The Care Quality Commission
  • Doctor
  • GP practice

Dr Manjit Singh Kainth

Overall: Good read more about inspection ratings

Primrose Lane Health Centre, Primrose Lane Practice, Primrose Lane, Low Hill, Wolverhampton, West Midlands, WV10 8RN (01902) 731583

Provided and run by:
Dr Manjit Singh Kainth

All Inspections

14 August 2023

During a routine inspection

We carried out an announced comprehensive inspection at Dr Manjit Singh Kainth on 14 August 2023. Overall, the practice is rated as Good.

Safe – Good

Effective – Good

Caring – Good

Responsive – Requires Improvement

Well-led – Good

We previously carried out an announced comprehensive inspection at Dr Manjit Singh Kainth on 23 March 2022 as part of our inspection programme. The practice was rated as requires improvement for providing safe, effective and well led services. The practice was rated requires improvement overall.

We carried out an announced comprehensive inspection on 14 August 2023 to confirm that the practice had carried out their plans to meet the legal requirements in relation to the breaches in regulations that we identified at our previous inspection on 23 March 2022. At this inspection on 14 August 2023, we found that the practice had resolved the concerns raised and was rated as good in areas where we had previously rated them requires improvement. The practice is now rated good for providing safe, effective and well led services.

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

This inspection review was a comprehensive follow up inspection to review whether the practice had addressed the requirements made following the inspection in March 2022. This inspection included a site visit to follow up on:

  • Any breaches of regulations or recommendations identified at previous inspections.
  • All 5 Key questions.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, considering the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently. 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 the findings with the provider.
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A 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 found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Our review of clinical records found patients on high risk medicines or those patients with long term conditions were managed in line with guidelines.
  • The practice learned from incidents, events and complaints and ensured learning was shared amongst the staff team.
  • We found the premises were well maintained, appeared visibly clean and tidy and there were appropriate infection prevention and control arrangements in place.
  • Patients received effective care and treatment that met their needs. Our review of clinical records found effective systems were in place for follow up and monitoring of patients with long term conditions.
  • Staff had the skills, knowledge and experience to carry out their roles effectively.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The way the practice was led and managed promoted the delivery of person-centred care.
  • The practice continually reviewed and monitored the effectiveness of their services.
  • Feedback from patients was mixed. The practice staff monitored patient feedback so they could take action to address concerns.
  • The practice had commenced a self-assessment process as part of a project with the local Integrated Care Board (ICB) to improve access for patients.
  • The culture of the practice drove the delivery and improvement of high-quality, person-centred care.

Whilst we found no breaches of regulations, the provider should:

  • Improve the uptake of childhood immunisations and cervical cancer screening.
  • Continue to improve outcomes for patient satisfaction results and monitor the impact of changes that have been implemented.
  • Actively monitor and improve patient access to the practice.

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

23 March 2022

During an inspection looking at part of the service

We carried out an announced focused inspection at Dr Manjit Singh Kainth on 23 March 2022. Overall, the practice is rated as requires improvement.

Set out the ratings for each key question

Safe – Requires Improvement

Effective – Requires Improvement

Well-led – Requires Improvement

We previously carried out an announced comprehensive inspection at Dr Manjit Singh Kainth on 1 March 2016 as part of our inspection programme. The practice was rated as requires improvement for providing safe services with an overall rating of good.

We carried out an announced focused inspection on 18 May 2017 to confirm that the practice had carried out their plans to meet the legal requirements in relation to the breaches in regulations that we identified at our previous inspection on 1 March 2016. At the focused inspection on 18 May 2017 we found that the practice had resolved the concerns raised and was rated as good for providing safe services.

We completed a review of Dr Manjit Singh Kainth on 11 December 2020 in response to whistleblowing concerns we received. The practice was not rated as an onsite visit did not take place.

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

This inspection review was a follow up focussed inspection to review whether the practice had addressed the requirements made following the review in December 2020. This inspection included a site visit to follow up on:

  • Key questions relating to the Safe, Effective and Well Led domains.
  • Any breaches of regulations or ‘shoulds’ identified in previous inspections.

How we carried out the inspection

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 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 the findings with the provider.
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A 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 Requires Improvement overall

We found that:

  • There was an absence of recorded contemporaneous information to demonstrate that the GP consistently fully assessed patients needs and delivered care and treatment in line with current legislation, standards and guidance.
  • Patients care and treatment was not consistently followed up in a timely and appropriate way.
  • Patients were referred to other services in a timely way however, we found that some referrals were completed without sharing appropriate information or the completion of an assessment.
  • Information documented in the patient electronic information system did not demonstrate that patients received effective care and treatment that met their needs.
  • Patient records indicated that receptionists were expected to communicate information of a clinical nature.
  • Systems for the safe management of medicines had improved. The provider could demonstrate that most patients receiving high risk medicines were appropriately monitored.
  • The way the practice was led and managed did not promote an inclusive culture where people could speak openly and be involved in the delivery of high-quality, person-centered care.

We found 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.

The provider should:

  • Encourage and support staff to have a say and be involved in the operation and any changes made at the practice.
  • Continue to review and monitor that all tests are completed for patients prescribed high risk medicines.

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

11 December 2020

During an inspection looking at part of the service

This report was created as part of a pilot which looked at new and innovative ways of fulfilling CQC’s regulatory obligations and responding to risk in light of the Covid-19 pandemic. This was conducted with the consent of the provider. We obtained the information in it without visiting the provider.

We previously carried out an announced comprehensive inspection at Dr Manjit Singh Kainth on 1 March 2016 as part of our inspection programme. The practice was rated as requires improvement for providing safe services with an overall rating of good.

We carried out an announced focused inspection out on 18 May 2017 to confirm that the practice had carried out their plans to meet the legal requirements in relation to the breaches in regulations that we identified at our previous inspection on 1 March 2016. At the focused inspection on 18 May 2017 we found that the practice had resolved the concerns raised and is was rated as good for providing safe services.

You can read the reports from our last inspections, by selecting the 'all reports' link for Dr Manjit Singh Kainth on our website at www.cqc.org.uk.

We completed a review of Dr Manjit Singh Kainth on 11 December 2020 in response to whistleblowing concerns we received.

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 found that:

  • There was no reassurance that the systems and processes in place ensured patients had appropriate and timely access to safe care and treatment and protected them from avoidable harm.
  • Information documented in the patient electronic information system did not demonstrate that patients received effective care and treatment that met their needs.
  • The provider had not recorded information in patient medical records to demonstrate that a clinical assessment, diagnosis and treatment plan was completed.
  • Patient records indicated that receptionists were expected to communicate information of a clinical nature.
  • Systems in place were not consistently followed to ensure all patients received an appropriate medicine review.
  • The provider did not demonstrate that patients receiving high risk medicines were appropriately monitored.
  • There was no reassurance that the arrangements for ensuring patients received effective care and treatment that met their needs was planned and delivered according to evidence-based guidelines.
  • The way the practice was led and managed did not promote the delivery of high-quality, person-centre care.

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.

We are considering the appropriate regulatory response to the issues we identified during this inspection. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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

18 May 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Dr Manjit Singh Kainth on 1 March 2016. A total of three breaches of legal requirements were found. After the inspection, the practice was rated as requires improvement for providing safe services.

We issued requirement notices in relation to:

  • Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) 2014 Safe care and treatment.
  • Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) 2014 Premises and equipment.
  • Regulation 19 HSCA (RA) Regulations 2014 Fit and proper persons employed

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Dr Manjit Singh Kainth on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 18 May 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified at our previous inspection on 1 March 2016. This report covers our findings in relation to those requirements.

Our key findings were as follows:

  • The recording of significant events had been reviewed and were sufficiently detailed to show that concerns identified about patients were appropriately followed up to protect them from the risk of potential harm.
  • The practice had a defibrillator in place and regular checks were carried out to ensure that it was working.
  • Recruitment procedures had been reviewed to ensure that all necessary employment safety checks were completed for all staff.
  • Records were available to confirm that environmental risk assessments had been carried out by the owners of the health centre. This included full fire and a legionella risk assessments. However an up to date legionella risk assessment was not available.
  • Procedures had been reviewed to ensure that staff were aware of their responsibilities related to the cleaning of the practice and records were completed to show cleaning schedules were maintained.

At our previous inspection on 1 March 2016, we rated the practice as requires improvement for providing safe services. At this inspection we found that the practice had resolved the concerns raised and is now rated as good for providing safe services.

However there were still some areas where the practice should make improvements:

  • Establish with the owners of the building whether an up to date full legionella risk assessment should be carried out and have documented evidence of any decisions made.
  • Review the completeness of records maintained to manage the systems put in place to minimise the risk of legionella.
  • Review the format of the minutes of meetings to clearly show the topics discussed.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

1 March 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Manjit Singh Kainth on 1 March 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and a system was in place for reporting significant events. However, the recording of significant events was insufficiently detailed to show that concerns identified about patients were appropriately followed up to protect them from the risk of potential harm.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.

  • Feedback from patients about their care was consistently positive.

  • Information about services and how to complain was available and easy to understand.

  • Patients said they were able to get an appointment when they needed one, which included urgent same day appointments.

  • 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.

  • The provider was aware of and complied with the requirements of the Duty of Candour. (the ‘Duty of Candour’ requires that providers of healthcare services must be open and honest with service users and other ‘relevant persons’ (people acting lawfully on behalf of service users) when things go wrong with care and treatment, giving them reasonable support, truthful information and a written apology).

Areas where the practice must make improvements:

  • Ensure that when significant events occur, patients receive reasonable support and appropriate actions are taken to prevent reoccurrence and to protect patients from the risk of harm.

  • Ensure that the defibrillator is checked and maintained to confirm that it is working or that an appropriate risk assessment is carried out to demonstrate why a working defibrillator is not needed at the practice.

  • Ensure that all necessary employment safety checks are completed for all staff. This should include identification checks, qualification, employment history and DBS checks.

Areas where the practice should make improvements:

  • Consider more regular formal practice meetings or documentating discussions that take place at informal meetings.

  • Ensure that staff are aware of their responsibilities relating to the cleaning of the practice and that records are completed to show cleaning schedules are maintained.

  • Ensure that records are available to confirm that environmental risk assessments, including legionella and fire risk assessments have been carried out.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice