Drs Mirza, Sukhani and Partners

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence that the service met people’s needs, and that staff treated people equally and without discrimination. At our last inspection, we rated this key question Good. At this assessment, the rating remains the same. This was because we found that the practice delivered person centred care, recognised the importance of flexibility and informed choice and continuity of care. Patients were provided with appropriate information. They were listened to and involved in their care, treatment, support and planning for the future. The practice was also proactive in supporting equity in access, experiences and outcomes for patients and tailored care and treatment, in response to people’s feedback and needs.

This service scored 75 (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 made sure people were at the centre of their care and treatment choices and decided, in partnership with them, how to respond to any relevant changes in their needs.

Feedback from people who use the service was generally positive with regards to interactions with both non-clinical and clinical staff, with varied examples given on the provision of person-centred care.

Positive feedback from the care home under the care of the practice was also noted around the delivery of person-centred care for residents.

Staff shared examples of how people were at the centre of their care and treatment choices and in partnership with them, decide how to respond to any relevant changes in their needs. For example, people were supported to understand their condition, care, treatment options and any advice provided.

The practice understood the diverse health and care needs of their patients, so care was joined-up, flexible and supported choice and continuity.

Continuity of care was highlighted in the feedback from people who use the service. People expressed satisfaction with being able to see the same GP regularly and the development of professional relations with staff, including non-clinical members. This contributed to a positive experience.

Staff told us how patients could pre-book appointments, with clinicians booking in patients for follow-up appointments with them or another suitable member of staff, when appropriate.

Care home representatives from the care home under the care of the practice described how the practice worked in partnership with them to meet the needs of their residents.

The practice had processes in place which considered the needs and preferences of different people, including those with protected characteristics under the Equality Act and those at most risk of a poorer experience of care. For example, while the practice had adopted a total triage model of care for patients since December 2024, reception staff provided additional support, as needed, to assist patients completing the online form.

The practice provided appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

We received mostly positive feedback from people who use the service about the provision of information, with one person expressing dissatisfaction with communications from the practice.

Staff told us how some of them could speak different languages, such as Punjabi and Urdu and supported the interpreting and translation for people who did not speak English as a first language. Additionally, the practice had access to interpreter services, including British Sign Language interpreters, and these were booked for patients when needed.

However, from the information on staff mandatory training that was set and shared by the practice, we were unable to confirm whether 4 clinical staff members were up to date with their training in relation to information governance and the General Data Protection Regulation (GDPR).

During our site visits, we also saw that at both locations, leaflets and notices were available in the waiting areas, advising patients on how to access support groups and organisations, with posters alerting patients to chaperone arrangements and requests. A television screen also provided patients with information at the Britannia House Surgery site. Telephone consultations and calls took place in appropriate environments to ensure confidentiality. At the main site (Hockwell), music was played in the reception/waiting area, so that conversations in consultation rooms were dulled and could not be overheard.

The practice complied with the Accessible Information Standard (AIS). For example, there was a hearing loop at both locations for people who are deaf or have difficulty hearing.

The provider was registered as a data controller with the Information Commissioner’s Office.

The practice had systems and processes in place to make sure information about people that was collected and shared met data protection legislation requirements. There was information on the practice’s website advising patients how their information was stored and managed. The practice’s website also provided information to patients, including links to other health and social care services which accepted self-referrals from patients.

The practice made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

Feedback from people who use the service with regards to how staff listened to and involved them was positive. This included discussions between clinicians and patients around care and treatment. However, one response shared negative experiences about the complaints process.

We noted that 84% of the people who responded to the 2024 GP Patient Survey said that during their last appointment the healthcare professional was good at listening to the patient. In addition, 81% said that they were involved as much as they wanted to be in decisions about their care and treatment. While these results were generally in line with local and national averages, involvement figures were slightly below local average of 88% and national average of 91%, respectively.

Staff we spoke with were aware of the practice’s complaints procedure and said they would advise people on how they could make a complaint if the person wanted to. This approach was reiterated by staff in their questionnaires.

People could provide feedback and complain online, by email, letter or verbally. They were also encouraged to give feedback online, through the NHS Friends and Family Test. During this assessment, the practice’s complaints leaflet was made available on the practice’s website. We saw that it was available onsite, at both locations.

Staff shared with us examples of learning from patient feedback that had resulted in changes and improved care for others. For example, for people with a learning disability.

In the year leading up to this assessment, the practice had recorded 4 complaints. We looked at the records for 2 of these complaints and found the practice had handled them in a timely way and responded appropriately.

Leaders told us that complaints were discussed in practice meetings and learning was shared with staff when identified. Additionally, positive feedback from patients which the practice termed as ‘plaudits’ were also shared with the team. This team sharing of information was reiterated by staff in their questionnaires. During the main site visit at Hockwell, we saw examples of these plaudits.

The practice made sure people could access the care, support and treatment they needed when they needed it.

We received positive comments in the feedback from people who used the service around accessing appointments and equity in access. Some people expressed satisfaction with the total triage model of care and the ease of the online booking system for making appointments and communicating with the practice. This contributed to a positive experience. However, one person expressed dissatisfaction with the total triage online system, appointment availability and been advised to only talk about one issue, per appointment.

Some staff members also reiterated the positive responses we received from people who used the service about the total triage model of care and the positive impact on appointments accessibility for patients and communications with the practice. This feedback was also noted by some staff in their questionnaires.

Additionally, we received positive feedback from the practice’s Primary Care Network (PCN) about the proactive engagement from Drs Mirza, Sukhani and Partners’ in their communications with patients, while the total triage model of care was introduced and set up.

Data from the 2024 GP Patient Survey showed the practice performed generally in line with local and national averages for the percentage of people who find it easy to get through to this GP practice by phone (42%); using their website (46%); and using the NHS App (37%).

The practice was aware of the results of the 2024 GP Patient Survey. Leaders told us that telephony data was collected and reviewed on a regular basis and how telephone calls to the practice had reduced to around 20 per day, following the introduction of the total online triage system.

During our site visits, we saw that while at the main site (Hockwell), there was an adjacent car park; there were no car parking facilities for patients at the branch site (Britannia House Surgery). Leaders told us that people were aware of this car parking issue at the branch site and no concerns had been raised by patients, about this matter. Additionally, patients could access face to face appointments at either site. We also saw that at both locations, there were notices at the front doors advising people how to request support from staff as required. This included access to the premises and interpreter/translation services.

Leaders also told us about the need to upgrade premises at both sites. During this assessment, they shared with us a refurbishment plan which included, renovation of premises, such as, flooring at the main site (Hockwell) and the replacement of examination couches, at both sites.

The practice offered a range of appointment including telephone and home visits with various clinicians. These included, GPs, an advanced nurse practitioner, practice nurses, a healthcare assistant and a clinical pharmacist who was employed via the PCN. Face to face appointments were available to patients at both sites, with the main site (Hockwell), open from 8am to 6.30pm Monday to Friday; and the branch site (Britannia House Surgery), open from 8am to 1pm Monday to Friday.

Enhanced services were organised via the practice’s Primary Care Network (PCN). When the practice is closed, patients can access support, treatment, and advice from the NHS 111 service.

The practice had processes in place so patients with the most urgent needs had their care and treatment prioritised. Both ‘urgent, or ‘same day’, and pre-bookable appointments were available.

The practice actively listened to information about people who were most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Feedback from people who used the service was generally positive. The total triage model of care and the online booking was found to be convenient and easy to use. People also referred to excellent care and treatment provision across family groups, with the option to request a female GP, when needed.

Care home representatives from the care home under the care of the practice also expressed satisfaction around the accessibility of the practice and how they worked together in a coordinated manner to meet the needs of residents.

Staff shared examples of reasonable adjustments made to support equity in people’s experience and outcomes. These included, Deaf people, people with a learning disability and older patients.

Leaders proactively sought ways to address any barriers to improving people’s experience, in response to people’s feedback and needs. For example, the practice’s telephone system for the main site (Hockwell) was updated to include an option which allows for a link to be sent directly to a patient’s mobile phone of the total triage model of care and its online booking system. Thus, enabling patients to retrieve the online form promptly and to submit it with ease.

However, from the information on staff mandatory training that was set and shared by the practice, we were unable to confirm whether 1 clinical staff member had completed training in equality and diversity; and if 2 clinical staff members had completed training to support autistic people and people with a learning disability.

The practice gave people support to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

We did not receive any feedback from people who use the service about planning for the future. However, positive feedback from the care home under the care of the practice was also received around planning for the future and end of life care for residents.

We reviewed 3 patients’ records where a do not attempt cardiopulmonary resuscitation (DNACPR) decision had been noted. One of these had been completed by a Drs Mirza, Sukhani and Partners GP and had been recorded in line with guidance. We also saw that where possible the patients’ views had been sought and respected and we saw that information had been shared with relevant agencies.

The other 2 DNACPR decisions had been carried out in a community or hospital setting and information about this decision had been recorded in patients’ records. However, a copy of the DNACPR decision was not available on 1 of these patient’s records. During this assessment, leaders told us that they would be contacting the relevant organisation directly and the patient’s records would be updated appropriately.