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Drs Sanomi and Olajide Inadequate

Inspection Summary

Overall summary & rating


Updated 6 December 2019

We carried out an announced comprehensive inspection of Dr Beheshti on 24 October 2019 as part of our inspection programme.

At this inspection we followed up on breaches of regulations identified at a previous inspection on 16 July 2018. At the last inspection in July 2018 we rated the practice as requires improvement overall.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected;
  • information from our ongoing monitoring of data about services; and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as inadequate overall.

We rated the practice as inadequate for providing safe services because:

  • There were gaps in recruitment checks, including in relation to Disclosure and Barring Service (DBS) checks, references, checks of professional registration, and immunity status.
  • Recommended actions from fire and health and safety risk assessments had not been completed in line with the suggested timeframes.
  • There were gaps in staff training, including for fire safety, safeguarding, basic life support and infection control.
  • There was no failsafe system in place for urgent two week wait referrals.
  • There was no documented risk assessment in place to support the decision not to take any medicines in the doctors’ bags to home visits.
  • We identified examples where safe prescribing of high-risk medicines could not be evidenced.
  • We saw a non-clinical staff member re-authorise repeat prescriptions for a patient.
  • There was no log or formal system to log receipt of safety alerts and record what action was taken by the practice.

We rated the practice as inadequate for providing well-led services because:

  • The delivery of high-quality care was not assured by the leadership, governance or culture.
  • Leaders could not demonstrate that they had the capacity and skills to deliver high quality sustainable care.
  • There was no documented business strategy in place.
  • There were weaknesses in the oversight of governance arrangements, for example in relation to effective recruitment and locum checks and clinical oversight of the healthcare assistant, the nurses and the pharmacist.
  • There was no effective oversight or monitoring of staff training.
  • Some of the practice’s policies did not contain all the necessary information, for example the adults at risk policy and the test results policy.
  • The systems for managing risks were not consistently effective, as some risks has not been identified or dealt with.

We rated the practice as requires improvement for providing effective services because:

  • Care and treatment was not always delivered in line with evidence-based guidance, as we found risks associated with high-risk medicines and urgent two week wait referrals.
  • Some of the practice’s childhood immunisation uptake rates were below the World Health Organisation target.
  • Gaps in mandatory training demonstrated the learning and training needs of staff were not assessed effectively.
  • There were no documented protocols for the healthcare assistant to follow and there was no evidence their induction included completion of the Care Certificate standards.
  • There was a lack of oversight of the clinical work being carried out by the healthcare assistant, the nurses and the pharmacist.

These areas affected all population groups, so we rated all population groups as requires improvement for providing effective services.

We rated the practice as requires improvement for providing responsive services because:

  • The practice’s GP patient survey result relating to access by telephone was significantly below the national average.
  • The system to share learning from complaints with staff was ineffective.

These areas affected all population groups, so we rated all population groups as requires improvement for providing responsive services.

We rated the practice as good for providing caring services because:

  • Staff treated patients with kindness, respect and compassion.
  • Feedback from patients was generally positive about the way staff treated people.
  • The practice respected patients’ privacy and dignity.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Continue to improve uptake rates for childhood immunisations and cervical screening.
  • Improve how patients with caring responsibilities are identified to ensure they receive the appropriate support.
  • Take action to improve low scores around telephone access as highlighted in the national GP patient survey.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Details of our findings and the evidence supporting our ratings are set out in the evidence table.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas


Requires improvement


Requires improvement
Checks on specific services

People with long term conditions

Requires improvement

Families, children and young people

Requires improvement

Older people

Requires improvement

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)

Requires improvement

People whose circumstances may make them vulnerable

Requires improvement