This practice is rated as Requires improvement overall. (Previous rating 25/03/2015 – Good)

The key questions at this inspection are rated as:

Are services safe? – Requires improvement

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We carried out an announced comprehensive inspection at Dr Kiren Kaur on 25 March 2019 as part of our inspection programme

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

• There was no evidence that all staff, including some clinicians, had received training in safeguarding.
• The practice did not follow its safeguarding policy in that it did not provide annual safeguarding training which all staff were expected to attend, and training was not always renewed in a timely manner.
• Not all staff had completed training in infection prevention and control.
• The infection control policy had not been reviewed since 2011.
• The process for managing uncollected prescriptions was not effective, with one prescription from 2017 being outstanding.
• The practice had some below average prescribing data and there was no plan in place for improvements to be made.
• Not all the required checks had been completed prior to some medicines being prescribed.

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

• There was no evidence the healthcare assistant had received appropriate training.
• Training was not well-monitored with some staff not completing mandatory training and some not updating their training at the appropriate time.
• Most staff had not had an appraisal since 2017.

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

• There was little evidence of systems and processes for learning and continuous improvement.
• Some policies were not being followed and some had not been reviewed for several years.
• The GPs had a heavy workload and there was no plan for the workload to be sustainable and no succession plan.
• There was not always formal support and assessment of staff.

We rated the practice as good for providing caring services because:

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.

We rated the practice as good for providing responsive services because:

• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

These areas where improvements were required affected all population groups so we rated all population groups as requires improvement.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Formalise the arrangement for using the GP from the other practice in the building when more GP capacity is required.
• Carry out practice-led clinical audits.

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

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Kiren Kaur on 25th March 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing well-led, effective, caring, responsive and safe services. It was also good for providing services for the populations groups we rate.

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.
• 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 any further training needs had been identified and planned.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand, however there was no evidence of the system being put into practice.
• Patients said they found it easy to make an appointment 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.

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

Importantly the provider should

• Ensure full clinical audits take place.
• Ensure patients with a learning disability receive the required health checks and annual reviews in a timely manner.
• Ensure complaints are handled and monitored in line with the practice policy.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice