Morden Hall Medical Centre

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At our last assessment, we rated this key question as Good. At this assessment, the rating remains the same.

The service had a good learning culture and patients could raise concerns. Managers investigated incidents thoroughly. Patients were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of patients, were clean and well-maintained and any risks mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved patients in planning any changes.

This service scored 66 (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 proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The practice had a significant event policy reviewed in June 2025, the practice showed us they used root cause analysis (RCA) to review and analyse significant events. All staff including non-clinical were made aware of significant events. Staff told us they could raise concerns and report when things went wrong. Staff told us that incidents were discussed during team meetings, and the learning outcomes were shared with staff.

Patients felt supported to raise concerns and felt staff treated them with compassion and understanding.

Managers encouraged staff to raise concerns when things went wrong. The practice held monthly meetings, of which we saw set agendas. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave patients support. Learning from incidents and complaints resulted in changes that improved care for others. Non-clinical staff told us they had weekly meetings where they discussed learning, and any issues could be raised. They fed back that senior leaders listened to staff and they had open discussions where they could feedback.

Clinical staff had peer to peer support, they often went through patient cases, they told us they were given adequate protected learning time.

The service worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when patients moved between different services. For example, the practice explained how they advocated for the safe transfer and transition for young adults, 17-18 with attention deficit hyperactivity disorder (ADHD).

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were generally managed in a timely way. For example, referrals were actioned by GPs, who would then send to care coordinators, and a final check would be done by the practice manager for safety netting. Care coordinators were responsible for chasing referrals and following up any rejections. However, we did identify 1 referral that was urgent that had not been processed.

The practice checked results daily, if GPs were away they operated a buddy system, so results were not missed.

On the day of the remote records review, we found 250 incomplete overdue tasks which had not been actioned, some dating back to February 2024. We reviewed a sample of 2 which involved minor surgery requests. We also found 2 prescriptions that had not been processed within the practice policy of 48 hours. We raised this with the practice, and they explained the 2 unprocessed prescriptions were raised by a trainee and should have been highlighted as outstanding tasks. The task in relation to minor surgery were not processed as the practice had paused minor surgery for the year. The practice informed us the respective trainers had been informed, and supervision arrangements had been reinforced. The other remaining task would be investigated and actioned.

The service worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving patients’ lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable patients and acted on concerns working in partnership with other organisations.

There was a separate safeguarding policy for adults and children which had been reviewed in June 2025.

The practice informed us they safeguarding meetings every 6 weeks where they spoke with a health visitor.

All staff we spoke with demonstrated a comprehensive knowledge of safeguarding. All clinical staff had completed level 3 safeguard training and non-clinical had completed level 2. We were told that 75% of staff had completed domestic abuse training Identification and Referral to Improve Safety (IRIS) at the time of the inspection.
The practice maintained separate lists for vulnerable adults and children. The lists were comprehensive and demonstrated good oversight of the management of safeguarding in the practice. We saw documented evidence of partnership working with other organisations for patients on these lists.

Information about how to escalate concerns to the local authority were available in the reception area. Staff described concerns they had dealt with, and how this was escalated to safeguard leads and discussed in practice meetings.

Data from the GP Patient survey 2024 showed a total of 95% of respondents were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment. This was above the local average of 92% and national average of 91%.

The service worked with patients to understand and manage risks by thinking holistically. They provided care to meet patients’ needs that was safe, supportive and enabled patients to do the things that mattered to them.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. Overall patients were advised on risks related to their condition and actions to take if their condition deteriorated. We saw sepsis signs displayed around the waiting room and staff we spoke to were able to explain what they would do if they encountered a deteriorating patient. All staff had completed sepsis awareness training.

The practice tried its best to offer continuity of care and gave the example of when a patient rings and is not feeling well, receptionist try to book the patient in with the same GP they had seen previously. Reception staff were also trained on using a traffic light system, so they knew how to prioritise patients in terms of urgency.

Clinical searches identified that patients were not always involved in managing risks in line with evidence-based guidance. One search we looked at a sample of 5 records and found 4 out of 5 patients sampled with previously raised HbA1c (a measurement of too much sugar in your blood) not on the diabetes register and not receiving care. Once this concern was raised the practice informed us all relevant patients were followed up under a structured recall and review system. The practice informed us that they had previously carried out a potential missed diagnosis of diabetes audit prior to the inspection.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed.

The practice manager had oversight of contracts and maintenance for the building and equipment. We saw examples of alerts which showed when a renewal was due, or when equipment was due to be checked for example portable appliance testing of electrical equipment.

Fire alarm tests were carried out weekly; fire extinguisher check was carried out annually. The practice had 6 fire wardens, all of whom had completed fire warden training.

A health and safety risk assessment had been undertaken in May 2025, there were a few actions, all had been addressed.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met patients’ individual needs.

There were a range of clinical and non-clinical roles within the practice. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Safe recruitment practices were followed.

We reviewed 5 staff records, which were mostly complete, and all files contained the necessary recruitment checks. This included, references, proof of identity and Disclosure and Barring Service (DBS), which were renewed every 3 years as per practice policy. However, we did find 2 staff contracts were signed by the practice but not signed by the employee. All staff (clinical and non-clinical) were up to date with role specific training. Non-medical prescribers informed us they had regular supervision from lead GPs, where prescribing history was checked and was discussed at length during appraisals. Annual audits on prescribing were undertaken as part of clinical supervision.

The practice informed us they worked with the information commissioning board (ICB) and had access to the Southwest London training hub, which gave staff access to a range of training courses.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

An external infection control audit was completed in August 2025 from which there were no outstanding actions. The facilities and premises were clean, and systems were in place to prevent the spread of infection. Personal protective equipment (PPE) was well stocked and placed appropriately throughout the building.

We saw 2 clinical rooms privacy curtains had not been changed since May 2024; however, the curtains appeared to be clean.

Hand hygiene training had been completed in September 2025, a hand wash audit was done every 6 months, with the last one completed in June 2025.

The practice kept a list of staff vaccines; however, this was not fully complete, the practice was aware and informed us they were working on updating this.

The service generally made sure that medicines and treatments were safe and met patients’ needs, capacities and preferences. Overall they involved patients in planning, including when changes happened.

Clinical searches were undertaken and out of 10 searches related to medications and long-term conditions there were 5 areas identified which needed improvement.

Overall staff involved patients in reviews of their medicines and helped them understand how to manage their medicines safely. Patients knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely. Staff followed protocols to ensure they prescribed all medicines safely, and ensured patients received all recommended medicines reviews and monitoring.

Medicines including controlled drugs were stored securely and at appropriate temperatures.

We sampled a range of Patient Group Directions (PGDs) and found 3 were not dated by an authoring manager but had signature. When we raised this with the practice, they explained this was an admin error. PGDs allow some registered health professionals to supply and/or administer specified medicines to a pre-defined group of patients, without them having to see a prescriber.

Daily records of the maximum and minimum temperatures were recorded. Staff were aware of what to do if any fridge had temperature readings outside of the required range. All fridges were lockable to ensure only authorised staff could access them.

Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Waste medicines were recorded and disposed of appropriately including medicines returned by patients.

Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. The provider generally had effective systems to manage and respond to safety alerts and medicine recalls, however, we found historic Medicines and Healthcare products Regulatory Agency (MHRA) alerts (safety communications issued to healthcare providers about potential risks with medicines and medical devices had not always been actioned. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was lower than local and national averages. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

Staff followed established processes to ensure patients prescribed medicines with specific risks received recommended monitoring. For example, we reviewed 5 patient records who were prescribed disease-modifying anti-rheumatic drugs (DMARD) which require regular blood monitoring, and we found no concerns. The practice used a range of electronic systems to track and monitor patients, alerts were flag on their system if a blood test needed to be done.