Dr Imran Gohar Also known as SYDENHAM HOUSE DOCTORS SURGERY

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

Governance arrangements were not fully embedded and documentation did not always provide clear evidence of oversight. Records relating to appraisals, training and performance management were inconsistent, and governance files were disorganised, making it difficult to maintain an up-to-date overview of risks. Leaders were aware of key issues and had acted upon them.

This service scored 71 (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 shared vision, strategy and culture. This was based on transparency, equity, equality, human rights, diversity, inclusion and engagement. Staff and leaders understood the challenges and the needs of people and their communities.

The practice’s ethos was “Curing with Care”. This was displayed on the website and was evident throughout the assessment, including in conversations with patients, feedback from people who used the service, interviews with staff and outcomes data.

The practice was proud to be a traditional, responsive GP practice embedded in the local community. Staff understood the unique characteristics of their patient population and the challenges patients faced. The service’s vision and strategy were not formally documented or regularly reviewed; however, this was proportionate to the size of the practice and the services provided. Staff were committed to serving their patients with kindness and respect, which reinforced the practice’s ethos.

The service was aware of local challenges affecting its population, including homelessness, drug and alcohol misuse and poor mental health. Services were accessible to all, and the practice was highly valued within the community. The provider delivered services with kindness, commitment and understanding, despite the challenges and risks it faced.

The team adapted services to meet the needs of the local population and ensure people were involved in their care. The provider worked alongside other practices and organisations within the locality to share resources. The lead GP had been elected as a Local Medical Committee representative, advocating on behalf of local GPs, and was involved in a pilot programme aimed at reducing Accident and Emergency admissions through collaborative working with local healthcare providers.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Whilst the practice continued to deliver high-quality, accessible and inclusive care to patients, governance systems were not yet fully embedded to support effective oversight in all areas. However, leaders acted on information relating to risk, performance and outcomes and shared relevant information securely with external stakeholders when appropriate.

Staff we spoke with were positive about their roles and felt confident raising concerns with leaders. They told us they met regularly as a team and received appraisals. However, this was not consistently evidenced within the documentation we reviewed. Systems to ensure staff were recruited and trained safely were not fully effective, and IT systems were not being used optimally to provide oversight of mandatory training. As a result, some gaps in training records were identified.

The practice demonstrated a good understanding of its population and had adapted services to meet local needs. It served a diverse population within an area of deprivation and staff showed a clear awareness of the challenges faced by patients. Performance data indicated that patients received good access services when required.

All staff we spoke with were clear about their individual roles and responsibilities. Leaders were visible, approachable and proactive in supporting staff, and regular meetings took place. However, documentary evidence of appraisals and performance reviews was not consistently available.

Staff had access to the policies and procedures required to undertake their roles. Communication within the practice was effective, supported by its relatively small size, which enabled information to be shared and cascaded quickly. However, many of these arrangements were informal and required stronger documentation and record-keeping to demonstrate assurance and effective governance.

Some governance records and folders were disorganised, which made it difficult to obtain an immediate and up-to-date overview of risks, staffing, patient feedback, complaints and resulting actions. This reduced the effectiveness of organisational oversight, although leaders were able to discuss relevant issues and actions being taken. The provider had identified the need for improved governance prior to our inspection, and was in the process of implementing new IT software and resources with a view to ensuring effective integration into the practice.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.