Drs Mirza, Sukhani and Partners

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 inspection, we rated this key question Good. At this assessment, the rating has changed to Requires Improvement. This meant that the service was not always led in a way that supported the delivery of high quality care, learning and innovation. The service was in breach of regulation in relation to governance. For example, systems and processes for assessing and monitoring patients, acting on medicines and safety alerts; and in relation to staff training. We also identified an absence of governance systems and processes regarding reviewing advanced nursing practitioners prescribing competence of these non-medical prescribers through regular review of their prescribing practice, supported by clinical supervision. We have asked the provider for an action plan in response to these concerns.

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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities, in order to meet these.

Staff told us that the practice was a happy and friendly place to work. They also shared a common aim to do the best they could for patients and strived to provide safe, high-quality, and compassionate care.

This positive feedback about the culture of the practice was also reiterated by staff in their questionnaires. However, not all staff said in their questionnaires that they had been involved in the development of the practice’s mission statement, vision and values. Leaders told us that while strategic decisions were undertaken by the practice’s senior leadership team, there were systems and processes in place which promoted collaboration with staff, in the progression of their vision, values and strategy. For example, open discussions in practice wide team meetings or during 1 to 1 sessions with staff.

Leaders had also been proactive to feedback from clinical staff of their Primary Care Network (PCN) who were assigned to the practice, by inviting them to meetings to support their integration to the team.

Additionally, the practice promoted a positive, compassionate, listening culture that supports trust and understanding between them and people using the service and is focused on learning and improvement. For example, there were systems and processes in place for people to provide feedback, raise concerns and suggest ways to improve the service or patient experience. This included positive feedback from patients which the practice termed as ‘plaudits’.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff fed back in their questionnaires that the leadership of the practice was visible and approachable. In our discussions with staff, this positive feedback about the practice’s leadership was reaffirmed. Staff also said that leaders listened to their feedback and shared examples where changes had been made. For example, systems and processes for the registration of newborn babies; and scheduling a specific clinic to improve the delivery of care, support and treatment for patients and staff experience.

We saw the leadership team worked with other practices in their Primary Care Network (PCN) and were engaged in the development of primary care services within the local area.

While the practice fostered a positive culture where people felt they could speak up and their voice would be heard, Freedom to Speak Up Guardian arrangements were put in place, during this assessment.

Staff fed back in their questionnaires that the practice had a Freedom to Speak Up Guardian and instructions of how to contact them. However, during this assessment, we found that arrangements were not in place for a Freedom to Speak Up Guardian who staff could contact outside of Drs Mirza, Sukhani and Partners. Consequently, staff were not aware of Freedom to Speak Up Guardians who offer support for staff to raise concerns, or speak up, when they feel they cannot in other ways.

During this assessment, the practice put in place a Freedom to Speak Up Guardian, through their Primary Care Network (PCN) colleague and added these details to their Whistleblowing Policy. These latest arrangements and corresponding policies and procedures require further work to make sure staff are aware of Freedom to Speak Up Guardian arrangements and they are fully embedded in the practice.

However, staff told us there was an open and honest culture within the practice. They felt able to raise concerns with the management team and leaders, without fear of retribution and said their voices would be heard.

The practice valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff feedback about the culture of the practice in the context of workforce equality, diversity and inclusion was positive.

The practice had policies and procedures in place that promoted workforce equality, diversity and inclusion.

The practice did not have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We saw instances where they did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

During this assessment, we saw examples of where the provider did not have clear and effective governance, management and accountability systems and processes in place, which were regularly reviewed and improved. For example, systems and processes for assessing and monitoring patients, acting on medicines and safety alerts; and in relation to staff training. We also identified an absence of governance systems and processes regarding reviewing advanced nursing practitioners prescribing competence of these non-medical prescribers through regular review of their prescribing practice, supported by clinical supervision.

Additionally, we saw evidence that information about risks, performance and outcomes was not routinely used to improve care and manage risks for people and staff. For example, regarding fire safety and infection prevention and control matters.

Examples of these findings have been highlighted in other parts of this report, such as under the key questions safe and effective and corresponding quality statements.

While the provider was responsive and proactive to feedback during this assessment, acting promptly to some necessary improvements with regards to patient care and management of risk for people and staff, more in-depth work is required to make sure the effectiveness of any changes made is reviewed and acted on appropriately to further develop and improve the management and delivery of good quality, sustainable care, treatment and support and to manage risk. Additionally, clear and effective governance, management and accountability systems and processes are put in place, with information about risks, performance and outcomes effectively used and fully embedded into routine practice.

Staff told us they felt supported by leaders and those we spoke with were clear on their roles and responsibilities and received regular appraisal and supervision. They had access to policies and procedures and knew who they could talk with, if they had a concern or question. This feedback was generally reaffirmed by staff in their questionnaires.

The practice understood their duty to collaborate and work in partnership, so their services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The practice worked in partnership with key organisations to support care provision, service development and joined-up care. For example, working relations with residents and care home staff was highlighted in the positive feedback from the care home under the care of the practice, with systems and processes in place so that services worked seamlessly for people.

The practice also engaged with people, communities and partners to share learning with each other that resulted in continuous improvements to the service, such as working with their Primary Care Network (PCN). They used these networks to identify new or innovative ideas that could lead to better outcomes for people. For example, the practice’s Patient Participation Group (PPG) was run and facilitated by their PCN and included the 6 practices of the PCN. We received positive feedback from the PCN on Drs Mirza, Sukhani and Partners active engagement with the group.

The practice focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Staff talked positively about their experiences of joining the practice, moving to new roles and the ongoing support and development.

Leaders shared with us examples of quality assurance and improvement activities undertaken for the period 2023 to 2025. For example, the practice had enrolled on the NHS England General Practice Improvement Programme (GPIP) in October 2023 and carried out a 26 week audit schedule of the practice’s systems and processes.

The practice involved people using their service in developing and evaluating improvement and innovation activities. For example, a total triage model of care for patients was implemented by the practice in December 2024. We received positive feedback from the practice’s Primary Care Network (PCN) regarding 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.

The practice was also involved in clinical audits such as, 2024/2025 review of patients with acute lower urinary tract infection which was led by the practice’s Integrated Care Board (ICB). However, the practice did not carry out in-house audits of their prescribing of medicines, such as, antibiotics and hypnotics which included, GPs and non-medical prescribers.