The Care Quality Commission
  • Doctor
  • GP practice

Kapur Family Care

Overall: Good read more about inspection ratings

Werneth Primary Care Centre, Oldham, Lancashire, OL9 7AY (0161) 271 3040

Provided and run by:
Kapur Family Care

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Kapur Family Care on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Kapur Family Care, you can give feedback on this service.

30 June 2021

During an inspection looking at part of the service

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

23 August 2019

During an inspection looking at part of the service

We carried out an announced inspection of Kapur Family Care on 23 August 2019 due to the length of time since the last inspection. Following our review of the information available to us, including information provided by the practice, we focused our inspection on the key questions safe, effective and well-led. Because of the assurance received from our review of information we carried forward the ratings for the caring and responsive key questions.

The previous inspection was 19 March 2015 and the practice was rated good overall and good in each of the key questions.

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 requires improvement overall and for all population groups.

We rated the practice as requires improvement for providing safe services because:

  • Not all staff had been trained in safeguarding adults or children.
  • Not all staff had received mandatory training in fire safety or infection control. This included staff involved in carrying out relevant safety audits.
  • There was no record of the immunisation or immunity status of non-clinical staff for conditions such as tetanus and measles, mumps and rubella (MMR).
  • The infection control audit had not identified gaps such as immunisation status and training not being completed.

We rated the practice as requires improvement for providing effective services because:

  • Mandatory training was not well-monitored. Several staff had not received training identified by the practice as being required, and training was not routinely updated in line with the practice’s policies.

We rated the practice as requires improvement for providing well-led services because:

  • Policies were not well-managed and not always followed with regard to staff training.
  • The practice’s objectives in their development plan for 2018-20 were not being adequately monitored. For example, one objective stated that staff should be up to date with safeguarding training. Several staff had either not been trained or had not repeated the training at the required intervals.
  • Audits were not always effective. For example, the infection control audit did not identify issues found during the inspection.
  • Training was not a priority. Staff carried out audits without receiving relevant training.
  • The practice had not acted on areas identified as needing improvement at our inspection in March 2015. For example, we had reported that the practice should have arrangements for patients with hearing problems in keeping with current guidance and good practice. This had not been actioned and there was no hearing loop in the reception area. The lead GP told us the building managers would not allow them to install one without their consent.

The area where the provider must make improvements is:

  • The provider must establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvement are:

  • The provider should have a protocol to follow if a Disclosure and Barring Service (DBS) check identifies previous convictions.
  • The provider should invite relevant parties to multi-disciplinary team meetings.

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

19th March 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Kapur Family Care on 19th March 2015. Overall the practice is rated as good.

They were good for providing safe, effective, caring, responsive and well led services and also good for providing services to all the population groups.

Our key findings across all the areas we inspected were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • Staff had received training appropriate to their roles and further training needs had been identified and planned.
  • Patients said they were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

There were areas of practice where the provider needs to make improvements.

Importantly the provider should :

  • The practice should implement a mechanism to store national safety alerts and clinical updates so they have a record to refer back to of those received and actioned.
  • The practice should ensure there are specific arrangements for patients with hearing problems in keeping with current guidance and good practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice