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Dr Mohan S Saini Inadequate Also known as Soho Medical Services

We are carrying out a review of quality at Dr Mohan S Saini. We will publish a report when our review is complete. Find out more about our inspection reports.


Inspection carried out on 22 July 2019

During an inspection to make sure that the improvements required had been made

We carried out an announced comprehensive inspection at Dr. Mohan S. Saini on 22 July 2019.

We carried out an inspection of this service following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a significant change to the quality of care provided since the last inspection.

This inspection focused on the following key questions:

  • Safe (this key question was opened on the day of the inspection)
  • Effective
  • Responsive
  • Well-led

Because of the assurance received from our review of information we carried forward the ratings for the following key questions:

  • Caring

We have rated this practice as inadequate overall.

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

  • The practice was unable to demonstrate that safety systems in place to ensure patients were safe and safeguarded from abuse were effectively managed or working as intended. For example, management of prescriptions, consideration and mitigation of risks and recruitment systems and procedures.

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

  • The practice was unable to demonstrate that clinical meetings were recorded for learning or that clinical quality improvement activity was effective.
  • Due to significant errors in coding and the practice’s inability to demonstrate that they were effectively monitoring this, they were unable to demonstrate that the data produced in the public domain was accurate. As a result, the practice were unable to assure themselves that they were providing effective care or treatment overall.

These areas affected all population groups, so we rated all population groups as inadequate

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

  • There was limited effective clinical quality improvement activity.
  • The practice was unable to show that staff always had the skills, knowledge and experience to carry out their roles.
  • The overall governance arrangements were ineffective.

We rated the practice as r

equires improvement for providing responsive services because:

  • The practice was unable to demonstrate that management of all complaints was effective. For example, the practice told us that verbal complaints were resolved on an ongoing basis but were unable to demonstrate any formal recording or documenting system to enable the practice to learn from these or continually improve.
  • Patient feedback data relating to access to care and treatment were higher than local averages in almost all questions.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients
  • Ensure patients are protected from abuse and improper treatment
  • Ensure that any complaint received is investigated and any proportionate action is taken in response to any failure identified by the complaint or investigation.
  • 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).

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 tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care

Inspection carried out on 25 February 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Mohan Saini practice on 25 February 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Patient Group Directions (PGD) had been adopted by the practice to allow nurses to administer medicines in line with legislation.
  • The practice had a system for the management of clinical waste, however on the day of the inspection it was not stored securely.
  • Document management processes were not effective, staff were unable to identify where they would locate some of the policies and procedures.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment. Staff had received training appropriate to their roles.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The GP had developed tools to support patients experiencing poor mental health. medication review template and a patient information template to educate and support patients.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

We saw areas of outstanding practice including;

The practice had a higher than average number of young patients. The GP had developed a face book page that they updated and monitored to improve communication with this population group. The page included information on health lifestyle and developments to services in the practice that would affect them. There were 400 followers.

The areas where the provider should make improvement are:

  • Implement a robust system for managing policies and procedures.
  • Ensure clinical waste is managed and stored safely.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice