Morden Hall Medical Centre

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our last assessment, we rated this key question as Good. At this assessment, the rating remains the same, however there were some areas that the practice needed to improve.

We looked for evidence that staff involved patients in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed patients’ care and worked with other services to achieve this. The practice was not consistently following recommended guidance for patients prescribed specific medication, or for the management of specific conditions. For example, clinical searches were undertaken and out of 10 searches related to the prescribing of medication and the monitoring of long-term conditions there were 5 searches which showed there was a need for improvement.

Patients were involved in assessments of their needs in most cases. Staff reviewed assessments taking account of patients’ communication, personal and health needs.

Care was based on the latest evidence and good practice in most cases. Staff worked with all agencies involved in patients’ care for the best outcomes and smooth transitions when moving services. Staff made sure patients understood their care and treatment to enable them to give informed consent. Where patients didn’t have capacity, and staff took decisions about the patient’s care in their best interest, they involved those patients who were important to the patient in the decision.

This service scored 67 (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 made sure patients’ care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them. However, there were some patients whose care and treatment needs were not always fully met. For example, from our review of clinical records 1 search showed 2 out of 5 patients with multiple exacerbation of asthma did not have an adequate asthma review following the treatment for exacerbation. When we raised this with the practice, they explained that 1 patient had not turned up for their appointment, however they would try contacting them again and the other patient they would try and re-engage with them.

A search showed 1 patient was overdue a thyroid blood test and another patient did not have their magnesium level checked; however, the level of risk was low. When we raised this with the practice, they confirmed they would recall the patients.

Another search showed 7 patients hadn’t had a thyroid function test monitoring for 18 months, prescribers were issuing medication without adequate checking. When we raised this with the practice, they informed us 3 patients had already been provided with blood test forms and the other 4 patients would be recalled.

Another search showed 6 patients prescribed a medicine often used to treat symptoms of an overactive bladder had not had a blood pressure check completed in the last 12 months. When we raised this with the practice, they informed us the patients would be reviewed.

They had a dedicated admin staff member to call patients in for coordinated appointments such as foot checks, weight, and blood pressure checks which would be done during one visit by a nurse.

We looked at the records detailing 5 mental health reviews and care plans and 5 records of patients requiring blood monitoring and found no concerns.

Feedback from patients using the service was positive. Patients felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. Reception staff were aware of the needs of the local community. Reception staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present. Staff checked patients’ health, care, and wellbeing needs during health reviews. Clinical staff used templates when conducting care reviews to support the review of patients’ wider health and wellbeing. The provider had effective systems to identify patients with previously undiagnosed conditions. Staff could refer patients with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

One search showed 2 patients care reviews with diabetes were not within expected standard of monitoring. Once this was raised with the practice they told us these patients would be prioritised for a proactive review and would be discussed during their next multidisciplinary meeting.

For all of the concerns raised the practice submitted an action plan the next day after the clinical searches explaining how they would improve monitoring of patients in the future.

The service planned and delivered patients’ care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards. Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical records we saw demonstrated overall care was provided in line with current guidance.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical records we saw generally demonstrated care was provided in line with current guidance, however we did find that guidance was not always followed for example 1 search showed that 3 out of 5 patients reviewed with a long-term condition were not being monitored in line with what was expected this was a moderate concern. When we raised this with the practice, they informed us they would be following up these patients.

From a sample of 5 patients, we identified that all 5 patients who had been prescribed 2 or more courses of rescue steroids in the last 12 months that clinicians were not issuing a steroid card. Steroid cards alert healthcare professionals to the risk of a life-threatening adrenal crisis.

Partners told us they supported staff to attend training courses and regularly undertook audits of records and documentation.

The nurse told us they used BNF, NICE and a variety of websites, NHS Guidance, best practice, immunisation and infection control guidance to keep up to date with delivering evidence-based care and treatment.

The practice aimed to recall patients in the month of their date of birth so they could adequately monitor and follow up patients.

For all of the concerns raised the practice submitted an action plan the next day after the clinical searches explaining how they would improve delivering evidence-based care and treatment in the future.

The service worked well across teams and services to support patients. They made sure patients only needed to tell their story once by sharing their assessment of needs when patients moved between different services.

Staff had access to the information they needed to appropriately assess, plan, and deliver patients’ care, treatment, and support. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

The practice informed us they had weekly meetings, daily discussion and peer reviews.

They had one to one meetings with staff and undertook staff surveys. The practice had very low staff turnover. They were a training practice and told us more than 50% of doctors who trained there stayed with them once qualified.

The practice regularly participated in PCN meetings and had frailty meetings. They worked closely with Central London Community Healthcare NHS Trust (CLCH) and had monthly MDT meetings with the district nurse, age UK, social prescribers and social service. They had a designated bypass line that vulnerable patients could call.

The service supported patients to manage their health and wellbeing to maximise their independence, choice and control. The service supported patients to live healthier lives and where possible, reduce their future needs for care and support.

Staff focussed on identifying risks to patients’ health, including those in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity. For example, the GPs could offer weight management referral programmes. They had posters for smoking cessation and talking therapies. Staff could signpost and refer patients for local dietary management, looking at cholesterol management. Posters were available in reception for self-referral.

The practice has a social prescriber who attended the practice twice a week, and clinicians could do a referral, reception and care coordinators were aware of this. Anyone diagnosed with cancer would be referred to the social prescriber. The practice told us they try to educate patients on non-clinical matters.

The service routinely monitored patients’ care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of patients themselves.

The practice did not meet all national targets for screening and immunisations however were very close to achieving the targets for immunisations. From the clinical notes we reviewed, we found that patients who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.

We were informed the practice was using the national system so every week they were checking patients who were due and would contact them to book appointments and they would continuously review the list. Staff receptionist and a GP went and spoke at a local Mosque to talk about screening uptake in March 2025.

The practice was aware of the lower screening uptake they tried to engage with patients by speaking at women’s group, however the practice feedback this did not improve the uptake, but it educated patients and gave awareness. They also developed their website. They had a designated admin recall staff member who contacted patients weekly, they also put alerts on their system, and sent automatic messages to invite patients to come in.

The practice undertook a range of audits to identify and monitor patients at risk of developing a long-term condition, they also ran a number of searches and had a dedicated admin staff member who would follow up with patient engagement.

The practice had undertaken a range of audits including sodium-glucose cotransporter 2, which is a protein in the kidneys that reabsorbs glucose back into the bloodstream (SGLT2) inhibitor prescribing for both diabetic and non-diabetic patients. For diabetic patients the percentage increase in SGLT2 prescribing was from 26% in 2023 to 50% in 2025. For non-diabetic patients with CKD the percentage increase was from 0% to 11%. This demonstrated quality improvement.

The service told patients about their rights around consent and respected these when delivering person-centred care and treatment.

All staff had completed mental capacity and deprivation of liberties training.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. The GP told us that if there was doubt as to someone’s capacity, this was also recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.

We reviewed 3 (DNACPR) records and found decisions were appropriate and were made in line with relevant legislation.