Dr Manjit Singh

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

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

At our last assessment, we rated this key question as Good. At this assessment, the rating has changed to Requires Improvement.

This service scored 54 (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.

87% of patients that completed the National GP Patient Survey data agreed that they felt their needs were met during their last GP appointment which was slightly lower than the local average of 88% and the national average of 90% and 95% of patients felt the healthcare professional they saw had all the information they needed about them during their last general practice appointment which was higher than the local average of 91% and the national average of 92%.

People we spoke with felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them. Staff 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. Reception staff were aware of the needs of the local community and staff working at the practice spoke a range of languages which provided support to the local practice population. A hearing loop was available; however, we found none of the staff we spoke with were aware of how to use it. Following the onsite assessment, we received assurances that training had been organised for staff on how to use the hearing loop. Staff checked people’s health, care, and wellbeing needs during health reviews. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing.

The provider had systems in place to identify people with previously undiagnosed conditions. Care plans and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) records were completed and reviewed regularly. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber, but on speaking with staff we were unable to gain assurances that the staff were aware of how to do a referral. Systems were in place to identify individuals with caring responsibilities, who were offered an annual review. All patients with a learning disability were invited to attend an annual health assessment.

There were appropriate referral pathways to make sure that patients’ needs were addressed. We found that staff had the appropriate skills and training to carry out reviews where appropriate.

The service did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them

During the remote clinical review, we carried out a search to identify people with asthma who had been prescribed 2 or more courses of rescue steroids in the past 12 months. The search identified potentially 11 people. We reviewed a random sample of 5 clinical records and found none of the patients had been reviewed following an exacerbation in line with clinical guidelines.

We carried out a clinical search on patients who had hypothyroidism and had not received the appropriate monitoring in the past 18 months. The search identified potentially 5 people. We reviewed the 5 clinical records and found 4 out of the 5 patients were overdue monitoring and 3 patients were also overdue medicine reviews.

Further reviews of the clinical system identified people with diabetes who had a HbA1c of 75 and over. A haemoglobin A1C (HbA1C) test is a blood test that shows your average level of blood glucose over time. The clinical search identified 84 people. We reviewed a random sample of 5 clinical records and found 4 of the patients were overdue diabetic reviews and medicine reviews. We discussed our findings with the clinical lead who informed us that DiCE (Diabetes in Community Extension) clinics were in place and these provided annual diabetic reviews. DiCE clinics are held regularly within practices in Sandwell to provide support and guidance from diabetic consultants and specialist nurses for patients whose diabetes is difficult to control, however they do not complete regular diabetic monitoring of all patients on the diabetic register.

We were unable to gain assurances that staff were up to date with evidence-based guidance and legislation. Overall, we found the remote clinical searches we undertook demonstrated the monitoring of patients with long-term conditions had not followed the National Institute for Health and Care Excellence (NICE) recommendations.

The service did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.

Staff told us that they had access to the information they need to appropriately assess, plan and deliver people’s care, treatment and support and they had enough information to plan and refer people and receive subsequent results and information following referral. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

The practice used GP locums on occasions. The practice were unable to demonstrate evidence of a locum pack being in place to provide guidance to GPs working at the practice.

We were unable to gain assurances that there were systems and processes in place to enable information to be shared between the provider and services to ensure continuity of care. We were told that there were regular meetings every 3 months with multi-disciplinary teams, however on reviewing the evidence provided we found the last meeting had been in December 2025, where some concerns had been discussed, but previous minutes of meetings showed no evidence that there was regular communication to ensure care was co-ordinated effectively.

The Primary Care Network (PCN) helped to support the practice by providing links to pharmacists, physiotherapists and social prescribers. On speaking with staff we were unable to determine the process for referring people to the social prescriber. We were told that patients were regularly referred, but staff we spoke with were unable to provide evidence of the referral process.

The service did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. The service did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

We found staff focussed on identifying risks to the majority of patients’ health, including those in the last 12 months of their lives, but patients at risk of developing a long-term condition were not always regularly monitored. We were told that people with caring responsibilities were offered support, however on speaking with staff they were unaware if a carers register was in place. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity and patients were encouraged to take an active role in reviewing their health and were given support to recognise changes.

Health promotion material was observed in the practice and further information could be found on their website that supported national priorities and initiatives to improve population health by supporting people.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

The practice had met the national targets for immunisations, but we found cervical screening data showed the practice had not achieved the national targets. The practice had achieved 60.5% for people aged between 25 to 49 years and 71.9% for people aged 50 to 64 years. This was below the national target of 80%. The practice nurse was available 2 days a week and patients were encouraged to attend when the nurse was available at the practice. There were plans in place to increase nursing provision to 3 days in the near future, which should provide more appointment availability.

The practice had completed some clinical audits aimed at driving continuous improvement, however we were unable to gain assurances that these were being used to improve patient care and operational efficiency. For example, we saw an audit for the management of stable angina which showed a total of 136 patients. The audit identified 128 patients had undergone surgical intervention and 8 patients were managed within primary care. We found no evidence to demonstrate what the outcome of the audit was and the action plan.

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. We reviewed a random sample of 3 records and found an alert was on the summary page for 2 of the patients to ensure all staff were aware that a Do not attempt cardiopulmonary resuscitation (DNACPR) were in place. We found decisions were appropriate and were made in line with relevant legislation.