Morden Hall Medical Centre

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

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

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.

In most cases the practice had clear responsibilities, however we did identify that safe and effective care was not always provided in line with best governance practices in some cases.

Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas.

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 and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of patients and their communities.

All staff had contributed to the development of the practice vision and strategy, which was kept under review. The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us leaders in the practice was approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

We saw a succession plan in place. Staff feedback there was strong teamwork and great support among team members. They were happy working at the practice, and leaders were approachable and operated an open-door policy. There were many long-standing staff members. Staff feedback they were given opportunities to develop and progress in different roles at the practice. They also feedback there was a good teamwork ethos, and they felt supported.

Leaders feedback a GP supervisor was available daily so junior staff could ask questions or discuss any patient concerns. Due to the open plan office leaders were always visible and could offer support.

The service fostered a positive culture where patients felt they could speak up and their voice would be heard.

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, and we saw examples where staff had used the arrangements in place to positive effect.

Leaders informed us staff had been advised who the Freedom to Speak up Guardian was. Staff confirmed they were aware of how to raise concerns and told us they felt confident to speak up internally and externally if the need arose.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for patients who work for them.

The service did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for patients who work for them.

Policies and procedures to promote diversity and equality were in place. We saw senior leaders had addressed concerns related to discrimination. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support disabled staff were in place.

We saw all staff (clinical and non-clinical) had completed equality and diversity training. Staff said they felt supported by management and worked as part of a team.

The service had clear responsibilities, roles, systems of accountability and good governance in most cases. However, we saw that safe and effective care was not provided in line with best governance practices in some cases.

In other areas, leaders and staff used governance processes to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

We saw the practice utilised a supervision schedule which clearly detailed which senior leaders were responsible for specific staff. All clinical staff had a nominated supervisor.

Staff were aware of the different lead areas each partner was responsible for and knew who they could go to if they had a concern.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for patients. They share information and learning with partners and collaborate for improvement.

The provider worked with other practices within their primary care network to offer extended access, and flu and covid vaccination programmes. Staff had made adjustments to improve coordination of their service with community healthcare services, including through recently established weekly meetings centred on the care of those at higher risk of hospital admission.

Although the practice had a PPG, they told us that work needed to be completed to develop the group and improve engagement. The practice informed they aimed to meet every 4 months.

The practice held monthly review meetings with the practice prescribing lead and the ICB medicines optimisation pharmacist.

Quarterly data reports were reviewed at the clinical governance meeting.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for patients. They actively contribute to safe, effective practice and research.

The practice had a quality improvement plan in place to help drive improvements in services This focussed on the appointment system. All staff were encouraged to put forward and test out new ways of working, and we saw examples of the nursing staff.

One of the partners participated in a project and did a presentation at the local community mosque in relation to chronic kidney disease CKD (a long-term condition where the kidneys do not work as well as they should). The practice had further presentations scheduled to talk at the mosque about diabetes and lifestyle changes to improve health outcomes.

The practice participated in the local Medicines Improvement Scheme as part of ongoing prescribing quality assurance and optimisation work. The scheme was supported by the Integrated Care Board (ICB) and focused on ensuring safe, effective, and cost-efficient prescribing in line with national guidance.

The practice also had in house training with the non-clinical team, where they were given the opportunity to develop in their roles, for example the practice manager had started out as a receptionist.