Dr Manjit Singh

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

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture

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 good governance.

This service scored 43 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The practice had a mission statement; however, we found none of the staff we spoke with were aware of the statement. The mission statement highlighted the practice wanted to provide accessible, compassionate, high quality primary care that supported the health and wellbeing of the practice’s diverse community. Following the onsite visit, we were told that all staff had been given a copy of the mission statement.

The practice was unable to demonstrate there was clear learning within the practice. We were told meetings with staff were held every month; however, minutes of the practice meetings showed the last meeting had been in December 2025. Learning from incidents and significant events was not a priority at the practice with 3 incidents having been recorded in the past 3 years.

Senior clinical leads were unable to provide evidence that there was a process in place for clinical supervision. We were told that clinical reviews were in place, but there was no documented evidence to support what had been discussed and on speaking with clinical staff at the practice, they were unaware of clinical reviews being completed.

Leaders demonstrated a positive and compassionate culture. Staff reported a positive experience of working at the practice. They described the culture as friendly, kind and inclusive.

Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

We were unable to gain assurances that there was effective management in place to ensure practice policies and processes were followed. Policies that had been provided as part of the provider information return before the onsite assessment showed important information such as named leads and links to supporting information were not included. We found on the day of the onsite assessment that we were unable to gain assurances that when something went wrong, people were given information on what actions had been taken. We found systems in place were not effective to monitor incidents or complaints.

Staff told us that their wellbeing was considered, and their views respected, and concerns were acted upon, however there was minimal documented evidence to demonstrate what actions had been taken when concerns had been raised. We were told that the leadership team worked with other practices in the PCN and were engaged in the development of primary care services within the local area. We requested evidence to demonstrate the practice’s involvement with the PCN; however, none was provided.

People did not always feel they could speak up and that their voice would be heard.

There was a whistleblowing policy in place, but there was no independent named freedom to speak up guardian. This had previously been identified in 2024 following a visit from the Integrated Care Board and was an action point for the practice to complete. No action had been taken. Following the onsite assessment, we received assurances this had been acted on and a named person was now in place, however we were not provided with an updated policy to demonstrate who had been given this responsibility. All staff had completed mandatory training which included equality and diversity.

The service did not always care about and promote the wellbeing of their staff. They did not always support or enable staff to deliver person-centred care.

There were policies and procedures in place for the safe recruitment of staff. Other policies included recruitment, equality and diversity, bullying and harassment and grievances.

All staff had access to regular appraisals, and revalidation. We were unable to gain assurances that there was a process in place for the supervision of staff in clinical roles. We were told that this happened informally and there was no documented evidence to support what was reviewed. On speaking with clinical staff they were unaware if clinical reviews were in place. There was an induction process in place for newly appointed staff, but we found not all staff had completed the induction. Staff told us that they were well supported and felt able to ask for advice. Staff told us they were encouraged to develop within their roles and training opportunities were available.

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

The provider was unable to demonstrate they had established governance processes that were appropriate for their service. Staff could access policies and procedures; however, we found a range of policies that lacked information, were out of date or were generic and had not been adapted to the specific needs of the practice. We found limited evidence that managers held regular practice meetings with staff, during which they discussed emerging risks. We found any actions arising from these meetings were not effectively recorded to ensure learning had been shared and future risks were mitigated.

During the clinical searches we identified no clear processes for the management of patients with long term conditions. We found clinical guidelines were not followed and there was a lack of knowledge on national guidance for the treatment of health conditions. For example, the exacerbation of asthma and appropriate follow up following the prescribing of steroids.

The clinical leadership team were unable to demonstrate that they had effective systems in place to ensure clinical updates were shared with the team and discussions were held to share clinical concerns. For example, we found the there was an ineffective process to identify, understand, monitor and address the actioning of safety alerts.

Staff had not used information to provide patients with the appropriate care and treatment. During the clinical searches we found potentially 32 people with a missed diagnosis of chronic kidney disease (CKD). 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.

The clinical leadership team had minimal systems in place to ensure the care of patients was discussed regularly at multi-disciplinary team meetings and through inhouse clinical meetings to ensure vulnerable patients and those with complex care needs were given the appropriate care and treatment.

There were ineffective processes to identify, understand, monitor and address current and future risks including risks to patient safety. This included a health and safety risk assessment, completion of the action plan and supporting evidence to demonstrate actions had been acted on.

We found there was no clear oversight to ensure risks to patients were considered, managed and mitigated appropriately. For example: Significant events were not actively recorded or learning shared to identify trends.

The practice was unable to provide evidence that quality improvement audits had been completed and action plans were in place to improve the quality of the services provided.

The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Leaders told us they worked with stakeholders and the local community. The practice was part of a Primary Care Network (PCN) which provided enhanced services to patients. We found the leadership team were unable to demonstrate what improvements were being made with the PCN. We asked the provider for copies of the PCN meetings where the practice had attended, however they were unable to provide these. Following the onsite assessment, we received evidence that the practice was involved in the PCN.

A patient participation group (PPG) had been implemented recently. We were unable to gain assurances how often meetings were going to be held. On speaking with a representative of the PPG, they told us 1 meeting had been held, however no minutes of what had been discussed were shared. Following the onsite assessment, minutes of a PPG meeting held in July 2025 were received. On checking the practice website, the last minutes of the PPG meeting were from 2015.

The practice offered extended access, flu and covid vaccination programmes. Staff had made adjustments and collaborated with local services to further support community healthcare services.

The service did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The leadership team were unable to demonstrate they held regular staff meetings to share learning from incidents and complaints and monitor the quality of the services provided. We were told that meetings were held every month, however evidence provided showed that during 2025 a total of 4 meetings had taken place. We reviewed the minutes of these meetings and found only one detailed information on an incident and complaint that had occurred. The practice could not provide complaints or significant event logs and we were unable to clearly see where the practice had embedded learning. Staff told us that they felt able to make suggestions and raise ideas, but we did not see evidence that this led to tangible improvements in practice.

The practice was unable to provide evidence of risk assessments, actions to mitigate risk and policies upon request. We found there was no clear process in place to monitor staff training and ensure staff had all received the appropriate updates to deal with emergencies. For example, sepsis awareness training. Following the onsite assessment we received evidence to confirm that all staff had now completed sepsis awareness training.

The clinical team were unable to demonstrate effective processes for the sharing and review of clinical guidelines and we found minimal evidence that regular audits were carried out to ensure patients received high quality sustainable care.

We found there was no quality improvement plan in place to help drive service delivery. The provider told us they worked collaboratively with the PCN to improve the experience of people using the service and to support the wider needs of the local community, but on requesting minutes of meetings the practice had attended with the PCN these were not provided. Following the onsite assessment we received evidence to confirm that the practice was part of the PCN.