Background to this inspection
Updated
30 July 2021
Kapur Family Care is located at Werneth Primary Care Centre, Featherstall Road South, Oldham, OL9 7AY. The practice has a large car park and there is a pharmacy in the same building.
The provider is registered with CQC to deliver the Regulated Activities diagnostic and screening procedures, family planning, maternity and midwifery services, surgical procedures and treatment of disease, disorder or injury.
Kapur Family Care is a member of Oldham Clinical Commissioning Group (CCG) and provides services to approximately 11,328 patients under the terms of a general medical services (GMS) contract. This is a contract between general practices and NHS England for delivering services to the local community.
There are three GP partners, one female and two male, and a female salaried GP. There is a practice nurse, two healthcare assistants and a clinical pharmacist. The practice has a practice manager and administrative and reception staff. At the time of our inspection there were two GP registrars attached to the practice. These are qualified doctors training to be GPs. two practice nurses, an assistant practitioner and two phlebotomists.
The National General Practice Profile states that 57% of the practice population is from an Asian background with 40% from white backgrounds, and 3% black, mixed or other. Information published by Public Health England, rates the level of deprivation within the practice population group as one, on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest.
Extended access is provided locally by IGP Care Limited, where late evening and weekend appointments are available. An out of hours service is provided by GTD Healthcare.
Updated
30 July 2021
We carried out an announced inspection at Kapur Family Care on 30 June 2021. Overall, the practice is rated as good.
The ratings for each of the key questions are:
Safe - good
Effective - good
Caring - good
Responsive - good
Well-led - good
Following our previous inspection on 23 August 2019, the practice was rated overall as Requires Improvement with the following ratings for each of the key questions:
Safe - requires improvement
Effective – requires improvement
Caring - good
Responsive - good
Well-led – requires improvement
We issued a requirement notice in respect of a breach of Regulation 17 (good governance) of the Health and Social Care Act (Regulated Activities) Regulations 2014.
At this inspection on 30 June 2021 we inspected the key questions safe, effective and well-led. We rated all these key questions good. The previous ratings of good for the key questions caring and responsive remain in place.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Kapur Family Care on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a comprehensive inspection to follow up on the breach of Regulation 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014 found in the inspection of 23 August 2019, and to be able to change the rating of the practice as appropriate.
How we carried out the inspection/review
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included:
- Conducting staff interviews using video conferencing
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider
- Reviewing patient records to identify issues and clarify actions taken by the provider
- Requesting evidence from the provider
- A short site visit
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 have rated this practice as good overall and good for all population groups.
We rated the practice good for providing safe services because:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm. Improvements had been made as follows:
- All staff had received mandatory training in safeguarding, fire safety and infection control.
- An in-depth infection control audit had been carried out, actioned and monitored as required.
- The immunisation and immunity status of staff was recorded.
We rated the practice good for providing effective services because:
- Patients received effective care and treatment that met their needs. Improvements had been made as follows:
- Mandatory training and other appropriate training was in place for all staff. Staff had completed the required training and it was well-monitored.
- Training was in place in line with practice policies.
The rating of good for the key question caring remained in place from the previous inspection.
The rating of good for the key question responsive remained in place from the previous inspection.
We rated the practice good for providing well-led services because:
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care. Improvements had been as follows:
- Policies were well-managed and monitored.
- Training had been a priority. The practice manager ensured staff were appropriately trained for their roles and this was monitored.
- The practice had a development plan that was monitored by the partners.
- All areas requiring improvement had been acted upon and monitored.
Whilst we found no breaches of regulations, the provider should:
- Increase the number of women attending cervical screening appointments.
- Work with patients who are identified as being pre-diabetic to monitor them and provide advice.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care