Dr Satnam Sodhi Also known as SMS Medical Practice

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 assessed all 8 quality statements from this key question. Our rating for this key question is good. We found that there was an embedded learning culture with which all staff were familiar. There were clear patient pathways in place and safeguarding processes were prioritised and regularly reviewed. The practice involved people in managing risks although the practice was sometimes missing early opportunities to diagnose and discuss diabetes treatment with people. The service was provided in a clean and hygienic environment and was staffed appropriately. However, the systems in place for medicines optimisation required improvement because we found that the practice was not always implementing national patient safety alerts or documenting medicines reviews with sufficient detail and did not have effective monitoring in place to identify these gaps itself. This was a breach of the legal regulation to provide safe care.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were supported to raise concerns and staff treated them with compassion and understanding. Patients did not raise any specific concerns about the learning culture at the practice.

Managers encouraged staff to raise concerns when things went wrong and staff understood their responsibility to report any incidents including near misses. The whole team discussed and learnt from clinical issues. Staff told us that there was an open culture, and that safety was a priority.

The provider had accessible processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints. Learning from incidents and complaints resulted in changes that improved care for others.

Patients have not raised any specific concerns about how staff, teams and services worked together.

Staff informed us that the practice prioritised care for their most clinically vulnerable patients. We found staff were knowledgeable in their role and were aware of support networks in the local area.

Partner organisations did not make any comments about how staff, teams and services worked together.

The provider had processes in place to work with other health and social care professionals and agencies, for example, to reduce the risk of avoidable hospital admissions. There were effective systems in place to track urgent referrals for suspected cancer. People using the service had access to a ‘social prescriber’ at the practice who could advise on available local resources to help with wider issues affecting people’s health and wellbeing, for example, housing problems.

Patients participating in the assessment did not make any comments about safeguarding.

Staff were trained to the appropriate levels for their role and leaders were able to demonstrate how safeguarding was being managed in the practice. There were discussions with other health and social care professionals when needed, to support and protect adults and children at risk of significant harm.

We did not speak with representatives from partner agencies as part of the inspection.

The provider had clear policies and processes in place to safeguard children and vulnerable adults. Safeguarding flowcharts, displaying the practice’s procedures for reporting and responding to safeguarding concerns, were on display in the practice for staff reference. Safeguarding correspondence was prioritised for a prompt response.

People told us that they were informed about any risks and how to keep themselves safe, including what to do and who to contact if their condition did not improve or if they experienced any unexpected symptoms.

Staff told us they had enough time to discuss any risks with people and update their records with this information.

We carried out a series of standardised searches of the clinical records. This showed that the practice was not taking all opportunities to diagnose diabetes. We identified several cases where consecutive blood tests indicated that the person had diabetes but this had not been identified and coded as such by the practice. The practice had contacted people and invited them for a further blood test rather than making and discussing the diagnosis with people and starting treatment to manage the risk more effectively. There were posters about how to recognise the signs of sepsis throughout the practice, including in reception, for both people and staff. The reception office displayed a ‘Red Flag Protocol’ to assist staff when managing potential emergencies over the phone.

Staff told us the environment, facilities and equipment were well-maintained so they could work safely and deliver good quality care to people. Staff were aware of the procedures for emergency evacuation, for example, in the event of fire.

We found no concerns regarding the care environment, equipment or facilities during our site visit. The equipment we inspected had been appropriately checked and serviced to ensure it was safe to use. The practice was equipped to deal with medical emergencies. Emergency equipment, including emergency oxygen and an automated external defibrillator (AED) were checked by staff to ensure they were safely stored and fit for use. At the time of our visit the provider did not log when these checks were undertaken but planned to log this information on the new practice management system. This change was subsequently confirmed after the assessment.

The provider had a constructive working relationship with the building management agency which provided regular assurance that safety policies were in place; procedures (such as water temperature monitoring; fire alarm testing and electrical safety testing) were being followed and the building was being well maintained.

People who participated in the assessment did not comment on staffing directly but a consistent theme in comments we received was that people were able to get appointments as needed.

The leaders told us they had recently recruited an additional locum doctor to ensure there was enough GP appointment capacity. Staff confirmed there were enough staff at all levels to provide a good service.

Recruitment checks were carried out in accordance with regulations. Staff had access to regular appraisals and the records we reviewed showed that staff employed for over a year had received an appraisal within the last 12 months. Staff were appropriately qualified and up to date with required training. The lead GP provided clinical oversight and supervision for clinical staff and associated clinical staff.

People told us the practice was always clean and tidy and we found no concerns relating to people’s experience of infection prevention and control at the practice.

Staff confirmed they received effective training and updates on infection prevention and control.

We observed the practice to be clean and well organised on the day of our visit, for example there were sufficient supplies of personal protective equipment and safe facilities for the disposal of sharps.

Infection prevention and control audits were carried out and the provider was acting on issues identified in the most recent audit from June 2024. For example, the provider had purchased wall mounted dispensers for personal protective equipment such as aprons and gloves. Our review of staff immunisation records showed gaps in the routine immunisation history for some staff. Following our inspection, the provider informed us that the relevant staff had received blood tests to review immunity and in future the practice would include immunisation history as part of its routine recruitment checks.

Patients did not raise any specific concerns about medicines or prescribing.

The leaders told us that the service had not previously had sufficient resource to enable them to consistently prioritise and implement all aspects of good practice in relation to medicines optimisation. We were told that the practice had recently been allocated additional clinical pharmacist resource and planned to use this to improve medicines optimisation within the practice, for example the scope, quality and documentation of medication reviews. Staff managed medicines-related stationery appropriately and securely, in line with the practice’s ‘Blank prescriptions policy’.

During our site visit we saw medicines were managed and stored safely. Vaccines were appropriately stored, monitored and transported in line with guidance to ensure they remained safe and effective. Staff showed us how they monitored and logged the stock levels and expiry dates for emergency medicines.

We carried out a series of standardised searches of the practice clinical records system. This highlighted areas for improvement. For example, people prescribed certain medicines for hypertension were not always being recalled for monitoring in line with guidelines. We saw evidence that the practice had contacted some people to remind them to book an appointment for the tests but did not have an effective policy in place for managing cases when people did not respond. We found that the practice had not fully implemented a national safety alert in relation to prescribing 2 particular medicines together (simvastatin and amlodipine). We identified 4 patients on this combination of medicines. There was no record of the risks having been discussed with them. We also noted that the quality of medication reviews was variable. Some of the review notes did not include details of people’s involvement in the review or the outcome. The leaders told us that they had recently been allocated additional clinical pharmacist resource and planned to use this to improve the quality and consistency of reviews and how they were recorded.

The provider performed well in relation to published prescribing indicators. For example, the practice scored significantly better than the English average for antibiotic and hypnotic medicines prescribing.