All inspections: Dr Kiren Kaur - Care Quality Commission

We carried out an announced inspection at Dr Kiren Kaur on 9 June 2023. Overall, the practice is rated good.

The ratings for each key question are:

Safe - good

Effective - good

Caring - good

Responsive - good

Well-led – good

Following our previous inspection on 23 March 2022, the practice was rated requires improvement.

The ratings for each key question at that time were:

Safe - good

Effective - requires improvement

Caring - good

Responsive – requires improvement

Well-led – requires improvement

We issued requirement notices in respect of breaches of Regulations 12 (Safe care and treatment), and 17 (Good governance).

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Kiren Kaur on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection of all five key questions. We also followed up on the breaches of regulations we found at our previous inspection.

How we carried out the inspection

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:

Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
Reviewing patient records to identify issues and clarify actions taken by the provider.
Conducting an interview with the provider using video conferencing.
Requesting evidence from the provider.
A short site visit.
Issuing questionnaires to staff.

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 key questions.

We found that:

The practice provided care in a way that kept patients safe and protected them from avoidable harm.
Patients received effective care and treatment that met their needs.
Staff dealt with patients with kindness and respect and involved them in decisions about their care.
Patients could access care and treatment in a timely way.
The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Although we found no breaches of regulations the provider should:

Monitor improvements required following the completion of risk assessments.
Organise personnel files so all required information is accessible and any omissions are apparent.
Check historic safety alerts and take action if required.
Work towards improving the uptake of childhood vaccinations and cervical screening.
Increase communication with the patient participation group (PPG), including patients who do not have Internet or social media access.

We found an area of outstanding practice:

Patients were able to contact the practice at any time during the day to access appointments. We saw evidence that telephone calls were spread throughout the day which meant patients were easily able to speak to the practice, including the period when the practice opened each morning. We saw that appointments, both face to face and telephone consultations, were available at short notice.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

We carried out an announced inspection at Dr Kiren Kaur on 23 March 2022. Overall, the practice is rated as requires improvement.

The ratings for each key question are:

Safe - good

Effective – requires improvement

Caring - good

Responsive – requires improvement

Well-led – requires improvement

Following our previous inspection on 23 August 2021, the practice was rated inadequate and placed into special measures.

The ratings for each key question at that time were:

Safe - inadequate

Effective – inadequate

Caring - good

Responsive – good

Well-led – inadequate

We issued a warning notice in respect of a breach of Regulation 12 (safe care and treatment), and imposed conditions on the provider’s registration in respect of breaches of Regulations 17 (good governance) and 18 (staffing).

We carried out a further inspection on 22 November 2021 to check the progress made with the warning notice. We found that the required improvements had been made.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Kiren Kaur on our website at www.cqc.org.uk

Why we carried out this inspection/review (delete as appropriate)

This inspection was a comprehensive inspection of all five key questions. We also followed up on the breaches of regulations we found in our previous inspection.

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 interviews with the provider and managers 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
Issuing questionnaires to staff

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 Requires improvement overall.

We rated the provider as Good for providing safe services.

The practice provided care in a way that kept patients safe and protected them from avoidable harm.

We rated the provider as Requires Improvement for providing effective services. Although improvements had been made, we found:

Formal monthly clinical supervision was not in place for the practice nurse. This had been a condition of the provider’s registration.
Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) decisions were not made appropriately.

We rated the provider as Good for providing caring services.

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

We rated the provider as Requires Improvement for providing responsive services.

Complaints were not routinely investigated.

We rated the practice as Requires Improvement for providing well-led services. Although improvements had been made we found:

The action plan put in place following the August 2021 inspection had not been monitored effectively. For example, the practice told us the website had been updated but we found it still contained inaccurate information.
The practice had not investigated formal complaint that had been made.
Incorrect information for patients was displayed on the website.
The provider had not identified they had not met the condition imposed on their registration.

We found two breaches of regulations. The provider must:

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

In addition, the provider should:

Include all relevant training is completed by new staff members.

We found an area of outstanding practice:

Patients were able to contact the practice at any time during the day to access appointments. We saw evidence that telephone calls were spread throughout the day which meant patients were easily able to speak to the practice, including the period when the practice opened each morning. We saw that appointments, both face to face and telephone consultations, were available at short notice.

I am taking this service out of special measures. This recognises the improvements made to the quality of care provided by this service.

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

We carried out an announced inspection for Dr Kiren Kaur on 22 November 2021. A site visit was not carried out. A CQC GP specialist advisor carried out clinical searches on the practice’s patient records system and discussed findings with the provider by video conferencing.

We inspected Dr Kiren Kaur on 23 August 2021. This was a full comprehensive inspection following a previous inspection where the practice had been rated requires improvement. Following the inspection of 23 August 2021, the practice was given an overall rating of inadequate with the following key question ratings:

Safe – Inadequate

Effective – Inadequate

Caring – Good

Responsive – Good

Well-led – Inadequate.

After the inspection on 23 August 2021 a warning notice was issued for a breach of Regulation 12 (safe care and treatment).

This inspection, carried out on 22 November 2021, was to check the progress made with the warning notice.

We found that improvements had been made in all the areas covered in the warning notice:

We found one patient prescribed Spironolactone had not had the required monitoring. However, this was only minimally overdue, the practice was aware of this and had included an alert on the patient’s clinical records, and there were specific reasons why the monitoring had not taken place.
All patients prescribed Amiodarone had had the required monitoring.
All patients prescribed Sodium Valproate had been properly managed.
We found no cases of potentially missed diagnoses of diabetes.

The rating of inadequate awarded to the practice following our full comprehensive inspection on 23 August 2021 remains unchanged. A further full inspection of the service will take place within six months of the original report being published and their rating revised if appropriate.

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

We carried out an announced inspection at Dr Kiren Kaur on 23 August 2021. Overall, the practice is rated as inadequate.

The ratings for each of the key questions are:

Safe - inadequate

Effective - inadequate

Caring – good*

Responsive – good*

Well-led – inadequate

*The rating of good for the key questions of caring and responsive remained in place from the previous inspection.

Following our previous inspection on 25 March 2019, the practice was rated requires improvement overall 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 requirement notices in respect of breaches of Regulation 12 (safe care and treatment) and 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Kiren Kaur on our website at www.cqc.org.uk

At this inspection on 23 August 2021 we inspected the key questions safe, effective and well-led. We rated all these key questions inadequate. The previous ratings of good for the key questions caring and responsive remain in place.

Why we carried out this inspection

This inspection was to follow up on the previous breaches of regulation and to allow us to change the rating of the practice if 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 inadequate overall and inadequate for all population groups.

We rated the provider inadequate for providing safe services.

There was no effective system to learn and make improvements following significant events.
The safeguarding audit had been inaccurately completed. Disclosure and Barring Service (DBS) checks were not requested at the frequency the practice had documented and safeguarding training was not at the level indicated in the audit.
Recruitment was not always carried out according to the practice policy or Schedule 3 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
We found issues relating to the required monitoring of patients prescribed certain medicines.
Medicine reviews did not contain relevant information.

We rated the provider inadequate for providing effective services.

Clinical supervision was not taking place.
Consent was not always obtained in line with guidelines.
Required blood tests for some patients were overdue.
We found cases of potentially undiagnosed diabetes.

We rated the provider inadequate for providing well-led services.

GP capacity had impacted on some quality issues.
Openness and honesty had not always been demonstrated and this shortfall had not been confronted when identified.
The provider had not identified actions required to deliver high quality care.
We saw several examples of ineffective governance systems.
Processes for identifying and managing risk were unclear.
There was little evidence of processes for learning and continuous improvement.

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 found three breaches of regulation. The provider MUST:

Ensure care and treatment is provided in a safe way to patients.
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
Ensure staff receive such appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform,

The Care Quality Commission will refer to and follow its enforcement processes in taking action reflecting these circumstances.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

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

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

Dr Kiren Kaur Also known as Moorside Medical Practice

All Inspections

9 June 2023

During a routine inspection

23 March 2022

During a routine inspection

22 November 2021

During an inspection looking at part of the service

23 August 2021

During a routine inspection

25 March 2019

During a routine inspection

25/03/2015

During a routine inspection

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)