Drs Mirza, Sukhani and Partners

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, provided them advice and support and regularly reviewed people’s care, working with other services to achieve this. At our last inspection, we rated this key question Good. At this assessment, the rating remains the same. This was because while we found areas for improvement in the quality statements for assessing needs, delivering evidence-based care and monitoring and improving outcomes; For example, systems and processes to identify and to make sure patients with long term conditions and patients with missed diagnosis of conditions were offered the care, treatment, appropriate investigations and monitoring were not always effective; we also found that generally staff worked together effectively across teams and services to support people; people were also supported to lead healthier lives and consent to care and treatment.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice did not always make sure patients care and treatment were effective because they did not always assess and review their health, care, wellbeing and communication needs with them.

As part of our assessment, a series of patient clinical record searches were undertaken by a CQC GP specialist advisor. The records of patients with long term conditions were reviewed to make sure the required assessments and reviews were taking place, in line with guidance.

These searches of the practice’s clinical records system included patients with asthma who had had 2 or more courses of rescue steroids in the last 12 months (excluding patients who have been prescribed regular steroids for other purposes). Another search looked at patients with chronic kidney disease (CKD): stages 4 and 5 who had not had a urea and electrolytes (U+E) test in the last 9 months. We also run a search for patients with hypothyroidism, who had not had thyroid function test monitoring for 18 months; with a further search involving patients with diabetes who’s latest HbA1c (average blood glucose (sugar) levels for the last 2 to 3 months) was >75mmol/l.

While we found no concerns in the monitoring of patients with CKD, not all patients with long-term conditions we looked at had had the appropriate assessments and reviews, in line with guidance. Systems and processes to identify these patients and to make sure they were offered the care, treatment, appropriate investigations and monitoring were not always effective.

As part of our series of patient clinical record searches, patients with missed diagnosis of conditions were also reviewed to make sure the required assessments and reviews were taking place.

We looked at patients with a potential missed diagnosis of diabetes and found that not all had had the appropriate assessments and reviews, in line with guidance. Systems and processes to identify these patients and to make sure they were offered the care, treatment, appropriate investigations and monitoring were not always effective.

During this assessment, the practice took action to review and contact patients identified through our patient clinical record searches and provided assurances of action plans and future assessments and reviews of patients with long term conditions and patients with missed diagnosis of conditions, in line with guidance.

However, feedback from people who use the service with regards to the assessing and review of their needs was positive. Some people said how they felt involved in the assessment of their needs and confident that their individual needs had been appropriately assessed and understood.

Staff also told us people’s communication needs were assessed and met to maximise the effectiveness of their care and treatment. For example the practice used digital flags within their clinical records system to highlight any specific individual need, such as the requirement for longer appointments or for an interpreter to be present.

The practice did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them. They did not always do this in line with legislation and current evidence-based good practice and standards.

As part of our assessment, a series of patient clinical record searches were undertaken by a CQC GP specialist advisor. Findings from these searches indicated that not all patients received care that was in line with legislation and current evidence-based good practice and standards. Examples of these findings have been highlighted in other parts of this report, such as under the key question: safe and corresponding quality statement: medicines optimisation and under the key question effective: and corresponding quality statement: assessing needs.

During this assessment, the practice took action to review and contact patients identified through our patient clinical record searches and provided assurances of an action plan and future monitoring, including systems and processes to make sure staff remained up to date with legislation and current evidence-based good practice and standards.  

However, while we did not receive specific examples from people who use the service about the delivery of evidence-based care and treatment, some people expressed satisfaction with timely referrals to specialist services and monitoring and reviews that were relevant to their care and treatment.

Staff also said they had access to evidence-based good practice and standards, such as those from the National Institute for Health and Care Excellence (NICE) and used these to support the delivery of evidence-based care and treatment.

Additionally, clinical staff told us that regular informal meetings were held among clinicians to discuss cases and share learning. They also engaged with professional forums to support them to keep up to date with national legislation, evidence-based good practice and required standards.

The practice made use of clinical system templates in the delivery of patient care and treatment.

The practice worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Feedback from people who use the service with regards to how staff, teams and services worked together was positive, including referrals to specialists. People also commented on how the whole practice team delivered a positive experience.

The GP Patient Survey is an independent national survey that tells us how people feel about their GP practice.

94% of the people who responded to the 2024 GP Patient Survey for Drs Mirza, Sukhani and Partners said during their last appointment, the healthcare professional had all the information they needed about the patient. This was in line with local and national averages.

Good working relations with residents and care home staff was highlighted in the feedback from the care home under the care of the practice. Regular communications and meetings supported care home and practice staff to be involved in assessing, planning and delivering residents’ care and treatment, working together to understand and meet their needs.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support.

Staff we spoke with told us information was shared between teams and services to ensure continuity of care. For example, when clinical tasks were delegated or when people were referred to specialist services and organisations.

The practice had referral pathways in place to make sure that patients’ needs were addressed.

The practice supported people to manage their health and wellbeing to maximise their independence, choice and control. The practice also supported people to live healthier lives and where possible, reduce their future needs for care and support.

There was some positive feedback from people who use the service about how the practice supported them to live healthier lives. For example, regular monitoring of people’s health, including health assessments and checks where appropriate and necessary with health and care professionals.

Staff shared examples of how they understood people’s needs and preferences and supported them to manage their own health, care and wellbeing needs. They also encouraged and supported people to make healthier choices to help promote and maintain their health and wellbeing. For example, referring patients to other agencies, such as weight management programmes. People also had access to Wellbeing Coaches employed via the practice’s Primary Care Network (PCN).

Information about conditions and lifestyle advice was available in the practice’s patient waiting areas, at both sites and via the practice’s website.

At the time of this assessment, the practice had 197 unpaid or family adult carers and 13 young carers on their register. This was about 3.4% and 0.02% respectively of the patients registered with the practice. A carers registration form was available on the practice’s website. The practice did not have an assigned carers champion. However, leaders told us how the practice encouraged and supported patients to register as carers, offering support and signposting to relevant organisations.

The practice had systems and processes in place to support bereaved patients and to make sure all death administration and liaison with relatives was coordinated, appropriately and sensitively.

The practice 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.

As part of our assessment, a series of patient clinical record searches were undertaken by a CQC GP specialist advisor. Findings from these searches indicated that the practice 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. Examples of these findings have been highlighted in other parts of this report, such as under the key question: safe and corresponding quality statement: medicines optimisation and under the key question: effective and corresponding quality statement: assessing needs.

During this assessment, the practice took action to review and contact patients identified through our patient clinical record searches and provided assurances of an action plan and future monitoring, including systems and processes to make sure people consistently experienced positive outcomes, meeting agreed expectations as set out in legislation and current evidence-based good practice and standards.

Leaders told us that 48 out of 57 people with a learning disability registered with the practice, had had an annual health check, in this financial year to date.

Patients aged 75 and over are also eligible for an NHS health check. Health checks for this population of patients were carried out by the practice as frailty health checks, with 36 out of 258 completed by staff from the practice’s Primary Care Network (PCN). For patients aged between 40 and 74 who are also eligible for an NHS health check, the practice had carried out 118 (around 13%) of the 866 patients registered in this age group, for the quarters 1 to 3 of 2024/2025.

However, in the feedback from people who use the service there were some positive comments about how the practice monitored and improved outcomes. For example, there were effective approaches to monitor people’s care and treatment and their outcomes, including long term conditions.

At the time of our assessment, the latest information from the UK Health Security Agency (UKHSA) showed the practice had met the national target for the number of children immunised against various infectious childhood diseases, except for the percentage of children aged 5 who had received immunisation for measles, mumps and rubella (two doses of MMR) which was slightly lower than the national target. However, shortly after our assessment, new data for the next period showed the practice was lower or slightly lower than the national targets across the 5 areas for the number of children immunised against various infectious childhood diseases.

Additionally, the latest information from NHS Digital showed the practice’s uptake of cervical cancer screening was below the 80% national target and below 70% uptake target and observed as 63.6%.

However, the practice monitored the numbers of children having the recommended childhood immunisations and the uptake of cervical cancer screening, carried out reviews of practice performance against the Quality and Outcomes Framework (QOF) and liaised with relevant agencies to improve the uptake of immunisations for children.

Staff also told us about systems and processes to encourage uptake of child immunisation and cervical cancer screening. For example, there were follow up arrangements for patients who failed to attend appointments, including clinicians following up on patients.

The practice told people about their rights around consent and respected these when delivering person-centred care and treatment.

We did not receive any concerns from people who use the service we had feedback from, regarding consent.

Care home representatives from the care home under the care of the practice expressed satisfaction with how staff spoke with residents, their families and their care home staff and considered resident’s choices and decisions, including consent.

Staff said they always obtained consent from patients or if appropriate their guardian. Chaperones were available on request. This was recorded under the patient’s records on the practice’s clinical system.

Staff also talked about the importance of making sure a patient had given their consent before sharing information with others, with a system in place to record if the patient had given their consent.

The practice’s website offered information around confidentiality and accessing patient health records, including requesting someone else’s information.