Drs Mirza, Sukhani and Partners

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 inspection we rated this key question Good. At this assessment, the rating has changed to Requires Improvement. This meant people were not safe and were at risk of avoidable harm. The service was in breach of the legal regulations relating to safe care and treatment. We have asked the provider for an action plan in response to these concerns.

This service scored 53 (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. For example, systems and processes specifically regarding patient safety alerts, required improvement.

As part of our assessment, a series of patient clinical record searches were undertaken by a CQC GP specialist advisor. We ran a search to identify patients who were affected by a safety alert about taking the medicine: Topiramate and identified 7 patients. Topiramate is a medicine used to treat epilepsy. We then looked at 5 of these patients’ records and found they had not been made aware of the risks.

We also found that generally the coding of patients’ records required improvement. For example, medicines were not appropriately linked to conditions on patients’ records.

Additionally, while the practice had implemented a new system in December 2024 for recording and acting on safety alerts received into the practice, such as those from the Medicines and Healthcare Products Regulatory Agency (MHRA), we found that when we spoke with staff there were variations in their understanding of this system. We also found that its corresponding protocol required further review and updating as although safety alerts were now managed by the practice’s Primary Care Network (PCN) Clinical Pharmacist through an online clinical system, no further details were available regarding safety alerts for staff to refer to and follow. This system and corresponding protocol require further work to make sure actions from them are fully embedded into routine practice, patients affected by them are always identified and actions taken to protect them from avoidable harm.

During this assessment, the practice took action to review and contact patients identified through our patient clinical record searches and provided assurances of their future monitoring and action plans, including systems and processes regarding the coding of patients’ records and safety alerts systems.

We did not receive patient feedback about the learning culture of the practice around safety.

Staff said they knew how to report concerns, safety incidents and near misses.

The practice had a system for recording and acting on significant events, with 1 recorded in the year leading up to this assessment. We looked at this record and saw that it had been investigated and any actions carried out.

Leaders also told us that significant events were discussed in practice meetings, with learning shared with the team when identified. This team sharing of information was reiterated in staff feedback.

The practice worked with people and their partners to establish and maintain safe systems of care, in which safety was managed, monitored and assured. They made sure there was continuity of care, including when people moved between different services.

Feedback from people who use the service told us the practice referred them appropriately to other services when needed and referrals were handled in a timely manner.

Staff had the information they needed to deliver safe care and treatment.

The practice planned and organised care and support with people, together with partners and communities in ways that ensure continuity. For example, care home representatives from the care home under the care of the practice, expressed satisfaction around how requests were managed for residents in a timely manner. These included registration matters and referrals to other services.

Referrals to specialist services were documented, contained the required information and there was a system in place to monitor delays in referrals. Secretarial staff also carried out administrative checks of referrals.

The practice also had systems and processes in place for the management of test results, and this was handled in a timely manner. However, as part of our assessment, a series of patient clinical record searches were undertaken by a CQC GP specialist advisor, and we found that generally the coding of patients’ records required improvement. For example, information from clinical correspondence on patients’ records was not appropriately recorded. When this was highlighted, leaders took appropriate action to improve systems and processes regarding the coding of patients’ records.

The practice 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. For example, not all clinical staff were trained to appropriate levels in safeguarding for their roles, as per national guidance and safeguarding was not regularly discussed in practice team meetings.

During this assessment, we found 1 clinical staff member had not completed training to the appropriate level of safeguarding for adults and children, in line with national guidance. Leaders told us that training to the right level of safeguarding adults and children would be completed by this clinical staff member. They also said they had risk assessed safeguarding training in adults and children for all clinical staff, including Health Care Assistants and as from April 2025, these would include training at level 3. Additionally, from the information on staff mandatory training that was set and shared by the practice, we were unable to confirm whether 1 non-clinical and 2 clinical staff members were up to date with their training in relation to safeguarding.

In addition, the practice did not have specific safeguarding meetings in place. Leaders told us that safeguarding concerns were discussed and actioned appropriately when any matters were raised about people. They also said that safeguarding was included in practice team meetings and discussed, as and when required. Minutes from the last 3 practice team meetings dated: 27 July 2024, 19 September 2024 and 19 February 2025, showed that safeguarding had not been listed or discussed as an agenda item.

However, the practice had designated safeguarding leads, administrative and clinical. Staff we spoke with were aware of the support available. This was reiterated by staff in their questionnaires.

Leaders told us that they had annual meetings with their Integrated Care Board (ICB) Safeguarding Team. ICBs are NHS organisations responsible for planning health services for their local population.

The practice 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 them to do the things that mattered to them.For example, staff were not fully equipped to respond to medical emergencies. At the main site (Hockwell), medical oxygen was kept on site and if needed, a community Automated External Defibrillator (AED) was available from a community centre, next door. However, this had not been risk assessed, with regards to accessibility. At the branch site (Britannia House Surgery), medical oxygen was also kept on site but there was no AED available. An AED is a portable lifesaving device that can give a casualty's heart an electric shock, when it has stopped beating normally in a sudden cardiac arrest. Additionally, for both sites, appropriate emergency medicines were kept. However, risk assessments had not been completed to explain why some medicines were not kept by the practice, at both sites.

During this assessment, leaders took our feedback on board and risk assessed their emergency equipment and medicines. They told us they had risk assessed the accessibility of the community defibrillator for the main site (Hockwell) and found it met requirements, in line with relevant national guidance; and a defibrillator had been ordered for the branch site (Britannia House Surgery). Leaders also said they had risk assessed emergency medicines not kept by the practice and would now include these in their stock. Additionally, a suction machine had been ordered for both sites.

However, in the feedback from people who use the service there were some positive comments about how people were involved with managing risks.

Staff we spoke with were aware of actions to take if they encountered a deteriorating or acutely unwell patient.

Clinical staff told us they advised patients on risks related to their condition and actions to take if their condition deteriorated.

The practice had systems and processes in place to make sure emergency equipment was regularly checked and fit for use and emergency medicines were in date.

The practice 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.

While the practice had contracts in place to make sure the premises at both sites were maintained and health and safety risk assessments and audits were undertaken, potential risks were not always identified and addressed. For example, during our main site visit (Hockwell), we saw that premises required refurbishing and leaders 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.

Additionally, fire safety arrangements for both sites required improvement. For example, the practice had carried out internal fire risk assessment checklists in August 2022 for the main site (Hockwell) and in September 2024 for the branch site (Britannia House Surgery). However, these did not include details on when they would be next reviewed. The practice also had a fire safety policy in place; but this required updating to reflect the differences in fire safety matters between both sites, such as alarm systems. Fire marshal was also noted as an official on this policy but there was no staff member assigned to this role and corresponding fire marshal duties listed. Leaders told us that fire marshal training had not been completed by the fire officer at the practice. While fire drills had been carried out in August 2024 for both sites, these had only included the 2 staff members on duty and no patients. Leaders also told us that their local community fire team had visited the Hockwell site recently and their feedback had been taken on board by the practice. However, the practice did not have records of this visit. In addition, 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 was up to date with their training in relation to fire safety.

However, staff were aware of the procedure for emergency evacuation, for example in the event of fire and knew who the fire officer was for the practice.

The practice had a business continuity plan in place which was monitored and reviewed. They also had systems and processes to make sure electrical equipment was regularly tested and medical equipment calibrated on a regular basis.

Internal legionella risk assessments had been carried out for both sites in April 2024. An external risk assessment had been completed for the main site (Hockwell) in May 2015 and the water storage system was changed to alleviate risk in September 2015. During this assessment, leaders told us that they were arranging for an external legionella risk assessment to be carried out for the branch site (Britannia House Surgery). During our site visits, we saw that the practice carried out regular monthly tests of the water system, at both sites. However, we noted limited details were recorded for these monthly water checks. During this assessment, leaders took this feedback on board, recognising it as an area for improvement.

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

For example, the practice could not demonstrate how they assured the competence of all staff employed in advanced clinical practice, including locums and there were no formalised systems in place for advanced nursing practitioners which included the prescribing competence of these non-medical prescribers through regular review of their prescribing practice, supported by clinical supervision and a systematic process. It was unclear how leaders monitored and assured themselves of nurses’ capability to practise at an advanced level. During this assessment, leaders took on board our feedback with regards to the lack of assurance of all staff employed in advanced clinical practice and recognised it as an area for improvement.

Additionally, as part of our assessment, a series of patient clinical record searches were undertaken by a CQC GP specialist advisor. Examples of our findings have been highlighted in other parts of this report, such as under this key question: safe and corresponding quality statement: medicines optimisation. The practice took action to review and contact patients identified through our patient clinical record searches and provided assurances of their future monitoring and action plans, including systems and processes regarding patient and medicines matters. For example, the coding of patients’ records. However, leaders also told us that they would be strengthening the support for clinical staff, including Primary Care Network (PCN) pharmacy staff, to make sure people received safe care that met their needs.

The practice had a staff training programme in place. However, from the information on staff mandatory training that was set and shared by the practice, we were unable to confirm whether some staff members (non-clinical and clinical) were up to date with their training. Examples of these gaps in the information provided for this assessment have been highlighted in other parts of this report, such as, under the key question: responsive and corresponding quality statement: providing information.

However, feedback from people who use this service was mainly positive regarding safe and effective staff, with one person sharing negative experiences about 1 non-clinical staff member.

Staff also told us they had protected time to complete mandatory training and access to regular appraisals, coaching or supervision. This feedback only included permanent staff members.

Records shared by the practice showed all staff had had an annual appraisal within the year leading up to this assessment. This included both clinical and non-clinical staff and included GP locum staff.

The practice had systems and processes in place to make sure recruitment checks were carried out in accordance with regulations, including for locum staff.

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

While the practice had contracts in place to make sure the premises at both sites were maintained and health and safety risk assessments and audits were undertaken in relation to infection, prevention and control, potential risks were not always identified and addressed. For example, cleaning at the practice’s both sites were carried out by a cleaning contractor. While leaders told us they liaised with cleaning staff to address any concerns noted, during our visits to both sites, we found that room cleaning schedules were not in place for staff to follow and complete. We also found that cleaning equipment and products were not stored safely. Additionally, a Control of Substances Hazardous to Health (COSHH) folder with safety data sheets was not available, at either site. During this assessment, leaders took on board our feedback and recognised cleaning matters as an area for improvement and said they would be contacting the cleaning company directly to address these concerns.

In addition, from the information on staff mandatory training that was set and shared by the practice, we were unable to confirm whether 1 non-clinical and 2 clinical staff members were up to date with their training in relation to infection, prevention and control.

During this assessment, the practice shared with us information about staff immunisations. However, we found that while compliance was monitored and records were held in line with guidance from the UK Health Security Agency (UKHSA), these did not always include all recommended vaccinations.

However, in the feedback from people who use this service, one person expressed satisfaction with the cleanliness of the practice, though the site was not specified.

The practice had designated infection, prevention and control (IPC) leads, administrative and clinical. IPC checklists were carried out for both sites in April 2024. A 2024/2025 staff handwashing audit had also been carried out by the practice.

The practice did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happened.

As part of our assessment, a series of patient clinical record searches were undertaken by a CQC GP specialist advisor. This included a review of the management of patients on medicines that require monitoring, as well as the review of prescribing generally, including effectiveness and quality of medication reviews and usage.

We found no concerns in the monitoring of the patients’ records we looked at who were taking Methotrexate, a disease-modifying antirheumatic drug (DMARD), However, we also reviewed patients who were prescribed Azathioprine, another DMARD and our search identified 3 patients, with 2 of these patients not been monitored appropriately, in line with national guidance.

We also reviewed patients with heart failure who were prescribed Aldosterone Antagonists and saw that 6 patients had not had the required monitoring. This medicine treats high blood pressure and heart failure. We looked at 5 of these patients’ records and found that they had not been monitored appropriately, in line with national guidance.

Additionally, we found 75 patients taking over 10 medicines with no medicines review in the last 18 months. We looked at 5 of these patients’ records and found that they had not been monitored appropriately, in line with national guidance.

In addition, we reviewed patients on oral non-steroidal anti-inflammatory drugs (NSAID) over 65 years or antiplatelet over 75 years and no proton pump inhibitor (PPI). PPIs are a group of medicines that decrease stomach acid production. We identified 14 patients who had not had the required monitoring. We looked at 5 of these patients’ records and found they had not been monitored appropriately, in line with national guidance.

We also found that generally the coding of patients’ records required improvement. For example, medicines were not appropriately linked to conditions on patients’ records.

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 assessment and monitoring of management of patients on medicines that require monitoring, medicine reviews and usage. This included systems and processes regarding the coding of patients’ records.

At the time of our assessment, the latest information from the GP NHS Business Services Authority Prescribing indicators showed the practice had not met the national targets for the average daily quantity of Hypnotics prescribed per Specific Therapeutic group Age-sex Related Prescribing Unit (STAR PU); and the number of antibacterial prescription items prescribed per Specific Therapeutic group Age-sex Related Prescribing Unit (STAR PU). Both were higher than the national target.

During our site visits, we saw that blank prescriptions at both sites were kept securely. However, there were no systems or processes in place, to monitor their usage. Additionally, we found that while staff had the appropriate authorisations to administer medicines, these required improvement. For example, empty rows were not scored in completed Patient Group Directions (PGDs) forms and no hard copies of the PGDs were kept at the branch site (Britannia House Surgery). During this assessment, leaders took our feedback on board and recognised these medicines matters as an area for improvement. For example, they told us that hard copies of PGDs were now kept at both sites.

However, there were some comments in the feedback from people that used the service which expressed satisfaction with the management of their medicines.

Feedback we received from care home representatives from the care home under the care of the practice was positive about their experience on behalf of their residents in respect of medicines management. They told us the practice was proactive in regular reviews of patient medicines.

During our site visits, we found that vaccines were appropriately stored and monitored as per national guidance, at both sites.