Mitcham Family 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. At this assessment, the rating remains the same.

The service was in breach of legal regulations in relation to good governance. There had been repeated breaches of regulation since the provider was first inspected in 2015. The practice had not established effective systems to consistently mitigate risks. There was limited collaboration between partners on events that affected the practice, such as significant events and complaints.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a vision of the care it wished to deliver. Staff understood the challenges and the needs of people and their communities.

Staff told us leaders in the practice were approachable and responded to any concerns raised.

Staff told us leaders in the practice were approachable and responded to any concerns raised.
However, as in previous inspections, we saw evidence of a culture where leaders did not work as a team and where differing views relating to ways of working were not handled effectively between the leaders, leading to open disputes in meetings which were not resolved. Staff told us that this represented an open culture and this did not significantly impact on morale or ability to complete tasks.

The practice had established Freedom to Speak up arrangements with other practices in the primary care network. Staff were aware of how to raise concerns.

The service valued diversity in their workforce. Adjustments were made to support disabled staff where needed.

The practice had not established effective systems to consistently mitigate risks, including risks related to recruitment, staffing and prescribing.

Systems and processes did not ensure that clinical care was of a consistently high standard.

As part of the assessment, we were sent examples of minutes of clinical meetings, practice meetings and patient participation group meetings. Most of the meeting minutes we reviewed did not have actions agreed in the meeting clearly identified and there was no consistent, documented, follow-up of actions previously agreed.Not all clinical staff were invited to clinical meetings or received the minutes.

Managers met with staff regularly to complete appraisals and performance reviews. Staff could access policies and procedures. Staff took patient confidentiality and information security seriously. Practice leaders were engaged with other practices in the area to develop primary care services.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people.

The provider worked with other practices within their primary care network to offer extended access, and flu and covid vaccination programmes.

In 2021 we found that there were disagreements between the partners about incidents that were identified and discussed, and that there was limited collaboration between partners on events that affected the practice, such as significant events and complaints. We found the same at this assessment.

There were areas where improvements had been made. Individual staff were involved in audit and research, and we heard about examples of whole-team working to improve care.