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Review carried out on 17 July 2019

During an annual regulatory review

We reviewed the information available to us about Morden Hall Medical Centre on 17 July 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 5 November 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Morden Hall Medical Centre on 5 November 2015. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • The practice operated an open and transparent approach to safety and had effective systems in place for reporting and recording significant events.
  • Risks to patients were assessed and managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with kindness and compassion, their privacy and dignity was respected and they were involved in their care and decisions about their treatment.
  • Information about the services provided including how to complain was available and easy to understand.
  • Patient’s we spoke with had mixed experience of making an appointment with some finding it easy and others experiencing a wait. Urgent appointments were available the same day.
  • The practice had good facilities and was equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by the partners and management.
  • The practice sought feedback from patients and staff, which it acted on.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider should make improvement are:

  • Develop systems to monitor the use of prescription pads.

  • Ensure recruitment practice includes two written references being sought with gaps in employment explored.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection carried out on 15 May 2014

During a routine inspection

We carried out an announced inspection of the service on the 15th May 2014. We found that the service was caring, effective, responsive and well-led. There were some improvements required to be safe.

We found that many of the GPs and nurses at the practice had not yet attended the necessary child protection training. Therefore some members of staff may not have been appropriately identifying and responding to the signs of abuse. We also found that criminal record bureau (CRB) checks had not been undertaken for non-clinical staff. There may have been a risk to patients because the provider had not ensured that all staff were suitable to carry out their roles. The provider has been given compliance actions to improve this and we will continue to review these at a follow up inspection.

Many patients had made comments about the telephone systems and appointment booking system being poor. Although the practice had taken some actions to improve the systems the complaints still remained high. The provider told us they would review this in more detail and make further improvements. We will continue to review this at our future inspections.

The practice had suitable arrangements in place to report significant events and share learning to prevent further reoccurrences. There was a detailed business continuity plan in place that covered what to do in the event of a serious incident like a fire or flood at the premises that could have an impact on services being available. Clinical staff in the practice met with multi-disciplinary teams to discuss patient’s treatments and care where this was appropriate.

There was a clear management structure in place with lead areas of responsibilities for the partner GP’s. Staff felt encouraged and supported by the management team and they knew where to go if they needed to report any issues. The management team had a clear business strategy planned for 2014/15. Part of the plans was to improve the telephone and appointment systems and refurbish the waiting room.

There was a lead governance person who was employed full time and was responsible for producing regular reports to the partners about how services were performing against any benchmarks. We saw audits were carried out to ensure safety and quality of care.

The practice provided spacious rooms, wheelchair access and hand rails along the corridors for patient with mobility problems. There were translation services for patients that did not speak English. We were told that the practice had staff members that could speak Urdu, Hindi, Polish, German and Italian. The practices’ website provided information in over 60 international languages to help people understand the healthcare services provided.

Inspection carried out on 15 May 2014

During Reference: R6 not found