Dr Mehboob Bhatti Also known as Sutton Road Surgery

We carried out an announced comprehensive inspection at Dr Mehboob Bhatti (Also known as Sutton Road Surgery) between the 4 December 2023 and the 22 December 2023. Overall, the practice is rated as inadequate.

The ratings for each key question are as follows:

Safe - Inadequate

Effective - Inadequate

Caring - Good

Responsive – Good

Well-led - Inadequate

Following our previous announced: comprehensive inspection at Dr Mehboob Bhatti (also known as Sutton Road Surgery) on 31 May 2016, the practice was rated as good overall.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Mehboob Bhatti on our website at www.cqc.org.uk

Why we carried out this inspection:

We carried out this inspection because of the length of time since the last inspection in 2016.

How we carried out the inspection:

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A site visit.

Our findings:

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We found that:

• The practice did not have appropriate systems in place for the safe management of medicines. This included ineffective systems for the regular monitoring and review of patients prescribed high risk medicines and medicine safety alerts, as action had not been taken to ensure patients were informed of potential risks with certain medicines. We found that medicine reviews were not detailed enough to demonstrate what was reviewed.
• The process for reviewing patients with long term conditions did not ensure patients received regular and appropriate reviews in line with current legislation, standards and evidence-based guidance supported by clear pathways.
• Patient records were not managed in a way that protected patients. Clinical records showed that a patient’s history, examination, clinical management plans, safety netting and follow up were not adequately documented in line with current guidance.
• There was limited monitoring of the outcome of care and treatment. For example, patient test results were not followed up or referred in a timely manner and referrals made were not consistently followed up and records maintained to keep track of the referrals to check patients had received an appointment.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Staff did not always follow up on the information they had to deliver safe care and treatment to patients.
• The practice was unable to demonstrate that all staff had updated their skills and knowledge to carry out their roles.
• The practice was unable to demonstrate effective supervision of staff carrying out their roles to ensure they were acting within their competencies.
• Published results showed that the uptake of childhood immunisations was below the target 90% as of March 2022 in all 5 indicators.
• The practice’s uptake for cervical screening as of March 2023 was below the 80% coverage target for the national screening programme.
• Leaders could not demonstrate that they had the capacity and skills to deliver high quality and sustainable care.
• The practice did not involve external partners to sustain high quality and sustainable care.
• There was little evidence of systems and processes for learning, continuous improvement and innovation.
• Governance arrangements needed strengthening to ensure there were clear and effective processes for managing risks, issues and performance.

We found breaches of regulations. The provider must:

• Ensure that care and treatment is provided in a safe way.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary for them to carry out their duties.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Whilst we found breaches of regulations, the provider should:

• Take action to remove items stored in the boiler room are removed and introduce checks to keep this area clear.
• Take action to increase the uptake of childhood immunisations particularly for children aged 2 years.
• Take action to increase the uptake of cervical screening.
• Review appointment times offered to provide ease of access for people who worked usual daytime hours and for children not to miss school.

Due to the seriousness of the breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 found at this inspection we took urgent action prior to the onsite visit, in line with our enforcement process and issued a letter of intent notifying the provider of the serious concerns which had been identified during the Care Quality Commission’s inspection.

The provider was invited to complete and send urgently an action plan, setting out how either they have already addressed each of the concerns identified in the letter of intent or provide within the action plan details of how they intended to address the concerns with a specific time frame for implementing each action and who would be doing it. The provider responded with a detailed action plan, which supported the mitigation of the level of risk.

As a result of our inspection findings, 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 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 Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health