Dr Mehboob Bhatti Also known as Sutton Road Surgery

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

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

At our previous inspection we found that leaders could not demonstrate that they had the capacity and skills to deliver high quality sustainable care. We were concerned that the practice did not have embedded governance arrangements in place to proactively identify systems for managing risks and assessing performance to ensure services were delivered in a safe and effective way to patients.

At this assessment we found an improvement in leadership and governance. There was an inclusive and positive culture of continuous learning and improvement shared by all staff. Leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred, sustainable and reduced inequalities. Leaders understood their local population and endeavoured to provide inclusive, flexible and accessible services. Leaders embodied the values they had set out for the practice and staff had embraced their strategy and vision for the future. There was an organised and mostly effective system of governance that managed risks and kept staff and people safe. Leaders had a clear business plan and gathered feedback and information about risks, performance and outcomes which they used effectively to make decisions about future developments.

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 had a shared vision, strategy and culture. This was based on transparency, equity, equality, diversity, inclusion, engagement, and understanding the challenges and needs of people and their communities. The provider had undergone significant change and development since our last inspection including recruiting a large number of new staff. However, the leadership team had managed to create a cohesive team and staff we spoke with described a positive, supportive and motivating workplace culture. The provider was aware of the projected increase in the local population and was working with partner agencies to address future challenges.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. Since our last inspection the practice staff had experienced instability and uncertainty within the leadership team as negotiations took place to find suitable partners to support the necessary quality improvement processes and secure the future of the practice. The implementation of a steering board comprising experienced primary care business managers and a new practice manager to support the lead GP had driven improvements in governance and was providing stable, strategic management and oversight of the practice. Active succession planning was in place to ensure the provider maintained quality and stability whilst transitioning from a single-handed lead GP to a partnership and continued to grow and develop for the benefit of people.

Staff told us leaders were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. The lead GP had many years of experience, and all staff spoke about their compassion, dedication and approachability.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider had established Freedom to Speak up arrangements including a freedom to speak up guardian. Staff were aware of how to raise concerns and were confident that they would be listened to and acted upon.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

Policies and procedures to promote diversity and equality were in place. The provider employed a diverse workforce which reflected the local population and supported service delivery. For example, some staff were multilingual and could provide translation support.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews.

The practice did not consistently maintain accurate records of staff training; however, when we sought clarification, evidence was available to demonstrate that the relevant training had been completed.

Managers had appropriate oversight of the skills, qualifications and scope of staff employed by the Primary Care Network (PCN).

The provider had mostly established governance processes that were appropriate for their service. Staff were aware of and could access all required policies and procedures. However, we found multiple low level concerns regarding accessibility and risk management that had not been identified by the provider’s own quality assurance processes. Formal systems for monitoring clinical and operational performance were in the early stages of implementation, and leads for different areas were actively developing and strengthening these processes. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Staff took confidentiality and information security seriously. The practice had a business continuity plan in place to maintain services in the event of a major incident.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated to implement improvements. The provider supplied GP services to a local residential care home. Feedback from the manager of the care home was uniformly positive with a noticeable improvement in the last 12 months.

The provider worked with other practices within their primary care network to offer extended access. Staff worked with members of the community multidisciplinary team to ensure that vulnerable people or those at the end of life received high-quality, integrated care.

The provider worked with independent health companies to provide dedicated services for people with chronic obstructive pulmonary disease (COPD).

The service focused on continuous learning, innovation and improvement across the organisation. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice. The provider had worked hard to rectify the issues identified during our last assessment and had an action plan in place to drive further improvement. While a fully coherent quality improvement strategy was still being developed, the practice had already begun meaningful quality improvement activity. For example, several medicines audits had been completed and a staff satisfaction survey had been carried out.