South Norwood Hill 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

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.

At our last assessment, we rated this key question as Requires Improvement. At this assessment, the rating has changed to Good.

This service scored 82 (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 people and their communities.

All staff had contributed to the development of the practice vision and strategy, which was kept under review. One member of staff said “there is a linear management structure” because management worked side by side with all staff including non-clinical staff feeling that all staff contributed to the development of the practice.

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 described leaders as “taking staff well-being very seriously.” They referred to managers as all having “open door policies” and they felt able to go to them for support at any time, without hesitation. 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.

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

The leaders told us that they acted with openness, honesty, and transparency with staff. One member of staff told us that the lead GP acted with “honesty and transparency.” The leaders told us they were committed to providing this environment for staff.

The practice had established Freedom to Speak up arrangements with other practices in the primary care network. They had an external Freedom to Speak up Guardian. Information on how to access them was on the internal Teamnet system. In addition to this staff were shown the whistleblowing policy and information relating to freedom to speak up during their induction.

Staff confirmed they were aware of how to raise concerns and told us they felt confident to speak up internally and externally if they need arose.

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

Policies and procedures to promote diversity and equality were in place. For example, the practice had a Bullying and Harassment policy and a Sexual Harassment Policy. They provided training to staff on LGBTQ+ and because of the training changes were made to make their workforce practices, including encouraging staff to amend their work email signature.

Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support staff with long-term conditions were in place.

At the previous inspection, the practice had governance processes and risk management systems that operated ineffectively. During this assessment we found that the practice had robust governance processes in place.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

There were clear lines of roles and responsibilities and all staff we spoke with and received feedback from were aware of their roles and the roles of others.

All staff we spoke with and received feedback from told us that the leaders and managers supported staff “very well.” Staff we spoke with were clear on their individual roles and responsibilities.

Managers met with staff regularly to complete appraisals and performance reviews. All staff files we reviewed had recent appraisals and we saw previous years appraisals indicating that they were completed with staff on an annual basis. Staff we spoke with confirmed that they had regular appraisals and referred to the process of support as “very supportive.”

The provider had established governance processes that were appropriate for their service. The practice manager demonstrated a good level of understanding and oversight of the operational running of the practice. If things occurred that could impact the service, they risk assessed appropriately. For example, they had a vacancy for a salaried GP for which they were having difficulty recruiting. This had been put on the practice risk register because they realised the impact it could have and wanted to ensure it was continually monitored.

They had systems and processes in place that allowed them to monitor premises and equipment checks efficiently. At the time of our inspection all equipment servicing and premises checks were up to date.

Staff could access all required policies and procedures via computers which were password protected with individual access.

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. We saw completed minutes of these meetings for the previous 12 months. Staff took patient confidentiality and information security seriously.

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

The provider worked with other practices within their primary care network (PCN) to offer extended access. They met monthly with lead partners and practice managers from the PCN. They used these meetings to share learning from shared clinical audits.

Staff had made adjustments to improve coordination of their service with community healthcare services, including through meetings centred on the care of those at higher risk of hospital admission.

The practice had an active patient participation group who they met with at least every 2-3 months, but sometimes more frequently if needed. Feedback from group members was positive. They told us they discussed things such as the development of the website, feedback from staff, and all feedback relating to negative experience from patients. One person from the group told us “if something goes wrong, they tell us about it,” indicating that the practice worked in partnership with patients to try and rectify if things needed improving.

The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome, and quality of life for people. For example, GP’s had specialisms in Ear, Nose and Throat (ENT) surgery and paediatrics. We saw examples where patients benefitted from these specialist skill and knowledge the GP’s had.

The practice provided many opportunities for staff to develop and learn. One person said they were “proactive, and supportive of staff development” another person stated, “opportunities are exceptional.”

The practice had a quality improvement plan in place to help drive improvements in services. The practice involved staff and the PPG in progressing the plan. For example, the practice sent the PPG the QOF survey, and they gave their opinion of increasing the practice extended hours by suggesting what the opening hours should be, and which location would be the most suitable for the local hub.

Both staff and patients gave example of improvements. For example, staff told us that patients repeated expressed difficulties in securing appointments and indicated that the booking process was not efficient. As a result, the practice reviewed their system which included allocating more staff to manage calls and appointments. This change improved patient access and reduced waiting times. All staff were encouraged to put forward and test out new ways of working, and we saw examples of the nursing staff.