Dr Mehboob Bhatti Also known as Sutton Road Surgery

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our last assessment, we rated this key question as inadequate. At this assessment, the rating has changed to good.

We found the service had made improvements in the effective key question following the previous inspection. The provider had embedded effective methods to ensure people’s need were fully assessed and recorded. Staff involved people in decisions about their care and treatment and provided them with timely advice and support. Staff regularly assessed people’s needs and ensured their care needs were met. Staff made reasonable adjustments where possible and supported people to access personalised care within the limitations of the care environment. Staff maintained up-to-date knowledge and provided evidence-based care that aligned with national guidance. The provider had improved the uptake of childhood immunisations and cervical screening since the last inspection however, further action was required to meet national targets.

The provider worked well with other services putting people at the centre of their care. Leaders promoted a preventative approach to care and supported people to engage with this model. There was a culture of improvement, where monitoring and understanding current outcomes in order to improve them was part of everyday work.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Feedback from people using the service was positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. In the National GP Patient Survey 52% of people reported they had a conversation with their healthcare professional about what was important to them when managing their conditions or illnesses, this is above the national average of 42.4%. Sixty-four per cent of people said they had agreed a plan of care with their healthcare professional to manage their conditions or illnesses compared with the national average of 44.9%.

Reception staff were aware of the needs of the local community. They used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present.

Staff checked people’s health, care, and wellbeing needs during health reviews. At the last inspection we raised concerns about a lack of recorded information to demonstrate that patients’ needs were fully assessed. To improve the quality of record keeping the use of templates when conducting care reviews had been introduced to support the review of people’s wider health and wellbeing. The provider had effective systems to identify people with previously undiagnosed conditions and had increased the number of NHS Health Checks to help them achieve this. The practice had completed 75 NHS Health Checks in the previous 4 months, just short of their target of 20 checks per month. These health checks had identified 18 people with previously undiagnosed conditions such as asthma and diabetes. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

During our previous assessment we had concerns about a lack of oversight for monitoring and acting on test results During this assessment the provider demonstrated that they now had an effective system for the management of test results. This meant results were reviewed by a GP before being entered into the patient record and if action was required the relevant staff were tasked to complete it. Systems were in place to ensure staff were up to date with evidence-based guidance and legislation, for example GPs had registered with a nationally recognised primary care education provider. Clinical records we saw demonstrated care was provided in line with current guidance.

The provider was utilising its non-medical clinical workforce to improve the overall management of people with long-term conditions. The practice nurse was trained in the management of asthma and had just completed training in diabetes management. As an independent prescriber this meant the practice nurse could undertake annual asthma reviews and begin first line treatment for people newly diagnosed with diabetes. The practice pharmacist carried out regular searches to identify people who required an annual long-term condition review or whose recent test results were not within the target range. The pharmacist also carried out face to face reviews with people with long-term conditions.

The provider partnered with an external company to carry out reviews of people with chronic obstructive pulmonary disease. Staff from this company liaised with the patient’s GP before and after this review.

The service mostly worked well across teams and services to support people.

Services providing out of hours care and NHS 111 could access the practice clinical systems and appointments systems.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The provider worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

We saw some examples of effective collaboration such as the practice pharmacist working closely with the Integrated Care Board (ICB) specialist diabetes pharmacist to improve the care and treatment of people. The practice nurse maintained effective support networks via an electronic messaging group set up and co-ordinated by the ICB Lead Nurse for all practice nurses in Birmingham and Solihull. Reception staff described close working relationships with local pharmacies who could provide ambulatory blood pressure monitoring services for people from the practice. Staff described how they referred people to the PCN social prescriber who provided a telephone service for people registered with the practice. However, some feedback we received suggested that communication between the provider and other services was not always effective

The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff focussed on identifying risks to people’s health, including those in the last 12 months of their lives, people at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

Leaders had made a collaborative decision with staff to focus on prevention and early identification. Work on this priority was in its early stages but was being supported by the use of searches to improve early identification of people at risk of developing long-term conditions. The provider was also upskilling staff to provide more detailed support around lifestyle modification, increasing the number of NHS over 40 health checks to a target of 20 per month and increasing use of the PCN social prescriber.

The provider had identified a high “Did not attend” (DNA) rate for NHS health checks due to the way they were structured over 2 appointments. They had changed this system so people only had to attend once and had a telephone follow up which had improved attendance rates. The practice provides longer appointments for health checks including up to 30 minute appointments for people with a learning disability.

In the National GP patient survey 76% of people said they had enough support from local services or organisations to help them manage their conditions or illnesses in the last 12 months. This is above the national average of 68.5%.

The service mostly routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves. From the clinical notes we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.

The provider was not meeting national targets for cervical screening. Changes to the way cervical screening data is recorded nationally meant a direct comparison of data for 2024 and 2025 was not possible. However, we saw the number of people effectively screened by the provider aged between 50-64 years had improved slightly. However, cervical screening for both age groups (25-49 years and 50-64 years) remains below the national target of 80%. For the age group between 25-49 years the practice screened 68% of people and 70% of the group aged 50-64 in 2024. The provider had taken action to improve uptake which included an effective call and recall system for these people and specific staff tasked to follow up people who were called for screening but did not make an appointment. The practice nurse contacted people who did not attend for a screening appointment and proactively followed up people who did not attend. Staff focused on educating people about why screening was important and offered appointments with the nurse or a GP so they could address any specific issues individually. The provider had also recruited a healthcare assistant through the PCN who provided phlebotomy (blood taking), which had previously been done by the practice nurse. This increased the capacity of nursing appointments available to be offered to people for cervical screening tests. There was an effective safety netting system to ensure that a result was obtained for every sample taken

At the time of our previous inspection the practice was not achieving the national target of 90% in any cohort of childhood vaccinations. Since then, the practice performance in providing childhood immunisations had improved significantly and they were reaching the national target of 90% in all but 1 cohort of vaccinations. Regarding this group (children aged 5 who have received 2 doses of measles, mumps and rubella vaccinations) the provider was aware of the issues affecting a sector of their population and was working with parents to educate them about the value of vaccination and to dispel myths about the associated risks. The provider was in the process of redesigning their call and recall protocol and had identified that they needed to provide information in a range of languages to encourage patient engagement. There was a programme of regular clinical audits of prescribing for non-medical prescribers but not for GP prescribing. This meant that the provider could not easily analyse individual GP prescribing behaviours and pick up on trends or outliers.

The clinical pharmacist had carried out a range of audits to improve outcomes for people. This included an audit of people prescribed insulin which ensured insulin was being prescribed correctly and provided a systematic approach for safer prescribing practice.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.