Thornton Heath Medical Practice

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 remains 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.
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 75 (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. The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges.
Staff feedback supported that the culture of the practice was friendly and supportive. The work atmosphere was nice, and people got along well.
 

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.
Staff feedback indicated that there was strong teamwork and great support amongst team members. They were happy working at the practice, and leaders were approachable and operated an open-door policy.
Leaders told us they encouraged team working across the practice and had established a “no-blame” approach. There was a learning culture that provided open and equal working relationship with colleagues.
 

The service fostered a positive culture where people felt they could
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, Staff knew who the Freedom to Speak up Guardian was. We saw the whistleblowing policy had been reviewed August 2025.
 

The service valued diversity in their workforce. They worked 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. We saw senior leaders had addressed concerns related to discrimination. Adjustments had been made to ensure all staff were valued. We reviewed staff training and found that all staff had completed their equality and diversity training.
Staff fed back that management had an open-door policy to discuss any concerns verbally for both staff and patients.
 

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate. However clinical searches did identify there were shortcomings with the management of some patients with long term conditions where the practice did not always act on the best information about risk, and outcomes. However, when this was raised the practice, they submitted an action plan and said they would review these patients.
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, 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 practice had weekly reception staff meetings and monthly clinical and practice meetings. Staff were aware of who different leads were for example, safeguarding, infection control, clinical governance leads.
 

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 service did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or 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, the practice told us they were working on recruiting more members and developing the the group.
 

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 people. They actively contribute to safe, effective practice and research.
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.