Sidley Medical Practice (a partnership consisting of Dr Asare and Mr Asante) v Care Quality Commission [2025] UKFTT 1225 (HESC)

First-tier Tribunal Care Standards

The Tribunal Procedure (First-tier Tribunal) (Health, Education and Social Care) Rules 2008

NCN: [2025] UKFTT 01225 (HESC)

2025-01574.EA-MOU

Hearing held on video on 17 to 19 September, 1 and 3 October 2025 (with Panel deliberations on 13 October 2025)

Before

Tribunal Judge M O’Neill

Specialist Member J Everitt

Specialist Member R Flynn

Between

Sidley Medical Practice (a partnership consisting of Dr Asare and Mr Asante)Appellant

-v-

Between

Care Quality CommissionRespondent

DECISION

Date 2025-10-14

[1]The APPEAL 1.1. This is an appeal by Sidley Medical Practice (A Partnership) (“the Appellants”) against a decision by the Care Quality Commission (“the Respondent”) dated 24 July 2025, to extend the suspension of the Appellant’s registration to carry on the Regulated Activities, from 16 July 2025 until 15 October 2025.

[2]Attendance 2.1. The hearing of the application was conducted remotely on 17 to 19 September and 1 and 3 October 2025. In attendance were: 2.2. On behalf of the Appellant:(a) Mr Simon Butler, Counsel.

(b) Mr Errol Archer, Solicitor-advocate.

(d) Dr Toby Longwill, General Practitioner - Expert Witness.

(e) Mr Frank Asante attended on 1 and 3 October 2025 as an observer. 2.3. On behalf of the Respondent: (a) Miss Clare Stevenson, Counsel. (b) Mrs Ros Foster, Solicitor (Hill Dickinson LLP). (c) Mrs Karen Antwi, Inhouse lawyer at the Respondent. (d) Mrs Frampton-Anderson, Inhouse lawyer at the Respondent. (e) Ify Osu, Inhouse paralegal at the Respondent.

(f) Michelle Fordham, CQC Inspector (“Michelle”).

(g) Mrs Chloe Frost, CQC Operations Manager.

(h) Mrs Serena Coleman, CQC Interim Deputy Director.

(i) Mrs Monika Ziółkowska, CQC Operations Manager.

(j) Dr Zishan Syed, CQC Specialist Advisor.

[3]Evidence 3.1. We considered the written evidence submitted to the Tribunal in advance and the oral evidence given to us at the hearing even if we do not mention it. We used the hearing to amplify and update parts of the written evidence and only record such of the oral evidence as is necessary to explain our decision.

[4]Procedural Matters The Bundles 4.1. We were provided with:(a) a main bundle which was paginated in sections from A to E. Including index pages and cover sheets the main bundle had 1286 electronic pages; and

(b) a main supplemental bundle which was paginated in sections from F to I. Including index pages and cover sheets the supplemental bundle had 199 electronic pages. 4.2. We were also provided with exhibits SA21, SA28, SA51 and a supplemental statement from Dr Longwill. Rule 14 Order 4.3. Under rule 14(1) of the Tribunal Procedure (First-tier Tribunal) (Health Education and Social Care Chamber) Rules 2008 (“the Rules”), it is ordered that no person may disclose or publish any matter likely to lead to a member of the public identifying any patient of Sidley Medical Practice. Mr Asante 4.4. Mr Asante did not attend the hearing on 17 to 19 September 2025. Mr Butler confirmed that he was instructed to represent both the Appellants, and, in those circumstances, we accepted that we did not need to consider rule 27 of the Rules. Whilst Mr Asante was not physically present at the hearing, he was represented by Mr Butler. Mr Asante did attend the hearing on 1 and 3 October 2025, but only in the capacity as an observer. Expert’s Joint Statement 4.5. On 12 September 2025, I issued an order directing the parties to prepare a Scott Scheule containing the issues in dispute. The parties had previously been directed to do this but had failed to comply with that direction. The Scott Schedule that was produced, whilst helpful, did not address all the factual issues in dispute. It did not address the 30 plus patients which the Respondent alleged had been placed at risk of harm. There was expert evidence from Dr Longwill and Dr Syed’s evidence was put forward as a specialist advisor. But there had been no attempt by Dr Longwill and Dr Syed to narrow the issues in dispute between them. 4.6. There was insufficient time to hear contested evidence on all of the example patients and so we directed (i) the Respondent to produce a list of the patients which the Tribunal was being asked to consider and (ii) for Dr Longwill and Dr Syed to meet to attempt to narrow the issues. The Appellants endorsed this approach, the Respondent objected to it. The substance of the Respondent’s objection was that there was not time to produce this work. We had little sympathy with these submissions. The Respondent had a large team of lawyers in the hearing who would be able to assist, and, in any event, this is work that should have been done prior to the hearing. We therefore directed a joint statement to be produced. 4.7. The joint statement was effective in that it reduced the number of patients the Tribunal was being asked to consider from over 30 to only 11. Late Evidence 4.8. Both parties attempted to produce late evidence. The evidence that we admitted is found in the updated supplementary bundle that was sent to the Tribunal on 2 October 2025. Where we refused permission to admit any document as late evidence, we did so because the document had been produced too late and to admit it would cause prejudice to the other party.

[5]Background AND KEY CHRONOLOGY 5.1. The Appellants were registered with the Respondent as a provider in respect of the regulated activities of diagnostics and screening, treatment of disease, disorder and injury, maternity and midwifery, family planning and surgical procedures (“the Regulated Activities”) from Sidley Medical Practice (“the Practice”), 44 Turkey Road Bexhill-On-Sea East Sussex TN39 5HE (“Turkey Road”) and Albert Road, Bexhill-On-Sea, East Sussex TN40 1DG (“Albert Road”) (Turkey Road and Albert Road together are “the Locations”). 5.2. The Respondent has had concerns about the Appellants’ provision of the Regulated Activities at the Locations for a number of years. Three Warning Notices were issued to the Appellants on 2 July 2024 (“the Notices”) in relation to breaches of Regulations 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (“the 2014 Regulations”). 5.3. The Notices required the Appellant to become compliant with Regulations 12, 17 and 18 of the 2014 Regulations at the Locations by 2 October 2024. No representations were made by the Appellants in response to the Notices. 5.4. Following the issue of the Notices, the Respondent received a series of whistleblowing complaints from staff working at the Locations and complaints from patients. 5.5. The Respondent undertook an unannounced inspection at the Locations on 11 April 2025 (“the Inspection”). At the Inspection the Respondent found the Appellants to be in breach of the requirements under the 2014 Regulations as follows:(a) Regulation 12(1): Safe care and treatment.

(b) Regulation 13(1): Safeguarding service users from abuse and improper treatment.

(d) Regulation 17(1): Good governance.

(e) Regulation 18(1): Staffing.

(f) Regulation 19(1) Fit and proper persons.

(g) Regulation 20(1) Duty of Candour. 5.6. The Appellants were also found to have failed to comply with a condition of its registration that required there to be a registered manager in place. 5.7. On 15 April 2025, the Respondent served the Appellants with a notice of decision suspending their registration until 15 July 2025 (“the First NOD”). On 12 May 2025 the Appellants filed an appeal against the First NOD. But that appeal was withdrawn, on the application of the Appellants, and by an Order dated 29 May 2025. 5.8. A discussion between representatives of the Appellants and the Respondent took place on 3 July 2025 as to the concerns that had given rise to the suspension and the remedial actions that would be required to address the breaches of regulation that had been identified. Those discussions did not give the Respondent the necessary assurance that the breaches had been addressed or that the Appellants had a proper understanding of the actions required to do so. As such the Respondent issued a notice of decision dated 14 July 2025, to extend the suspension until 15 October 2025 (“the Second NOD”). 5.9. The Appellants have appealed against the Second NOD. 5.10. On 22 July 2025, the Respondent served the Appellant’s with a notice of proposal to cancel the Appellant’s registration with the Respondent. We were told during the hearing that the Respondent has now served the Appellant with a notice of decision to cancel the Appellant’s registration with the Respondent.

[6]Legal Framework The Legislative Provisions 6.1. The relevant legislative provisions are as follows. 6.2. Section 18 of the 2008 Act. Section 18(1) provides that:

“The Commission may at any time suspend a person's registration under this Chapter as a service provider or manager for a specified period”. 6.3. Section 31 of the 2008 Act, makes provision for an urgent procedure to suspend the registration or extend a period of suspension of a person registered as a service provider. Section 31(1) provides that: “If the Commission has reasonable cause to believe that unless it acts under this section any person will or may be exposed to the risk of harm, the Commission may, by giving notice in writing under this section to a person registered as a service provider or manager in respect of a regulated activity, provide for any decision of the Commission that is mentioned in subsection (2) to take effect from the time when the notice is given”. 6.4. Section 32 of the 2008 Act, provides a right of appeal against a decision issued under section 21 of the 2008 Act. 6.5. Under section 32(5) of the 2008 Act the Tribunal: “may confirm the decision or direct that it is to cease to have effect”. 6.6. Under section 32 (6) of the 2008 Act, the Tribunal also has the power: (a) “to vary any discretionary condition for the time being in force in respect of the regulated activity to which the appeal relates, (b) to direct that any such discretionary condition is to cease to have effect, (c) to direct that any such discretionary condition as the Tribunal thinks fit shall have effect in respect of the regulated activity, or (d) to vary the period of any suspension”. 6.7. We remind ourselves that in an appeal under section 31 of the 2008 Act, the Tribunal is not reviewing the decision of the Respondent. The appeal is de novo and the Tribunal is required to consider all the evidence available to it at the date of the hearing. The Tribunal is not restricted to a consideration of the matters available as at the date of the Second NOD. The Burden and Standard of Proof 6.8. We further remind ourselves that: (a) the burden of proof is on the Respondent to establish that the relevant test in section 31 of the 2008 Act has been met; (b) the standard of proof required is whether there is “reasonable cause to believe”

(c) reasonable belief is judged by the informed observer test:

“The reasonable belief is to be judged by whether a reasonable person assumed to know the law and possessed of the information available would believe that a person might be at risk if the conditions did not take immediate effect”

. The Issues 6.9. The factual issues for determination by the Tribunal were those set out in the Scott Schedule and the Joint Statement of the experts. 6.10. There was no dispute between the parties, that as regard any dispute of fact, the standard of proof to be applied was the civil standard (i.e. balance of probabilities).

[7]Analysis Factual Analysis 7.1. For ease of reference, for each of the below subheadings, we adopt the wording of the allegations set out in the Scott Schedule. Issue One: Carrying out the Regulated Activities without there being a registered manager in place. 7.2. It was not in dispute that:(a) it was a condition of the Appellants’ registration with the Respondent that there be a registered manager in place;

(b) as at the date of the Inspection, the 3 July meeting and the date of hearing, there was no registered manager in post; and

(c) there had been no registered manager in post since prior to the previous inspection in May 2024. 7.3. We decided that the failure by the Appellants to appoint a registered manager may expose patients of the Practice to the risk of harm. Our reasons are: (a) A registered manager was a condition of the Appellants’ registration. (b) Dr Asare’s witness statement did not explain why there was no registered manager or what attempts had been made to recruit one. We were referred in the Scott Schedule to paragraphs 34 to 37 of Dr Asare’s witness statement. Those paragraphs referred only to a practice manager and a business manager. A registered manager is not the same as a practice manager or business manager. Registered managers have a legal responsibility and can be personally accountable for ensuring that a registered provider is complying with its regulatory obligations. (c) Dr Asare explained in his oral evidence that he had applied to be the registered manager, but his application had been refused. Further, that Mr Asante had applied but subsequently withdrew his application. Further still, one of the proposed new partners, Dr Kumar, had applied to the CQC to be the registered manager but his application had also been refused. Dr Asare further explained that in August 2025, another individual (“MS”) had applied to the CQC to be the registered manager but his application remained outstanding. None of this detail was in Dr Asare’s witness statement. We were provided with no documents or further information (e.g. MS CV, employment history, record of qualifications or experience) regarding MS. Given the complete absence of detail in the information that we were provided with, we had no confidence that the Appellant would have a registered manager in post in the near future and going forward.

(d) Section 2 of the 2014 Regulations sets out the fundamental standards that providers of regulated activities must meet. The Explanatory Memorandum to the 2014 Regulations makes clear that the fundamental standards were introduced to ensure that service users received safe, quality care and treatment. It therefore follows that if a service provider is not complying with the fundamental standards, there is a risk that service users will not receive safe, quality care and treatment. In other words, if a service provider is not complying with its regulatory obligations, patients may be exposed to the risk of harm.

(e) As is explained in greater detail below, we were satisfied on the evidence that the Appellants’ conduct breached Regulations 12, 13, 15, 17, 18 and 19. Further, we were satisfied that the Appellant had a history of non-compliance as was demonstrated by the warning notices. In our judgment, a likely cause or contributing factor to these breaches was because no individual in the Practice was assigned to take responsibility or be accountable for ensuring the Appellant’s regulatory compliance i.e. there was no registered manager.

(f) Given we were not persuaded that there was any likelihood that Appellants would have a registered manager in post in the near future and going forward, we remained equally unpersuaded that the Appellants would be able to comply with their regulatory obligations. This may have placed the Practice’s patients at a risk of harm.

(g) It was submitted by Mr Butler in the Scott Schedule that the Appellants had a “reasonable excuse” because they had made reasonable efforts to recruit a registered manager, and they had plan in place. We reject that submission both as a matter of fact and law. As we set out above, Dr Asare’s evidence both as to the efforts the Appellants had taken and their proposed plan to recruit a registered manager was completely lacking. We were not therefore persuaded that the Appellants had made reasonable efforts to recruit a registered manager, or that they had a workable plan in place to secure one; all efforts to date had failed. In any event, the concept of a reasonable excuse arises from section 33 of the Health and Social Care Act 2008 (“the 2008 Act”). Section 33 of the 2008 Act had no application in these proceedings. Section 33 was concerned with the criminal offence for failing to comply with conditions which falls outside the jurisdiction of the First Tier Tribunal. Regulation 12: Safe Care and Treatment 7.4. Regulation 12(1) of the 2014 Regulations provides that:

“Care and treatment must be provided in a safe way for service users”

. Regulation 12(2) goes on to provide a non-exhaustive list which a registered person must do to comply with regulation 12(1). 7.5. It is alleged by the Respondent that Issues Two to Six (as set out in the Scott Schedule) demonstrate multiple breaches of Regulation 12. This is denied by the Appellant. Issue Two: Patients could not access services for timely and appropriate care. 7.6. We were satisfied on the evidence available to us that Patients were unable to access services for timely and appropriate care. We accepted that this was a breach of Regulation 12 of the 2014 Regulations. Our reasons were: (a) We were not persuaded that the Appellants had an established and effective system for triaging and prioritising those patients that attempted to access services in person or via the telephone. (b) Michelle’s evidence was that at the inspection she discussed how patients access services with members of the reception team. Michelle was told that: (i) patients who accessed services via the internet were prioritised for clinical services via Anima software; but (ii) patients who attempted to access services by the telephone or those who attended in person were not triaged. They were allocated appointments on a first come first served basis. (c) In his submissions, Mr Butler sought to dismiss or minimise the importance of Michelle’s evidence on the basis that it was inevitable that some staff would be more technologically confident than others. In light of Dr Asare’s evidence (discussed below), we reject those submissions and accept Michelle’s evidence. (d) Dr Asare accepted that the Anima system was not being used by the reception team for telephone and in-person appointment requests. He confirmed in his oral evidence that he had been aware of this since the system was installed in summer 2024 but he was not able to explain what actions he had taken to ensure that the staff did use the system. This meant that for a period in excess of six months Dr Asare had been aware that patients were not being properly triaged, but Dr Asare took no action to remedy this. This may have placed patients at a risk of harm. (e) The only mitigation strategy that Dr Asare offered was training. We were not provided with copies of the relevant staff members’ training records but even if we were to accept Dr Asare’s evidence the fact that staff had been trained was insufficient to mitigate the risk of harm. Dr Asare knew the reception staff were not using the Anima system to triage patients and he should have taken proactive steps to remedy this. He did not and by failing to act may have placed patients at a risk of harm. (f) Furthermore, if staff had been trained but still did not feel confident to use the Anima system, then what this tells us is that the training was ineffective and/or had not been consolidated by those who had received it. Dr Asare offered us nothing to persuade us as to how this would be remedied. There was no evidence before us to show how the relevant staff would be trained to effectively and confidently use the Anima system going forward. Patients may therefore remain at risk of harm. (g) We were not persuaded by Dr Asare’s evidence as regards the EMMA system. We were shown no analysis as to how the EMMA system would address the identified risks, no process mapping to implementation, and no proposed training programme for those intending to operate the system. We were not therefore persuaded that the EMMA system would aid patient triage. (h) We were not persuaded that all relevant staff had received red flag training. Red flag training is essential to ensure that the staff have the knowledge and are confident in gathering essential information or understanding potential red flags for risks to patient health. Dr Asare appeared to place complete reliance on technology (i.e. all patients should be triaged through the Anima software). Whilst we take no issue with the use of appropriate technology, a practice needs to have contingency arrangements in place in the event the technology fails. The Appellants did not persuade us that they had any such contingency arrangements. Dr Asare made no mention of Red Flag Training in his witness statement; he referred only to Care Navigation Training (which is something different). Dr Asare confirmed in his oral evidence that he was unable to say which staff had received Red Flag Training and which had not. The absence of Red Flag Training may have placed patients at a risk of harm. (i) We accepted Michelle’s evidence that the role proposed by the Appellants for the duty doctor in triaging patients who present for urgent appointments was not clear and was not documented. 7.7. Given the above analysis we were satisfied on the evidence that patients were unable to access services for timely and appropriate care which was a breach of Regulation 12 of the 2014 Regulations. This may have placed patients at a risk of harm Issue Three: Poor clinical assessments 7.8. The Respondent’s position was that the Appellants were unable to provide assurance that patients had access to timely and appropriate clinical assessment and that patients were being placed at risk of harm due to delays in responding to tests and blood pressure readings. 7.9. The Respondent identified a sample of eight patients which it claimed had been placed at risk of harm. Following the exercised undertaken by Dr Longwill and Dr Syed, and as is set out in their joint statement, the parties were agreed as to the following: (a) Patient 1: Both GP experts agreed there is no risk of harm. (b) Patient 2: Both GP experts agreed that the patient was placed at a risk of harm. (c) Patient 3: Both GP experts agreed that the patient was placed at a risk of harm. (d) Patient 5: Both GP experts agreed that the patient was placed at a risk of harm. 7.10. The GP experts were unable to agree as regards Patient 6. 7.11. Dr Syed’s written evidence was, in summary: (a) On 15 January 2025 the patient provided raised blood pressures readings. This patient had a history of Transient Ischaemic Attacks (“TIA”). (b) On 28 January 2025 (13 days later) the patient was treated with medication. The note entries state that medication was given “in view of poss TIA.” (c) Having a TIA is a medical emergency and so this patient had been placed at risk of harm. The patient had submitted elevated blood pressure readings, indicative of a potential cerebrovascular risk. The patient’s known history of TIA substantially increases the urgency with which such symptoms must be assessed. (d) There was a 13-day delay between the presentation of the blood pressure readings and the documented initiation of treatment, during which the patient remained at increased risk of stroke or further TIA. (e) Further, the documentation ‘in view of poss TIA’ is ambiguous as it was unclear whether the author was suggesting the patient had experienced another recent TIA or was referring to the past history of one. 7.12. In his oral evidence, Dr Syed explained that his concern was about the delay. When he reviewed the patient’s medical records there was no record that when the patient had provided the 11 blood pressure readings on 15 January an average of those readings had been taken. Dr Syed had no issue with the fact that medication had been prescribed, but with a patient with a past history of TIA his opinion was that this should have alerted more scrutiny. Certain risk factors, such as a past history of TIA, should suggest more prompt treatment. In his opinion the practice should have provided a review sooner rather than 13 days. 7.13. Dr Longwill’s written evidence was, in summary: (a) On 15/01/2025 the patient sent in 11 blood pressure readings which ranged from 130/65 to 163/88. This gave an average reading of 146.8/77.5 mmHg. (b) A blood pressure of 146.8/77.5 shows a slightly raised systolic blood pressure which would be classified as “stage 1 hypertension”. (c) The diagnosis of hypertension could have been improved e.g. by considering either 24-hour monitoring or home monitoring over 7 days. But in view of the previous suspected TIA, it was reasonable to start treatment for hypertension and it was reasonable to start treatment within two weeks (i.e. by 28/01/2025). 7.14. We decided that this patient was placed at risk of harm. Both doctors agreed that the patient’s notes were ambiguous and in our judgment this in itself created a risk of harm. Further, it was agreed that there was no record of any average of the blood pressure readings being taken. As there is no evidence that the average was calculated, we conclude that this was not done. We accepted Dr Syed’s evidence that it was only by calculating this average that the clinical risk could be assessed. It therefore follows that the clinical risk to this patient was not properly assessed on 15 January and by waiting until 28 January 2025, this placed the patient at risk of harm. 7.15. Patient 8, 9 and 10 had been prescribed Mirabegron. Both the GP experts agreed that any patient taking Mirabegron needs to have regular blood pressure checks (annual as a minimum) to reduce the risk of uncontrollable hypertension while on Mirabegron which can result in increased risk of heart attack and stroke. 7.16. Both the GP experts agreed that if the Tribunal accepts Dr Asare’s evidence that a blood pressure check was planned for each of these patients, then the practice did not expose the patient to a risk of harm. 7.17. Dr Asare’s evidence, as set out in his statement was that the practice runs a weekly recall list to identify those patients who require blood tests that week. The patients are contacted and asked to book in for the relevant test. If a patient does not book an appointment an escalation procedure is followed which ultimately can result in the patient being denied their medication. This process is documented in section 7 of the medicine management policy at SA21. We accepted Dr Asare’s evidence and therefore decided that patients 8, 9 and 10 had not been placed at risk of harm. 7.18. Both GP experts agreed that Patients 2, 3 and 5 had been placed at a risk of harm and we decided that Patient 6 had been placed at risk of harm. Accordingly, we were satisfied that Patients 2, 3, 5 and 6 were unable to access timely and appropriate clinical assessments and that these patients were placed at risk of harm. Further, this was a breach of Regulation 12(1) of the 2014 Regulations. Issue Four: Unsafe monitoring of medicines 7.19. The Respondent’s position was that patients had been placed at risk of harm as they had not been safely monitored on their medicines. This included a failure to monitor and prescribe safely to people and address risks raised by the Medicines and Healthcare Products Regulatory Agency. 7.20. The Respondent identified a sample of fourteen patients which it claimed had been placed at risk of harm. Following the exercise undertaken by Dr Longwill and Dr Syed, and as is set out in their joint statement, the parties were agreed as to the following: (a) Patient 11: Both GP experts agreed there is no risk of harm. (b) Patient 12: Both GP experts agreed there is no risk of harm. (c) Patient 14: Both GP experts agreed there is no risk of harm. (d) Patient 15: Both GP experts agreed there is no risk of harm. 7.21. Patient 13 had previously been prescribed apixaban which is a drug used to treat suspected blood clots. This medication was no longer required. Both GP experts agreed that the apixaban was on the medication list when it need not be, and the records could be improved by removing it. Dr Syed’s evidence was that the medication was on the repeat prescription list, and this caused a greater level of risk i.e. the risk that it would be reissued when not needed. But when asked questions on this Dr Syed became uncertain as to which medication list it was actually on i.e. he wasn’t certain if it was the repeat prescription list. We accept that if a drug was on the repeat prescription list, then this presents a higher risk of it being issued in error than if it was on the acute medication list (which was explained to us to mean medications prescribed for short term use). We accept that the medical records could have been improved because the practice had never prescribed apixaban, it had been prescribed by the hospital for short term use. But without better evidence that the apixaban was on the repeat prescription list, we unable to conclude that it was. Accordingly, we were not persuaded that Patient 13 had been placed at risk of harm. 7.22. Patients 16, 17, 18 and 19 had all be prescribed Amiodarone, a drug used to treat arrhythmia. The point of dispute between the GP experts for all these patients concerned the lack of monitoring of the patients’ magnesium levels. 7.23. Dr Longwill’s evidence was that British National Formulary (“BNF”) does not mention monitoring magnesium. He explained in oral evidence that the BNF is a pharmaceutical publication that has information and advice on prescribing medicines. Dr Longwill’s evidence was that because the BNF does not mention magnesium there is a responsible body of GPs who would not have checked the patients’ magnesium levels. 7.24. Dr Syed’s accepted that the BNF did not mention magnesium monitoring. But Dr Syed’s evidence was that the Specialist Pharmacy Service (“SPS”) advised that once a patient is stable their magnesium levels should be monitored every six months. He explained that in his view, all GPs had an obligation to undertake continuous professional development and stay current in their prescribing knowledge. His view was that a responsible body of GPs would have stayed up to date with their knowledge and checked patients 16, 17, 18 and 19’s magnesium levels. We asked Dr Syed whether it was just reasonable for a GP to check both the BNF and the SPS or whether he considered this to be the gold standard; he explained that it was the gold standard. 7.25. We were not persuaded that patients 16, 17, 18 and 19 had been placed at risk of harm. We preferred Dr Longwill’s evidence to Dr Syed’s evidence. We did not agree with Dr Syed assessment of the risk measured against the gold standard of care. No professional, including GPs, are judged against a gold standard. Rather they are judged against the standard of care provided by a reasonably competent body of other GPs in similar circumstances. We accepted Dr Longwill’s evidence that this standard would be met by considering only the BNF which made no mention of magnesium monitoring. 7.26. Patient 21 had a past medical history of asthma, depression, bipolar disorder, ADHD, and obesity. An asthma and control test (“ACT”) was submitted by the patient on 08/12/2024 with a score of 7. The patient also comments:

“I need to find out what triggers are because my asthma has been out of control since January of this year. Please refer me to a specialist. I have been off sick 3 months in 1 year”. 7.27. Both the GP experts agree there was a risk to this patient with an ACT score of 7. 7.28. Dr Syed’s evidence was that there was no evidence in the patient’s medical records that they had been seen on or around 08/12/2024 and there was no evidence of any referral. This meant the patient had been placed at risk of harm. 7.29. In his report, Dr Longwill notes that the patient was sent a text message on the same day advising the patient to book an appointment with the asthma nurse. Dr Longwill opines that the clinician who reviewed the ACT had 2 options; directly book the patient an appointment themselves, or message the patient to book an asthma review appointment if they were confident an appointment could be booked by the patient urgently. In Dr Longwill’s professional opinion, if the Tribunal is persuaded that the patient had good access to an urgent asthma review appointment then there would be no risk of harm to the patient. 7.30. Dr Longwill records in his report that during 2024 there are 134 entries in Patient 21’s medical records. The consultations are mainly regarding the asthma, mental health and an abscess. Dr Longwill then lists the consultations in 2024 regarding asthma. Mr Butler’s submission was that these entries show that Patient 21 was able to access an urgent asthma review appointment and so on Dr Longwill’s evidence, there was no risk of harm. We did not agree for the following reasons: (a) We accept that on 30/01/2024, 27/06/2024, and 12/11/2024 the patient made contact with the practice and on those dates was able to secure an urgent same day appointment. (b) But on 05/03/2024 an invite was sent for an asthma review. No appointment was booked. (c) On 16/04/2024 the patient was called for an asthma review, but it was not convenient for them to call. No appointment was booked. (d) On 01/07/2024, there is an Anima entry regarding the asthma and a medical certificate. The patient did not attend a face-to-face appointment on 04/07/2024 to review the asthma. The patient was also called on the same day, but did not answer. The patient was also sent a text message regarding the non-attendance. The Patient did then attend a face-to-face appointment on 05/07/2024. 7.31. In our judgment, what the medical records show, when viewed as a whole, is that on some occasions Patient 21 has been able to secure an urgent asthma review appointment but not always. The medical records show a history of not following up on appointment invites and non-attendance at appointments. In our judgment considering the patient’s history and considering her comorbidities (mental health difficulties and ADHD) the practice should have done more than just send a text. At the very least, the practice should have followed up the text on 08/12/2024. There is no record of this being done and so we conclude that it was not. Accordingly, we were persuaded that Patient 21 had been placed at a risk of harm. 7.32. Patients 22, 23, 25 and 26 had all be prescribed aldosterone antagonists. The GP experts both agreed that patients who had been prescribed aldosterone antagonists should have monitoring blood tests taken every 6 months and that in each patient’s case this guideline frequency had been breached. 7.33. Both experts also agreed that when Dr Syed had offered his original opinion this was based on the CQC EMIS search only. This search flagged Patients 22, 23, 25 and 26 because as at that date they were all over the 6 month frequency guideline but by the time the GP experts met to produced their joint statement, each of these patients had had the relevant blood test. We summarise the position in the table below The data is taken from Dr Longwill’s report. The accuracy of the data was not challenged. : Patient number Dates of blood tests Breach period 23 22 28/04/2025, 25/09/2024, 15/07/2024 and 07/03/2024 7 months, 3 days 23 11/04/2025, 03/10/2024, and 20/06/2024 6 months, 8 days 25 06/05/2025, 01/10/2024 and 13/02/2024 7 months, 5 days and 7 months, 18 days 26 17/04/2025, 23/09/2024, and 26/06/2024 No breach 7.34. Dr Syed accepted in his oral evidence that because of Patients 22, 23, 25 and 26 had a monitoring blood test in April or May 2025, the risk to them had been significantly reduced despite the fact that the 6 month frequency window had been breached. In light of this evidence, we were not persuaded that Patients 22, 23, 25 and 26 had been placed at risk of harm. 7.35. In summary, of the 14 example patients, we decided only Patient 21 had been placed at a risk of harm. This was nevertheless a breach of Regulation 12 of the 2014 Regulations. 7.36. We decided that the Appellants did not have clear and defined lines of accountability underpinned by established and effective medicine management processes. Further, this may put patients at risk of harm. Our reasons are: (a) We accepted the Respondent’s case that the Appellants were not clear about which named staff were accountable for the safe management of medicines. We were not persuaded that it was clear as between Dr Asare and Mr Asante who the medicine management lead was. At paragraph 22 of his witness statement Dr Asare states that: “Mr. Frank Asante was the medicines management lead”

. Dr Asare confirmed this in his oral evidence. Mr Asante did not provide a witness statement and did not give oral evidence. (b) We considered the transcript of the 3 July meeting at MF 9-12. What that transcript shows is that Michelle had great difficulty trying to establish from Dr Asare and Mr Asante who the medicine management lead was. At parts of the meeting, Mr Asante took responsibility for the role, but later in the meeting, Dr Asare appeared to take responsibility. What is clear, is that the position was not clear vis a vis Dr Asare and Mr Asante. We did not have the opportunity to ask Mr Asante any questions as he had chosen not to provide a witness statement or give oral evidence. Given Mr Asante’s role as a partner in the practice, the pharmacist and an Appellant in these proceedings, we considered his lack of engagement to be a real cause for concern. (c) The Appellants’ documents did not clarify the position. In particular: (i) The parties were unable to show us where in the Medicines Management Policy (MF18) clear and defined lines of accountability were set out. The policy did not make clear who the medicine management lead was. (ii) The Appellants’ organisational chart identified Mr Asante as the medicine management lead. (iii) The Appellants Medicines Alert Policy 2025 (Exhibit MF/17) assigned responsibility to the practice manager for ensuring “that a system is in place for the practice to receive, disseminate, and act upon alerts…” In our judgment this falls squarely within the responsibility of the medicines management lead. 7.37. In our judgment, the confusion evidenced in the above documents is indicative of the fact that there are no clear and defined lines of accountability underpinned by established and effective medicine management systems or processes. This may place patients at a risk of harm. 7.38. In summary, we decided that Patient 21 had been placed at a risk of harm and that the Appellants did not have clear and defined lines of accountability underpinned by established and effective medicine management processes which may place patients at a risk of harm. This was a breach of Regulation 12(1) of the 2014 Regulations. Issue Five: Staff were not trained or confident to respond to clinical emergencies 7.39. We decided that non-clinical staff were not effectively trained or confident to respond to clinical emergencies. Our reasons were: (a) Michelle’s evidence was that she has been told that there was not always a GP present at Albert Road when the surgery was open, and the staff did not feel confident responding to clinical emergencies. We accepted that evidence. This was corroborated by the e-mail dated 19 September 2025 from the caretaker provider admitted as late evidence. That showed that a significant proportion of staff had not completed basic life support training in the current year. (b) The evidence put forward by the Appellants was wholly insufficient. We were not persuaded that the Appellants had any effective systems or processes for identify the training needs of its staff or for ensuring that those needs are met. (c) What was most concerning to us, was Dr Asare’s attitude to training which was very clearly expressed at paragraph 26 of his witness statement. Dr Asare stated:

“Staff training for emergencies had already been completed so there was no reason to do this again”

. It is essential that the non-clinical staff are not only trained what to do in an emergency but that the training is effective and updated so that the non-clinical staff feel confident in how to respond. If not, then patients presenting with emergencies symptoms when no GP is present would very clearly be placed at a risk. 7.40. The fact that non-clinical staff were not effectively trained or confident to respond to clinical emergencies placed may have patients at a risk of harm. Had there been an emergency when no GP was present at Albert Road, the staff would not have known or been confident in what to do. 7.41. It was not in dispute that the following emergency medicines were not available in the emergency response kit at the Locations: Dexamethasone, Prednisolone, diclofenac, glucagon, Buccal midazolam or rectal diazepam. 7.42. At paragraphs 220 and 221 of his report, Dr Longwill stated as follows:

“In my opinion, a practice would complete a risk assessment as to whether they required dexamethasone, prednisolone or diclofenac. Oral prednisolone is regularly prescribed by GPs (e.g. in cases of exacerbations of asthma or more serious allergic reactions). Oral prednisolone takes hours to have an effect, therefore I would not consider it mandatory to have on an emergency drugs trolley. A GP practice would also need to consider whether their service should store dexamethasone (e.g. for the management of croup) and diclofenac (for analgesia) on site. If the practice is in the vicinity of an emergency department, they may decide not to store these medications. In my opinion, I would consider rectal diazepam (for seizures) and glucagon (for hypoglyceamia) as important items on an emergency drugs trolley. However, as the CQC states, these items are not mandatory. If the practice have completed a risk assessment with regard to these medications, then they have not exposed the patients to a risk of harm”. 7.43. It was the Respondent’s case that no risk assessment was in place for these medicines. 7.44. As part of their late evidence, the Appellants produced a document headed, “Emergency Medications Risk Assessment”

. Dr Asare confirmed in his oral evidence that this was the risk assessment that he relied on. Despite its title, we were not persuaded that this document was a risk assessment of sufficient utility to be relied upon. There is no one standard form that a risk assessment must take. But, as a minimum, it should (i) identify the potential risks, (ii) determine who might be harmed, (iii) evaluate the risks with control/mitigation measures, (iv) record findings, and (v) be regularly reviewed. The document relied on by the Appellants fell hopelessly short of this. Our reasoning can be explained by using dexamethasone as an example. As noted above, Dr Longwill’s evidence was that that if the Appellants’ practice was in the vicinity of an emergency department, thenit may be appropriate not to store dexamethasone onsite providing it has been risk assessed. But Dr Asare confirmed that the closest emergency department to the Locations was Conquest Hospital which was over 6 miles away. The practice is not therefore within the vicinity of an emergency department, but this is not considered as part of the document relied upon by the Appellants. The document produced by Dr Asare was insufficient as a risk assessment and patients may therefore have been placed at risk of harm. 7.45. Given the above, we were persuaded that patients may have been placed at risk of harm which was a breach of Regulation 12(1) of the 2014 Regulations. Issue Six: No effective systems in relation to infection control 7.46. Mr Butler submitted that this issue was not set out in the Second NOD and therefore his client had not given evidence on it. We should not therefore consider it. We did not agree. The issue was the breach of regulation 12. Michelle’s evidence was exactly that, her evidence. As is set out above, we are required to consider this matter de novo and that means we take into consideration all the evidence available at the date of the hearing. We therefore considered Michelle’s evidence. 7.47. Michelle’s evidence was, that staff had reported that Dr Asare had: (a) poor hand hygiene; (b) failed to be bare below the elbow when conducting intimate examinations; and (c) been seen wearing an outdoor coat whilst performing the examinations that was inappropriate. 7.48. Whilst this evidence was not challenged, we were not persuaded that it carried sufficient weight for us to make a finding that there were no effective systems in relation to infection control. 7.49. Michelle’s evidence was that the Appellants were unable to produce a practice immunisation policy (paragraph 57). No such policy was produced during the course of the proceedings. Accordingly, we decided that no such policy existed. It is important to have a practice immunisation policy to help prevent the spread of infectious diseases. It therefore follows that the lack of such a policy may place patients at risk of harm because it’s a key safeguard against the spread of disease that did not exist. 7.50. It was not disputed that there was no record of Dr Chopra’s immunisations. In our judgment this was symptomatic of there being no practice immunisation policy. 7.51. We accepted that the staff at the Albert Road surgery had not been trained how to use the spill kits and were not confident to use them. We accepted Michelle Fordham’s evidence on this. Dr Asare produced no documentary evidence to persuade us otherwise. We were shown no training records. Spill kits are designed to clean up hazardous materials and to protect people from harm. As the staff did not know how to use them, this may have placed patients at risk of harm. Mr Butler sought to dismiss the importance of this point in his submissions by suggesting that it was nonsensical to suggest that a practice full of doctors and nurses would not know how to safely clean up hazardous spills such as bodily fluids. These submissions miss the point. It was the Respondent’s case, which we accepted, that non-clinical staff at Albert Road were often in the surgery with no clinical staff. In circumstances where there is no doctor or nurse present, non-clinical staff cannot rely on them for help. The non-clinical staff should be trained, they were not, and so this presents a risk of harm. 7.52. We were not persuaded that patient bloods were taken in a non-sterile waiting room. We were provided with no specific evidential examples, and Dr Asare gave oral evidence that room 8 (which was immediately off the waiting room) was available for bloods to be taken. In the absence of specific evidence to the contrary we accepted Dr Asare’s oral evidence. 7.53. Given the above finding, we were persuaded that patients may have been placed at risk of harm which was a breach of Regulation 12(1) of the 2014 Regulations. Regulation 13: Safeguarding service users from abuse and improper treatment 7.54. Regulation 13 provides that: (a) Service users must be protected from abuse and improper treatment in accordance with this regulation. (b) Systems and processes must be established and operated effectively to prevent abuse of service users. (c) Systems and processes must be established and operated effectively to investigate, immediately upon becoming aware of, any allegation or evidence of such abuse. Issue Seven: Safeguarding. Including: Lack of effective and established safeguarding processes/systems 7.55. The Respondent’s case was that the Appellants did not have an established and effective safeguarding system. The Respondent relied on Michelle’s evidence. Michelle’s evidence is at paragraphs 71 to 94 and 192 to 196 of her witness statement. At paragraph 77 she states:

“I spoke to the safeguarding lead Dr Asare who confirmed that he maintained 13 safeguarding registers on EMIS. The 13 registers related to 1184 patients. Dr Asare confirmed the records were correct and the high number of people listed was evidence of their thoroughness”. 7.56. Also at paragraph 77, Michelle states: “The Practice had continued to maintain a safeguarding log of concerns on an excel spreadsheet for incidents raised by staff. This was kept separately from the clinical system and assigned safeguarding codes. The Practice had appointed an administrative lead and a practice nurse to oversee the safeguarding log. They met three times a week to progress and review concerns”. 7.57. In her oral evidence, Michelle confirmed that following the inspection in April and the 3 July 2025 meeting, her understanding of the Appellant’s safeguarding system was that it comprised these 13 registers. Separate to that was the log which was overseen by the administrative lead and practice nurse. 7.58. Dr Asare’s evidence is at paragraphs 85 to 106 of his witness statement. At paragraph 86, Dr Asare states: “The safeguarding at risk log (which includes all patients on the safeguarding list) is reviewed daily and also weekly and any concerns are escalated to the monthly safeguarding meeting if they are not urgent. Any urgent concerns are discussed immediately, directly with the safeguarding lead, Dr Asare”. 7.59. At paragraph 88, Dr Asare refers to the excel spreadsheet at Exhibit SA33 as being the safeguarding at risk log. 7.60. In his oral evidence, Dr Asare explained that Michelle had misunderstood the safeguarding system during the inspection in April. The 13 registers that she referred to in her witness statement were not the safeguarding list, these were just for “internal monitoring”

. He explained that the safeguarding at risk log was a manually produced list onto which concerns are added. 7.61. We were satisfied, on the evidence available, that the Appellants did not have adequate safeguarding arrangements to protect their most vulnerable patients. This may have placed patients at a risk of harm. Our reasons are: (a) Dr Asare was unable to explain to us with any clarity how the safeguarding system at the Locations worked. Given Dr Asare was identified as the practice safeguarding lead, this was a serious concern. The safeguarding system was not adequately explained in Dr Asare’s witness statement. At paragraphs 86 and 87 of his statement, Dr Asare explained that: (i) There is a safeguarding at risk log (which includes all patients on the safeguarding list). A screen shot of this log appears at Exhibit SA33. (ii) The log is reviewed daily and also weekly and any concerns are escalated to the monthly safeguarding meeting if they are not urgent. (iii) Any urgent concerns are discussed immediately, directly with the safeguarding lead, Dr Asare. (iv) This is a new procedure that was implemented in approximately September/October 2024. (b) But Dr Asare’s statement did not explain how this log came to be populated, whether this was done automatically through some kind of system search or whether it was manually produced and how it interrelated with the patients’ records. We were unable to establish from Dr Asare’s witness statement how the system operated to prevent abuse of service users or how it operated to investigate, immediately upon becoming aware of, any allegation or evidence of such abuse. (c) We were provided with no records of the alleged daily, weekly and monthly reviews of the safeguarding at risk log. Dr Asare was not able to explain why, if that log was reviewed daily, weekly and monthly, Michelle was able to identify the errors in the 13 registers. Michele’s evidence was that if the systems, as a whole, were regularly reviewed, they should be accurate and cross reference. We were not therefore persuaded that the alleged reviews took place. (d) We asked Dr Asare to explain in his oral evidence how the system worked and how the various registers interrelated, but he was not able to do this. His oral evidence was confused and unintelligible. (e) As set out above, he described the 13 registers that were referred to in Michelle’s evidence as being for “internal monitoring”. In our judgment this was inconsistent with paragraph 89 of his witness statement which suggested that were interrelated in some way. Dr Asare confirmed that the Appellants did not run Ardens safeguarding searches. We were not told how the registers interrelated. (f) We considered Exhibit SA33 which we were told was the safeguarding at risk log, but this was just a screen shot of the log. We did not have access to the actual spreadsheet comprising the log and so could not consider it or its operation in any detail. Michelle confirmed in her oral evidence that she had never seen this spreadsheet. Dr Asare did not accept this, his evidence was that Michelle was only interested in the 13 registers. We preferred Michelle’s evidence on this. Part of Michelle’s role in the inspection was to gain an understanding of the Appellants systems and processes and so it would make no sense for her to dismiss highly relevant information. (g) Dr Asare’s evidence was inconsistent with the Appellants own documents. Dr Asare’s evidence was that the safeguarding system was a new system that had been “implemented in approximately September - October 2024”. (h) We considered the action plan at MF5 which we understand (from Michelle’s evidence) was sent by the Appellants to the Respondent on 24 March 2025. The action plan is set out in a three-column table. Column One contains comments from the Respondent, Column Two explains how the Appellants intended to address the Respondent’s concerns and Column Three explained the position as of 21 March 2025. (i) The comments regarding safeguarding in Column One are taken from the Warning Notice dated 2 July 2024. The comments state:

“On the day of our visit and during our remote interviews staff were unsure who the safeguarding lead(s) were. There was a lack of evidence to demonstrate a safeguarding register was regularly used to maintain oversight of concerns and actions. Staff, including practice management, were unsure whether a register existed or who managed it. The main practice Ardens safeguarding register search had never been run on the system. We found a search under a locum GP (Dr Plumpton) which had been run 21 May 2024. No-one could explain this GP’s role in safeguarding”. (j) Column Two stated: “The staff have been shown how to access the safeguarding folder on EMIS and Ardens and the safeguarding register on Ardens has been updated”. (k) Column Three stated: “There are posters in every clinical room detailing the Safeguard lead and contact details, it is also documented on the EMIS noticeboard when logged in. We have an Enhanced Care co-cordinator to support with proactive care for vulnerable groups including safeguarding. There is a safeguarding register that all members of staff can report safety concerns on. This information is reviewed by our trainee ANP and Enhanced Care co-ordinator. It is then reviewed by our Quality Assurance Lead and Senior Partner, which is then brought to be discussed at our regular safeguarding meetings. The Ardens search is also run on a weekly basis”. (l) There is no mention in Column Three of a new safeguarding system being introduced in September or October 2024. But of most significance, as of March 2025, the Appellants were very clearly representing to the Respondent that they did make use of Ardens Safeguarding Searches and maintained an Ardens register. We asked Dr Asare to explain this. His evidence was that the Ardens search being referred to in Column Three was for medications not safeguarding. We reject that evidence. When Columns One, Two and Three are read together it is very clear that the Ardens searches that are mentioned are specific to safeguarding. His witness evidence is therefore inconsistent with this action plan. (m) No mention is made of the new safeguarding system in any of the safeguarding policy documents we were provided with. At paragraph 88, Dr Asare states: “A description of this process will be added to the Safeguarding Policy when next revised”

. We did not consider this satisfactory. (i) First, the adult safeguarding policy (at MF19) was issued on 11 September 2024 and the child safeguarding policy (at MF20) was issued on 11 October 2024. If the Appellants had introduced a new safeguarding system in September or October 2024, no explanation has been provided as to why this was not set out in the relevant policies that were produced at or around the same time. (ii) Second, the safeguarding policies that we were provided copies of in the bundle (at MF19 and MF20) were not due to be renewed until September and October 2026. This is an unreasonably long period of time for them to be out of date on such a critical issue. These documents should have been updated prior to the hearing, such that the Tribunal was better able to understand the process or system being used. 7.62. In addition to the above, it was the Respondent’s case that the Appellants’ safeguarding policies were sub-optimal. Michelle’s evidence was that the policies did not define roles and responsibilities such as who should contact parties who failed to attend and whether this should be by text, telephone call or letter. There was no clear escalation process should parties fail to engage. We accepted that evidence. 7.63. Michelle’s evidence was also that there was inaccurate information available to staff regarding safeguarding. Information displayed on a poster within the practice was out of date. This referred staff to the Clinical Commissioning Group, an organisation that ceased to exist in July 2022. This evidence was not challenged and so we accepted it. 7.64. Given the above, we were persuaded that the Appellants had failed to establish and operate effective systems and processes to prevent abuse of service users which was a breach of Regulation 13 of the 2014 Regulations. Further, we accept this this may have placed patients at a risk of harm. Regulation 15: Premises and equipment 7.65. Regulation 15 provides that all premises and equipment used by the service provider must be: (a) clean, (b) secure, (c) suitable for the purpose for which they are being used, (d) properly used, (e) properly maintained, and (f) appropriately located for the purpose for which they are being used. 7.66. Regulation 15 also provides that the registered person must, in relation to such premises and equipment, maintain standards of hygiene appropriate for the purposes for which they are being used. Issue Eight: Fire safety standards were not adhered to 7.67. The Respondent’s case was that the Appellants had a history of non-compliance as regards fire safety and so the Tribunal could have no confidence that they would be compliant going forward. 7.68. Michelle’s evidence was that she had spoken with Fire Officer Mark Simes of East Sussex Fire Service. He stated that he had an old fire risk assessment that identified risks requiring mitigation, but those risks had not been actioned (paragraph 99). 7.69. At paragraph 120 of Dr Asare’s witness statement, he acknowledged that there were fire mitigation actions to be taken in 2024, but he stated that:

“these actions were all competed”

. Dr Asare referred to a document exhibited at SA50 to show the actions had all been complete. SA50 was in fact missing from the bundle. Earlier in the hearing we had identified that various of the Exhibits to Dr Asare’s statement were missing and we directed that this be remedied. SA50 was not provided and so we could not consider it. In light of this, we preferred Michelle’s evidence over Dr Asare’s. We were not persuaded that the Appellants had remedied all the risks identified in the 2024 fire risk assessment. We therefore agreed that the Appellants did have a history of non-compliance as regards fire safety risk assessments. 7.70. It was not in dispute that a further risk assessment at Albert Road had been completed by East Sussex Fire Service in June 2025 and that this risk assessment had identified breaches of several fire safety regulations and the necessary remedial actions. In addition, as part of their late evidence the Appellants produced the following documents: (a) Jamie Bollard Associates – Fire Risk Assessment for Albert Road (“the JBA Fire Risk Assessment”). (b) A renovation schedule of works with proposed costs (“the Schedule of Works”). 7.71. The JBA Fire Risk Assessment had been instructed by the Appellants in response to the risk assessment by East Sussex Fire Service in June 2025. It stated:

“The Sidley Medical centre Albert Road is currently seen as having a Substantial risk to life”

. Accordingly, on the Appellants’ own evidence Albert Road, in its current state of repair, placed patients accessing the building at a substantial risk to life. 7.72. We understand that Dr Asare relied on the Schedule of Works in an attempt to persuade us that the risks identified in the JBA Fire Risk Assessment would be fully mitigated. We were not so persuaded. On the evidence available to us, we were not persuaded that the Appellants were able to finance the identified actions. The Schedule of Works estimated the costs of the remedial works to be around £87,030. Dr Asare disputed that the £87,030 was the figure solely for the remedial fire works; his evidence was that the actual cost of the actions in the JBA Fire Risk Assessment was closer to £37,000. We did not accept that evidence. The actions listed in the Schedule of Works was the same list of actions in the JBA Fire Risk Assessment. But even if we were to accept Dr Asare’s estimate as to the costs of the works, we remained unpersuaded that the works were affordable. Dr Asare explained that he had a fund available to cover the works but we had no documents to support this. We asked what conversations the Appellants had had with those who advised the Appellants on matter of finance but we did not get an answer. Accordingly, we were not persuaded that the Appellants could complete the necessary works and given their history of non-compliance we were not persuaded that they would in any event. 7.73. Given we were not persuaded that risks identified in the JBA Fire Risk Assessment could or would be mitigated, if Albert Road was to be used then this would place patients at a substantial risk to life. As the premises at Albert Road put patients at a substantial risk to life they were not suitable for the purpose for which they were being used and so this was a breach of Regulation 15 of the 2014 Regulations. Issue Nine: Albert Road - Unsafe, inaccessible and unsuitable for clinical interventions 7.74. It was the Respondents case that: (a) The Albert Road surgery was potentially unsafe because the second-floor consultation room floor was bowing and bouncy to walk on. (b) The Albert Road surgery in a poor state of repair generally. (c) The lift at Albert Road was broken and had been for three to six months. (d) Exterior access paths, including a vehicle ramp and steps were in a poor state of repair and uneven under foot. 7.75. Dr Asare accepted in his evidence that some renovation works were required at Albert Road. He confirmed that the lift had now been fixed and was working. 7.76. We were not persuaded on the evidence available to us to make any findings as the safety or otherwise of the Albert Road premises other than those set out above regarding fire safety. The Respondent’s evidence was limited to five paragraphs in Michelle’s witness statement. Michelle did not exhibit any photographs or professional reports. The evidence failed to satisfy the civil standard of proof. Regulation 17: Good Governance Issue Ten: No established and effective systems in place to ensure safe care and treatment for people. 7.77. Regulation 17 of the 2014 Regulations provides that systems or processes must be established and operated effectively to ensure compliance with the requirements in Part 2 of the 2014 Regulations. 7.78. It was the Respondent’s case that the Appellants had no established and effective systems in place to ensure safe care and treatment for people. 7.79. At paragraphs 106 to 111 of her statement, Michelle set out the status of the work queues on the day of the inspection. Other than being given headline numbers as to the documents in the queues that were urgent, we were provided no further detail on the documents in the work queues. We were not shown any specific example of any item in the workflow being identified as urgent but not being actioned within 24 hours. We were not therefore persuaded that the matters raised by Michelle at paragraphs 106 to 111 of her statement demonstrate a risk of harm. 7.80. At paragraph 113 of her statement, Michelle states: “The salaried GPs were allocated ten items, any combination. Staff did not know if these were risk based. The partner Dr Asare was issued whatever other documents remained to review and action. This left significant quantities of work outstanding but shown allocated to Dr Asare. On 11 April in addition to providing clinics he had 230 documents to review (138 urgent), 499 clinical tasks (210 urgent), 208 laboratory results to review (129 urgent), 237 prescription enquiries (30 urgent) and potentially 60 prescriptions to sign from that day if not shared with the salaried GPs”. 7.81. Dr Asare deals with this at paragraph 109 of his statement. He states: “I have asked the caretaker to clear the items referred to from the work-flow queue and the caretaker agreed to email me to confirm that none of the 138 patients noted in the queue were at any risk of harm. Please see the email from the caretaker at Exhibit SA48”. 7.82. We considered the e-mail at SA48. We were not persuaded that it showed what was claimed by Dr Asare in his witness statement. In our judgment, it would be impossible for a single GP to undertake the volume of urgent work outlined by Michelle at paragraph 113 of her statement. We were therefore persuaded that this may have placed patients at risk of harm. The volume of work meant there was a real risk of urgent actions being delayed. 7.83. It was the Respondent’s case that the Appellants had no effective and established systems to ensure the accuracy of records. This is dealt with by Michelle at paragraphs 117 to 120 of her statement. 7.84. At paragraph 117 of his statement Dr Asare states: “We acknowledge that some patient records were inaccurate and we were seeking to hold Data Vitality to account, where they had not been meeting standards agreed with the Practice. I acknowledge that responsibility ultimately lies with the Practice but it was right for us to make contact with Data Vitality, which was done and a robust plan has been put in place, to ensure that standards are met”. 7.85. We were not however provided with any details as to what this plan with Data Vitality was. In the absence of this detail, we were not persuaded that there was any such plan. If patients records are not accurate then this may place those patients at a risk of harm. 7.86. It was the Respondent’s case that the Appellants had no established and effective systems in place to record and learn from significant events. This is dealt with by Michelle at paragraphs 125 and 126 of her statement. 7.87. Dr Asare does not deal with this in his witness statement. 7.88. As part of the Appellants’ late evidence, we were shown five significant event analysis documents. These documents relate to the significant events identified by Dr Syed as part of the inspection. 7.89. Dr Asare explained in his oral evidence that only himself and Mr Asante would be involved in any discussion regarding these significant events. We asked him why he did not involve the individuals who had been involved in the actual events and he explained that he did not need to because he was able to gather all the necessary information from the patient records. This was a concern to us, especially given what was stated at paragraph 208 of Michelle’s witness statement. That was: “The Appellants told us on 3 July 2025 that they had conducted significant event analysis into the care of the patients that we had highlighted to them as potentially at risk of harm. They told us they had discussed the incidents as partners, written up the incidents and were intending to discuss them with the wider clinical team when their CQC registration was reinstated and they were returned to the registered location. I checked an EMIS audit provided by Vita Healthcare of all clinical records the Appellants had accessed during their period of suspension (Exhibit MF/25). I found the Appellants had accessed only 2 of 6 patients clinical records, which they had told us they had completed significant event analysis of, in their correspondence submitted on 9 July 2025”. 7.90. Michelle’s evidence was corroborated by the records at MF25 and so we accepted her evidence. We did not therefore accept Dr Asare’s evidence. It therefore follows that Dr Asare was producing the significant event analysis documents without having properly gathered the relevant information relating to each event. 7.91. Furthermore, the Appellants offered no evidence to persuade us that they had established and effective systems in place to record and learn from significant events. The documents produced as late evidence related only to those matters which had been identified by the Respondent at the inspection. We were shown no evidence of the Appellants proactively pursuing their own significant event analysis on significant events they had identified themselves. We were not therefore satisfied that the Appellants had established and effective systems in place to record and learn from significant events. This may have placed patients at risk of harm. 7.92. Given the above, we were satisfied that the Appellants lacked established and effective systems to ensure safe care and treatment for people, which was a breach of Regulation 17 of the 2014 Regulations. This may have placed patients at a risk of harm. Regulation 18: Staffing Issue Eleven: Insufficient numbers of suitably qualified, competent, skilled and experienced clinical staff to provide safe care. 7.93. Regulation 18(1) provides that sufficient numbers of suitably qualified, competent, skilled and experienced persons must be deployed in order to meet the requirements of Part 2 of the 2014 Regulations. 7.94. It was the Respondent’s case that the Appellants employed insufficient numbers of suitably qualified, competent, skilled and experienced clinical staff to provide safe care. The Respondent pointed to the following factors as evidence of its position: (a) It was normal for GP practices to schedule a maximum of 16 appointments into a session to provide contingency for staff to seek clinical guidance or conduct additional investigations and referrals. This was regularly exceeded in the Appellants’ practice (paragraphs 132 to 139 of Michelle’s statement). (b) Patients were routinely contacted at unreasonable hours of the day (paragraphs 141 to 143 of Michelle’s statement). (c) The Appellants had vacancies within their staff team that may cause delays to people receiving appropriate care, and increase workloads for the remaining staff, resulting in backlogs of information requiring actioning. 7.95. The Appellants’ position was that under the caretaker provider staffing levels had remained pretty much unchanged and so the Respondent’s position was without foundation. 7.96. We were persuaded that the Appellants had insufficient numbers of suitably qualified, competent, skilled and experienced clinical staff to provide safe care. The most compelling evidence was the e-mail from the caretaker provider dated 19 September 2025. That e-mail showed the fragility of the situation at the practice. The overall position at the practice is summarised as follows: “GP cover is safe, with daily session totals consistently between 31–45 per week in September and October. Nursing and long-term condition capacity remain stretched, with high backlogs and reliance on remote/locum roles. Staff feedback highlights workload pressures, low morale, and lack of clear leadership. Recruitment of an interim practice manager and lead nurse are intended to address these gaps. The current model is safe but fragile and reliant on locum and remote provision”. 7.97. We noted that the Appellants had agreed to a recruitment strategy but only on a locum basis. Under the subheading “Recruitment”, it can be seen that: (a) The Appellants have “agreed to the recruitment of an interim practice manager locum (with a view to permanent) and an interim lead nurse (with a view to permanent)”. (b) There are adverts “currently out for clinical administration staff”. (c) “A paramedic who left a few months ago has been replaced on an interim basis (working 24 hours per week, equivalent to 0.64 FTE)”. 7.98. It was not in dispute that there has been a very high turnover of staff. Moral in the practice is very low. Given the Appellant’s focus on locum recruitment as opposed to maintaining a solid and stable workforce, we had no confidence that the overall staffing picture would improve or could be maintained in the long term. 7.99. What we take from this is that the current model is unworkable in the long term and patients may therefore be exposed to the risk of harm. We were persuaded that the Appellants were in breach of Regulation 18(1) of the 2014 Regulations. Issue Twelve: Staff were not appropriately supported or supervised. 7.100. Regulation 18(2)(a) provides that persons employed by the service provider in the provision of a regulated activity must receive such appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform. 7.101. It was the Respondent’s case that staff were not appropriately supported or supervised. 7.102. Michelle’s evidence was: (a) There were no records to show that Dr Maloney had been supervised. (b) There were no records to show Dr Chopra had been supervised. 7.103. Dr Asare does not address this in his witness statement. We were not provided with either Dr Maloney or Dr Chopra’s supervision records. Dr Asare did not explain in his oral evidence what system or process is or would be in place going forward to ensure that staff were supervised and appraised as is necessary to enable them to carry out the duties they are employed to perform. We did not have sight of any supervision or appraisal policy. 7.104. Given the lack of any evidence from Dr Asare, we accepted Michelle’s evidence. The Appellants were unable to show that either Dr Maloney or Dr Chopra’s had been supervised or appraised, and so we concluded that they had not been supervised or appraised. We were therefore satisfied that staff were not appropriately supervised or appraised which was a breach of Regulation 18(2)(a) of the 2014 Regulations. This may have placed patients at a risk of harm Regulation 19: Fit and proper persons employed Issue Thirteen: People employed had not been assessed as fit and proper. 7.105. Regulation 19 of the 2014 Regulations provides: (1) Persons employed for the purposes of carrying on a regulated activity must: a. be of good character, b. have the qualifications, competence, skills and experience which are necessary for the work to be performed by them, and c. be able by reason of their health, after reasonable adjustments are made, of properly performing tasks which are intrinsic to the work for which they are employed. (2) Recruitment procedures must be established and operated effectively to ensure that persons employed meet the conditions in: a. paragraph (1), or b. (b)in a case to which regulation 5 applies, paragraph (3) of that regulation. (3) The following information must be available in relation to each such person employed: a. the information specified in Schedule 3, and b. such other information as is required under any enactment to be kept by the registered person in relation to such persons employed. (4) Persons employed must be registered with the relevant professional body where such registration is required by, or under, any enactment in relation: a. the work that the person is to perform, or b. the title that the person takes or uses. (5) … 7.106. It was the Respondent’s case that the people employed had not been assessed as fit and proper. The Respondent relied on the evidence from Michelle, which was: (a) Dr Maloney had commenced their employment on 3 October 2005 but there was no references or equivalent satisfactory evidence in relation to their previous employment. They did not have a full employment history such as a CV on their file. There were no records/documents to show they had relevant qualifications other than their professional registration on the GMC website. They had no health questionnaire or information on their physical and/or mental health. They had no record of their immunisations. (b) Dr Chopra was employed as a GP locum. They started their employment with Sidley Medical Practice on 5 September 2023 and were providing eight sessions a week. The Practice had no record of his references or equivalent satisfactory evidence to show in relation to his previous employment. They had no health questionnaire or information on his physical and/or mental health. They had no record of his immunisations. 7.107. Dr Asare did not deal with this issue in his witness statement. In his oral evidence, he explained that the practice did maintain a log but that log was not a document that was in evidence before us. 7.108. In his submissions, Mr Butler maintained the position that because Dr Maloney and Dr Chopra were registered GPs that should have been enough for the Respondent. We reject those submissions. Regulation 19(4) requires that any persons employed must be registered with the relevant professional body but in addition to that Regulation 19(3) requires that the information specified in Schedule 3 must be available in relation to each such person employed. Schedule 3 specifies the following: (a) Proof of identity including a recent photograph. (b) A copy of a criminal (or enhance criminal) record certificate. (c) Satisfactory evidence of conduct in previous employment. (d) Satisfactory documentary evidence of any qualifications. (e) A full employment history, together with a satisfactory written explanation of any gaps in employment. (f) Satisfactory information about any physical or mental health conditions which are relevant to the person’s capability, after reasonable adjustments are made, to properly perform tasks which are intrinsic to their employment. 7.109. The Appellants were unable to demonstrate compliance with Schedule 3 as regards Dr Chopra and Dr Maloney and so were in breach and Regulation 19. 7.110. It was submitted by Mr Butler that as Dr Chopra was employed as a locum GP then the obligation to comply with Regulation 19 and Schedule 3 fell on the Primary Care Network that supplied him. We reject that submission. Miss Stevenston directed us to CQC Guidance - GP mythbuster 106: Staff not directly employed by a GP practice. In relation to employment that guidance states: “The meaning of 'employed' in the regulations is wider than staff employed on an employment contract. It means anyone who works for the provider, under their ongoing direction and control. Providers need to ensure that all the staff they manage have had the appropriate recruitment checks. This is irrespective of who holds the employment contract. A provider does not necessarily have to physically carry out or repeat all the recruitment processes. But they must reasonably assure themselves that it has been done. For example, someone provides services to a GP practice yet is directly employed by a local NHS trust, federation, Primary Care Network or Integrated Care Board (ICB). It would be essential for the practice to obtain assurances. This could be a: (a) letter of confirmation (b) memorandum of understanding (c) service level agreement from the trust”. (a) letter of confirmation (b) memorandum of understanding (c) service level agreement from the trust”. 7.111. In our judgment this guidance is entirely consistent with Regulation 19. Dr Asare provided us with no evidence other than his oral testimony that he had obtained any assurances as regards Dr Chopra. We therefore accept that people employed had not been assessed as fit and proper, which was a breach of Regulation 19. Whilst we accept that in respect of Dr Chopra and Dr Maloney there was no risk of harm, we were satisfied that the lack of recruitment checks may, in different circumstances, have placed patients at risk of harm. The very purpose of these checks is to safeguard patients and removing that safeguard may expose patients to a risk. Regulation 20: Duty of candour Issue Fourteen: Failure to be open and transparent with the Respondent 7.112. Regulation 20(1) of the 2014 Regulations provides that: “A health service body must act in an open and transparent way with relevant persons in relation to care and treatment provided to service users in carrying on a regulated activity”. 7.113. A “relevant person” is defined in the 2014 Regulations as being a service user (i.e. a patient) a person lawfully acting on their behalf (in certain circumstances). 7.114. It was the Respondent’s case (as set out in the Scott Schedule) that the Appellants had failed to be open and transparent with the Respondent and this had constituted a breach of Regulation 20. Miss Stevenson accepted in her closing submissions that Regulation 20 was concerned about the duty of candour as between a GP Practice and its patients, not the practice and the regulator. Accordingly, Miss Stevenson accepted that Regulation 20 had no application. We do not therefore consider it further. Application of the Legal Test 7.115. Having consider the facts, as set out above, we go on to apply those facts to the legal test. We remind ourselves that the test is whether we have reasonable cause to believe that unless enforcement action is taken, any person will or may be exposed to the risk of harm. 7.116. In his submissions, Mr Butler emphasised the fact that at the start of these proceedings the Respondent had identified over 30 patients who the Respondent claimed had been placed at risk of harm, but by time the GP experts submitted their join statement this was number was reduced to 11. It was reduced further by the end of the GP experts’ evidence and has been reduced further still by the decisions we have made. There in fact remain only patients 2, 3, 5, 6 and 21 who were placed at risk of harm. 7.117. We were told that the Practice has circa 14,000 patients. The fact that only five patients have been identified as being placed at a risk of harm is relevant but, on its own, not determinative. There is no obligation in the legislative test to identify any patient who has been placed at harm. We need only be persuaded that there is a reasonable cause to believe that absent enforcement action, patients will or may be exposed to the risk of harm. Depending on the facts of the situation, it could be reasonable to form such a belief in the absence of any evidence that any specific patient has been placed at risk of harm. We have therefore treated Mr Butler’s submissions on this point with some caution. 7.118. Without prejudice to the above paragraph, we were satisfied that (i) the Appellants were in breach of a condition of their registration (having failed to appoint a registered manager), and that (ii) the Appellants had breached Regulations 12, 13, 15, 17, 18 and 19. The breach of Regulation 12 had placed patients 2, 3, 5, 6 and 21 at a risk of harm. Further, for the detailed reasons explained earlier, we were persuaded that the Appellants’ wider regulatory breaches plus the breach of the conditions of their registration, gave us reasonable cause to believe that unless enforcement action is taken any person will or may be exposed to the risk of harm. 7.119. We therefore move on to consider what enforcement action is proportionate in all the circumstances of the case. Under section 32(5) of the 2008 Act, we have the power to confirm the Second NOD or direct that it is to cease to have effect. Under section 32(5) of the 2008 Act, we also have the power to direct that any such discretionary condition as the Tribunal thinks fit shall have effect in respect of the regulated activity or vary the period of any suspension. 7.120. We were not invited to consider a variation of the suspension period and so we do not consider it further. 7.121. The parties did not address us on the imposition of conditions, but we nevertheless considered whether conditions were appropriate in this case. The regulatory breaches that we have identified are multiple and wide ranging. This would make any combination of conditions difficult to enforce and potentially unworkable. Nor would they manage the risk of harm to patients. We were in any event provided with no potential conditions to consider. 7.122. Given the above, our only option was to confirm the Second Notice of Decision and extend the suspension to 15 October 2025. We were satisfied on all the evidence that unless the suspension remained in place, patients may be exposed to the risk of harm. Relevant to this decision are the following additional factors: (a) The regulatory breaches we have found in this decision are serious. Moreover, the Appellants have shown little appreciation for their seriousness. This is very clearly demonstrated by the remedial actions taken by the Appellants in the time between the inspection and the final hearing of this appeal. As is explained in detail above, those actions were either insufficient in themselves or we were provided with insufficient documentation to be persuaded as to their sufficiency. (b) Linked to the above was the role Mr Asante played in these proceedings or lack thereof. Mr Asante is a partner in the practice and a named appellant in these proceedings. Yet he engaged very little with the Respondent during the inspection and not at all during these proceedings. He chose not to give evidence to the Tribunal. It was not in dispute that Mr Asante had previously resigned from the partnership but later withdrew his resignation. We were not persuaded that Dr Asare and Mr Asante had a functional working relationship. In a partnership consisting of only two partners a functioning working relationship between the partners is essential. (c) The Appellants had a history of non-compliance as regards their regulatory obligations. This is shown not only by their non-compliance with the Warning Notices issued in July 2024, but also their non-compliance with the 2024 fire risk assessment from East Sussex Fire Service (see above). (d) The Respondent has now issued the Appellants with a notice of decision to cancel their registration. A suspension cannot continue indefinitely without an end point but this recent notice of decision provides such an end point. 7.123. For all these reasons we decided that there was reasonable cause to believe that unless the suspension is extended a person will or may be exposed to the risk of harm. We therefore decided to confirm the Second Notice of Decision.

[8]Decision 8.1. The Second Notice of Decision is confirmed. 8.2. The appeal is dismissed. 167. First-tier Tribunal (Health, Education and Social Care) Date Issued:14 October 2025