Manor Park Medical Practice

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment, we rated this key question as requires improvement because we identified a breach in regulation 17, good governance as there was a large amount of patient notes that were not summarised.At this assessment, improvements had been made and the rating has changed to good.

This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

Leaders described the vision and values and told us their aim was to ensure that colleagues see the practice not simply as a workplace, but as an extended family where teamwork, kindness, and mutual support are embedded into everyday practice. The culture at the practice was open, supportive and focused on learning and improvement. They promoted a positive, compassionate, listening culture that supported trust and understanding between staff and patients using the service. The practice strived to deliver high-quality patient care.

The practice had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They actively encouraged an open, honest, and transparent culture throughout the practice. Leaders told us that they placed great importance on the health, wellbeing and professional satisfaction of every staff member. Leaders wanted colleagues to feel respected, supported and appreciated. The practice had daily huddles with reception and administration teams, managers and the on-call GP to check in with how staff were feeling and address any concerns. A staff survey had been completed and findings showed that all 40 staff members that had completed the survey felt valued and were made to feel an important part of the practice. The staff feedback we received directly also reflected positive findings. Staff told us that it was an enjoyable place to work and leaders were approachable, supportive and always listened and took action.

The practice fostered a positive culture where people felt they could speak up and their voice would be heard. The practice had established Freedom to Speak up arrangements with another practice manager in the primary care network. The freedom to speak up policy was accessible to all staff, so staff knew how to raise concerns.

The practice valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. There were policies and procedures to promote equality and diversity. Staff could speak multiple languages. Most staff had completed their equality and diversity training. Leaders made reasonable adjustments to support staff to carry out their roles well. For example, desk equipment was modified and flexible working hours were available. The practice acknowledged they were multi-cultural and hosted religious events to celebrate Diwali and Eid to support staff beliefs.

During the previous inspection, we identified a breach in regulation 17 (good governance) due to the number of patient notes that were not summarised. During this assessment, leaders provided us with evidence that all summarising had been completed and was up to date. They had employed a summariser to ensure this task was completed in a timely manner.

The practice had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. There was visible and accessible clinical leadership across the organisation. A GP partner was based in the reception area to provide immediate, on-the-ground, clinical support. All clinical leads actively participated in daily multidisciplinary huddles to support operational oversight, risk identification, team communication, and coordinate decision-making across the practice. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

A combination of informal daily huddles and formal meetings were had on a regular basis. Clinical concerns and emerging risk were discussed, and meeting minutes were shared with staff. It was identified that some of the meeting minutes lacked detail and clarity, and actions were not always followed up during the next meeting. This was addressed with leaders, and they acknowledged this and assured us meeting minutes would include more detail going forwards.

Managers met with staff to complete annual appraisals. Performance reviews were also in place on a more regular basis when necessary. Staff could access all required policies and procedures.

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

A GP partner was passionate about health education and raising health awareness in the community. They delivered health promotion talks on common health issues in various community places. The GP partner regularly hosted Asian radio stations to discuss various health topics, informing the community of ways to benefit their health. Patients had expressed the positive impact this had on their health outcomes. For example, the cervical screening uptake increased following a talk on the radio about the importance of this testing.

The practice met with the patient participation group (PPG) regularly. The practice were trying to recruit more members to gain a better insight into patient experience. In September, the practice hosted a health fayre with the PPG. The fayre offered various health tests accompanied by advice leaflets and was attended by 1,025 patients. 982 blood glucose checks were completed, those with high readings were advised to contact the in-house pharmacist for further advice. 970 blood pressure checks were completed. 205 patients had high readings and were advised appropriately.

The practice worked well with other practices in the primary care network (PCN) to ensure patient care was optimum. For example, practices in the PCN could refer to Manor Park Medical Practice for Spirometry care, which greatly reduced referral waiting times.

The practice had a strong focus on continuous learning, innovation and improvement across the organisation. They consistently encouraged creative and forward‑thinking approaches to delivering equality of experience, improved outcomes and enhanced quality of life for people. Leaders actively contributed to safe, effective practice, fostering a culture where learning was embedded into everyday care.

Staff participated in quality improvement work and were proactive in being involved in projects and developing innovative ideas to benefit patients. For example, they introduced an online triage system in November 2025, which significantly reduced the number of inbound calls, and enabled patients to access services more efficiently without the need to call the practice. This new system enabled more time for staff to contact patients about their long-term condition management and reduced the phone call waiting time for patients calling the practice.

They were a training practice that supported the education and development of future healthcare professionals. They hosted medical students from university. Leaders told us they bought fresh perspectives, updated clinical knowledge, and recent hospital-based experience, which positively contributed to shared learning and continuous improvement across the wider practice team. They also hosted secondary school students to inspire and encourage future careers within healthcare. The practice employed a pharmacist technician to improve workflow efficiency and provide greater clinical support.