Dr Manjit Singh

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm.

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

The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 41 (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 did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Managers encouraged staff to raise concerns when things went wrong and staff felt there was an open culture. The provider had processes for staff to report incidents, near misses and safety events, however we found limited evidence to demonstrate that significant events and incidents were used to share learning and mitigate future risks. Evidence provided showed the practice had recorded 3 incidents in the past 3 years. We were told of a significant event that had recently occurred, however there was no evidence to demonstrate that the incident had been documented. The leadership team told us they planned to discuss it at the next practice meeting. Following the onsite assessment we received minutes of a meeting that had been held on 18 May 2026. There was no evidence that the significant event we had been informed of had been discussed or documented to ensure learning was shared with the practice team. The practice had a significant events policy, but on reviewing the policy we found that it contained information that was significantly out of date. There was also a reporting form in place, but we received mixed responses from staff on if they would use it. Following the assessment, we received an updated policy.

There was a complaints form in place and details on the practice website of how to raise a complaint, however we were not assured there was a system to record and investigate complaints. We were told that complaints were dealt with on the day, but there was minimal documented evidence to support this. Information reviewed demonstrated that people had opportunities to provide feedback, but on speaking with patients they were unaware of the process.

We found there were no systems in place to ensure compliance with the requirements of the duty of candour, with the leadership team unaware what the duty of candour meant. There were limited processes in place for effective communication and shared learning. We received mixed responses to how often practice meetings were held. We were told that they occurred every month, but on reviewing minutes of staff meetings we found the last one had been held in December 2025. At this meeting, the minutes of the meeting showed a complaint and significant event had been discussed. Further evidence showed that other meetings had been held in September 2025, May 2025 and March 2025, however there was no evidence that incidents or complaints had been shared with the team to improve learning and the quality of care.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

There were systems in place to ensure all patient information including laboratory test results and referrals were reviewed and actioned in a timely manner. Referrals to specialists and urgent services, including 2-week-wait (2WW) referrals, were managed through a clear process.

The provider was part of the primary care network (PCN) and we were told they attended regular meetings with other agencies across the locality to share and discuss information relating to patient care and treatment. The last practice meeting had been held in December 2025 and the minutes of the meeting showed minimal evidence that multi-disciplinary discussions were held. We requested minutes of the last multi-disciplinary team meeting and PCN meeting, however this evidence was not provided. Following the onsite assessment we received evidence to demonstrate that the practice was an active member of the PCN.

The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.

Safeguarding policies were in place and known to staff, however on reviewing the policies we found they lacked information including the named lead for safeguarding.

We were unable to gain assurances that regular meetings were held to discuss safeguarding concerns with the community teams and within the practice to ensure patients received the appropriate support. We were told by the senior clinical lead that safeguarding meetings were held every 3 months; however the last meeting minutes we reviewed were from December 2025. Previous minutes were dated September 2025, May 2025 and March 2025 and there was no evidence that safeguarding concerns had been discussed. Following the onsite assessment, we received minutes of a meeting that had been held on 18 May 2026, which documented a safeguarding concern had been discussed with the practice team. However, there was no evidence to demonstrate what had been discussed, the outcomes and if any further action was required.

Majority of staff had been appropriately trained in safeguarding procedures, but on reviewing staff training we found one of the clinical staff had no record of updated safeguarding training since 2022 and no evidence that Deprivation of Liberty (DoLs) training had been completed.

The practice maintained a list of vulnerable people. On reviewing the safeguarding registers, we found that families living in the same household were not linked with children where safeguarding concerns had been identified.

Records we examined showed that some staff had no recent DBS checks in place. We asked the leadership team how often a DBS would be requested and were told a DBS for clinical staff or a DBS update would be completed by non-clinical staff every 3 years. On reviewing staff personnel folders, we found DBS updates had not been completed since 2019 and 2021 for some staff and for one member of the clinical team we found no evidence a DBS was in place. DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.

The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff told us what actions they would take if they had a deteriorating patient, however we found no staff had completed sepsis awareness training and there was no information to provide staff with an understanding of sepsis and the actions to take. Following the onsite assessment we received evidence to demonstrate that staff had now completed sepsis awareness training. Emergency equipment was available and maintained, but we found items listed as being part of the emergency store not in place. A search of the premises was carried out and the missing item was found and put in the emergency medicine stock.

The practice had registers in place to support those patients who were vulnerable or who had mobility or communication needs. A hearing loop was in place, but we found none of the staff were aware of how to use the loop. Following the assessment, we were assured that training had been organised for staff on how to use the hearing loop.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

On the day of assessment, we were unable to gain assurances that a health and safety risk assessment had been completed. The leadership team assured us that there was an assessment in place, but no evidence was provided to confirm this. Following the onsite assessment we received evidence to demonstrate a health and safety risk assessment had been completed. A fire risk assessment had been completed in June 2025. One of the actions from the fire risk assessment was to review the electrical wiring. We were told that this had been completed, however there was no evidence available to demonstrate this action had been acted on. The practice were unable to provide evidence that fire evacuation procedures were regularly reviewed and tested.

The practice were unable to provide completed assessments for the control of hazardous substances (COSHH). Evidence provided by the practice showed equipment was regularly calibrated and electrical items were PAT (portable appliance testing) tested. The latest calibration of equipment had been completed in August 2025.

During our site visit we found the premises were well maintained. Contracts were in place to ensure the premises were clean and well maintained. Clear signage around the building supported people and staff in the event of an emergency evacuation.

Staff had been provided with training in health and safety related topics such as fire safety and infection control.

There was a business continuity plan in place to provide guidance for dealing with a major disruption to the service, for example an IT failure.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

On speaking with the clinical staff, we were unable to gain assurances that there were systems in place for the monitoring of staff, which included regular conversations as part of their clinical supervision. We found most staff were up to date with training, except no staff had completed sepsis awareness training and we found no evidence of training updates for safeguarding and deprivation of liberty for one of the clinical team. Following the onsite assessment we received evidence to demonstrate that staff had completed sepsis awareness training. The development of staff was managed appropriately and staff were working within their agreed areas of competence.

The practice had recruitment policies in place; however, we found some staff had out of date disclosure and barring checks. On reviewing staff files, we found 3 clinical staff had no record of immunisation status. On the day of the assessment, 2 clinical staff were able to obtain their immunisation status. Annual appraisals were completed. Some new staff had participated in a structured induction programme and were required to complete mandatory training within appropriate timeframes, but we were unable to confirm that all staff had completed an induction. Personnel folders were unorganised; we found the professional registration of one of the clinical team in the folder of another.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

An infection control audit had been completed to identify potential risks and take appropriate action where required. The audit had been completed in June 2025, with the practice having achieved 98%. We found there was an action plan in place, however on checking what actions had been completed we found the implementation of a record to demonstrate the decontamination of equipment had not been implemented. Following the onsite assessment, we received evidence to demonstrate that the record was now in place.

We found the premises to be clean and maintained, however on reviewing the storage of cleaning equipment, we found it was stored incorrectly which increased the risk of potential spread of infection.

Privacy curtains were in place and most were dated within the recommended guidelines for changing every 6 months, however we found one room where the curtains had not been changed since June 2025.

On speaking with staff, we were unable to gain assurances that they were aware who was the designated infection, prevention and control lead. Staff had completed training relevant to their role. Staff were aware of the systems and processes to follow to ensure clinical specimens were handled safely.

The practice had policies in place for infection, prevention and control which was accessible to staff and staff were aware of the action to take. For example, in the event of a sharps or contamination injury. The policy required updating to show the designated infection control lead and how to report notifiable infections. Following the onsite assessment we received an updated policy.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

As part of the assessment, we carried out remote clinical searches to review how patients’ medicines were monitored and if the appropriate care and treatment was being received. We reviewed patients who had been prescribed Aldosterone Antagonist medicines. Aldosterone Antagonist medicines are used in the treatment of high blood pressure and heart failure. The clinical search identified potentially 5 out of 14 patients on these types of medicines who had not had urea and electrolyte (UE) monitoring within the past 6 months. We reviewed the records of 5 patients and found 2 patients were overdue monitoring. The 2 patients identified showed 1 patient had not had a UE test since 2020, however the results of a test were pending which had been completed in May 2026 and the second patient had not had a test since January 2025.

We carried out a search to identify the number of patients with a potential missed diagnosis of chronic kidney disease (CKD). The search identified potentially 32 people with a missed diagnosis. We reviewed a random sample of 5 clinical records and found 4 patients had a missed diagnosis of CKD and 1 patient’s record mentioned CKD, but this had not been clinically coded.

A clinical search was carried out to identify the number of patients who had been prescribed gabapentinoids who had not had a review in the past 12 months. Gabapentinoids are medicines used to manage nerve pain. The search identified potentially 19 patients out of a total of 44 who had not had the appropriate review. We reviewed a random sample of 5 records and found all 5 patients required a review. Clinical records showed 4 patients were overdue a medicine review, 2 patients were overdue a dose review.

We carried out a search to identify patients who had received a medication review in the past 3 months. The search identified 63 patients. We reviewed a random sample of 5 records and found medication reviews had been completed.

The practice worked with the clinical pharmacists from the local Primary Care Network (PCN) to monitor people and the prescribing of medicines. The provider was aware of safety alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA), however we were unable to gain assurances from the clinical team of the system in place to ensure alerts were acted on. We carried out a clinical search on ACE/ARB medicines plus aldosterone antagonist medicines used for the treatment of patients with heart failure which had potential risks to cause high potassium levels, to check if patients had a UE test within the past 6 months. We reviewed a random sample of 5 clinical records and 4 out of the 5 patients were overdue monitoring.

Emergency medicines, vaccines and medical equipment had clear monitoring processes in place. On the day of the onsite assessment, we found one of the emergency medicines listed by the practice was not in place. Staff searched the premises and found the medicine which was returned to the secure cabinet. There were arrangements in place for the management of vaccines and for maintaining the cold chain with fridge temperatures routinely monitored and vaccines reviewed at random were in date and stored appropriately, however the data logger that was in place was switched off. The leadership team were unaware why the data logger was not switched on. We saw medical gases, such as oxygen, stored safely and completed required safety risk assessments.

We found the management of prescription stationery was not secure. Blank prescriptions were recorded when they were removed from their location, however, we found the recording of scripts was not accurate and did not match what was remaining of the stock. The leadership team were unable to provide an explanation of where the unaccounted prescriptions were. We also found staff using blank prescriptions for note taking. The practice used electronic prescribing for patients’ medicines, some patients preferred to collect a prescription. We were told that regular checks of prescriptions awaiting collection took place on average every month, but we found prescriptions awaiting collection dating back to 2025.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was lower than local and national averages.

As part of the provider information return that we requested prior to the onsite assessment, we were sent the repeat medicines guidance policy. On reviewing the policy, we found this was a policy generated by the Integrated Care Board. The guidance clearly stated that the policy was to be used as a guide and practices had to produce their own repeat prescribing guidance. We found this had not been acted on and the leadership team were unaware this needed to be done. Following the onsite assessment, we received a repeat prescribing policy dated 2023 that had been updated the day after the onsite visit.