS Foundation Trust (MPFT).

Automatic doors and level ramp provided easy access to the premises. Car parking was available outside the health centre.

Leaders told us they had recently devised a new business continuity plan.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and the risks identified addressed. However, although portable appliance tests had mostly taken place some equipment did not have appropriately dated labels. In one consulting room we found a multi-socket device which held many electrical plugs. There were window blinds with cords that required a risk assessment, and a red emergency call bell cord set within the ceiling away from walls in a consulting room which required a risk assessment. One consulting room had been reported for general refurbishment to the landlords by the practice leadership and they were awaiting a response.

Following the onsite inspection, leaders took action to mitigate the risks and informed their estates team for them to action. There was no mercury spill kit or risk assessment in place for a mercury sphygmomanometer, used to check patients’ blood pressure, in one of the consulting rooms. Following the onsite visit leaders told us a risk assessment and mercury spill kit were put in place.

The practice waiting room area was not immediately obvious to people using the service as several practices were co-located with a waiting area located between their reception areas. The waiting area was to the side of the reception desk, had no raised chairs and it would be difficult to manoeuvre a wheelchair. The leaders advised they had as a team considered how they could rearrange the area to better signpost and meet the needs of their patients. They advised following our onsite visit that this had been actioned.

Safe recruitment practices were not always followed. We found a lack of appropriate recruitment records in particular for the locum GPs. The practice manager was able to demonstrate they had requested this information without effect.

We found that this was a repeated regulatory breach with the same findings reported on a lack of appropriate recruitment records in particular for the locum GPs, during our inspection in October 2023.

Leaders advised that following the last inspection in October 2023, an interim practice manager provided some part time support to the practice, until they appointed a new practice manager in March 2025. The team consisted of a full time GP and locum GP support as required, a nurse practitioner, a general nurse, and a pharmacy technician who were all supported by the practice manager and reception/administration staff.

Leaders told us there were enough qualified, skilled and experienced staff in place to support registered patients. Staff with enhanced roles received supervision and supportive opportunities for development. The team worked together well to provide care to meet people’s individual needs. Staff told us there were sufficient staff to meet the needs of people although suggested additional GP hours would be beneficial.

We found training was mostly up to date, learning needs and development of staff was managed appropriately. Where gaps in training had been identified the practice manager had tried to source training, such as learning disability and autism training tier 2. The nurse practitioner advised their role included appointments for children and pregnant women and that they worked within their competencies with GP support available. However, there was no oversight on the training achieved by the locum GP staff. There were no records available to review for the locum GPs.

Staff were positive about the support, training and development they received. Staff working in enhanced roles told us support from GPs was always available, a system for regular audit of their prescribing and consultations was in place.

The service had a designated infection prevention and control (IPC) lead and staff had been in receipt of relevant on-line training. The nurse practitioner completed IPC audits. All staff were aware of the named lead in IPC.

We found that the infection prevention and control (IPC) policy did not contain the information required to support staff. In particular, notifiable diseases, the appropriate reporting agency and contact details in order to report any notifiable diseases.

NHS estates arranged the cleaning contract for the building. We found there were no cleaning schedules in place for the consulting rooms. Leaders advised they would report this for actioning following our feedback.

Staff were aware of the actions they would take in the event of an incident relating to the control of substances hazardous to health (COSHH). Staff had access to adequate supplies of personal protective equipment.

A recent IPC audit had been completed; however, we found this had not highlighted the issues we identified whilst on site at the practice. For example, in one consulting room we found a fabric chair had a tear, there was rust on the top of a metal bin, rust markings on the flooring and on the couch, a sharps bin that was undated and unsigned and stored at below waist height/level.

Clinical waste procedures were in place.

Staff vaccinations were mostly maintained in line with current UK Health and Security Agency (UKHSA) guidance if relevant to their role.

Our clinical searches found potential risks to patients regarding legacy patient safety alerts from the Medicines and Healthcare products Regulatory Agency (MHRA).

We found a significant number of clinical system electronic patient alertsthat had not been actioned. This was fed back to the practice for actioning.

In patients prescribed a disease-modifying antirheumatic medicine we found the instructions on the prescription did not always include the day of the week for administration, that the condition for which the patient was taking the medicine was not always linked within the clinical record and that blood results were not always downloaded electronically or noted prior to repeat prescribing.

As an example, our clinical searches showed the total number of patients on two particular groups of medicines used to treat high blood pressure was 307, and the potential number of patients identified by our searches who had not had required monitoring was 28 (9%). Three people on a medicine used to treat heart rhythm problems and had not had the required monitoring and 2 had no record of a monitoring electrocardiogram (ECG). A patient with atrial fibrillation with a raised score when using a tool used to assess the risk of stroke in individuals with atrial fibrillation had not been prescribed anticoagulation. We found there was a potential need for monitoring bloods and ECG to be completed.

Our clinical searches found that some medicine reviews lacked the detail expected as they had consisted of a single line entry stating medicine review.

Staff regularly checked the expiry dates for all medicines and vaccines. However, there was no system in place for medicine stock level checks. The recommended emergency medicines were available within the practice, however there was no risk assessment in place for the 2 medicines not held. Leaders following this feedback implemented risk assessments. Medical gases, such as oxygen, were available at the co-located practice to which two practice jointly held access. A member of the co-located practice team completed the recommended checks. An oxygen cylinder actually held in the practice within a consulting room was found to be empty. Following feedback to leaders a replacement oxygen cylinder was ordered.

Prescription stationery was stored securely. However, we looked at the system in place to record the receipt and use of prescription stationary. The prescription stationery security auditing system was not auditable. This limited the ability to monitor and ensure the safe management of prescription stationery. Staff were not aware of the sequential nature of the serial numbers on prescription stationery.

Vaccine fridge cold chain monitoring was not always robust. We found there was no fridge temperature data logger and 3 gaps in dates for recording fridge temperatures were absent in the records reviewed. Following feedback to leaders they advised they had ordered a fridge temperature data logger.