Dr Kumudini Khare Also known as Dr Khare Medical Practice

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating has remained, requires improvement.

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 and good governance. We have taken action in response to these breaches of regulation.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision and culture. The mission statement was to provide ‘professional, accessible, high quality, comprehensive healthcare services that inspired confidence in our patients and our community.’ The vision for the service included aims which included the provision of the best possible outcomes for patients in a safe and welcoming environment. The practice values comprised of being accountable, fair, professional, innovative and caring. Staff were aware of the mission statement.

Feedback we received from staff regarding the culture within the practice was very positive. They remarked on the difference made since the appointment and commencement of their new practice manager. They told us it was a positive and friendly environment to work in, the culture was open, transparent, blame free and non-discriminatory and they enjoyed working there.

Leaders were aware of the challenge that could be presented by the impact of any staff attrition and had focused on ensuring staffs wellbeing during times of change.

The service had inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation.

Staff spoke positively about the leaders, that they were approachable and responded to any concerns raised. We saw the lead GP worked with other practices in the primary care network.

Staff had completed Care Quality Commission questionnaires and those returned were all positive in respect of the practice manager’s positive impact and of the clinical support available.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff were aware of who the freedom to speak up guardian was and what whistle blowing was. The service had established Freedom to Speak up arrangements with the Integrated Care Board.

Staff were aware of how to whistle blow and who the Freedom to Speak Up Guardian was and what their role was in supporting staff. Staff felt that they could speak up and were confident their voice would be heard and acted upon.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Policies and procedures to promote diversity and equality were in place. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support staff were in place.

The service as a small team had clear responsibilities, roles, systems of accountability and held awareness of good governance. However, we found gaps in some of the systems and process in place. For example, recruitment checks for locum staff, infection prevention and control audits and policy, patient triage systems had a lack of guidance to support staff, a lack of monitoring recalls for some patients, legacy patient safety alerts, some practice environment risk assessments and risk assessments on the emergency medicines not held by the practice. Our clinical searches identified patients as having the potential for a missed diagnosis of chronic kidney disease (stages 3-5). There was a lack of governance and oversight in these areas. Several areas of concern detected during this inspection had been identified at our last inspection in 2023.

The leadership were responsive to our findings. Where able to do so they acted upon our findings promptly.

Leaders supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Staff could access required policies and procedures on the practice electronic shared drive as well as a printed version for staff who preferred this method. Leaders completed staff’s annual appraisals, and the lead GP completed staff’s non-medical clinical competency reviews on a monthly or regular basis.

The provider had some established governance processes. The lead GP reported awareness that additional IT upskilling would further support workflow within the service, away from a paper led process in some areas. For example, with pathology result reviews, legacy patient safety alert searches and for the potential undiagnosed conditions as demonstrated within our clinical searches during the inspection. There was no documented or formalised succession plan in place in respect of the service. This was also a reported concern during our inspection in October 2023.This posed a potential risk as there remained a reliance on the lead GP as the clinical lead responsible for the all the service’s regulated activities, without any long-term substantive deputising arrangements in place. Sustainability workload risks were highlighted during our inspection, such as gaps seen in clinical governance oversight.

Leaders held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. We found that these did not follow a regular agenda item approach managers which the practice manager advised they would implement.

Staff took patient confidentiality and information security seriously.

The service clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They ensured referrals made were followed up and appointments offered, and patients were updated.

The practice was supported by a proactive Patient Participation Group (PPG). The PPG acted as a conduit for communication between the local community and the service. Members of the PPG were active with the local community and linked with local community groups. The practice manager had completed a review of their patient demographics and noted the practice may benefit from the addition of a virtual PPG group which may encourage the engagement and involvement of younger and working age patients too in order to ensure an inclusive approach to the patients voice and feedback.

The practice worked in partnership with key organisations and agencies to support the provision of care and joined up working.

The service provided pathways for staffs continuous learning and improvement across the organisation and local system. Staff told us they were supported with education and opportunities for career progression, many staff havingworked at the practice for over 20 years.

There was a limited programme of quality improvement in place due in part to the smaller number of practice staff members who worked part time and the lead GPs available time.

We found that there were some missed opportunities for learning and improvement within our clinical searches and the governance system findings.