Hatch End 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 Good. At this assessment, the rating has changed to requires improvement.

At this assessment we found the service in breach of legal regulation in relation to Regulation 17 – Good governance.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The Practice was committed to working together to provide patients’ the highest quality of accessible personalised care. This was by listening to the needs and views of their patients’ and to treat them as individuals with the respect and dignity and to always act with integrity and respect. The practice values were to treat their patients with dignity, respect and compassion ensuring patients’ needs were prioritised.

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. All staff we spoke with told us leaders in the service was approachable and responded to any concerns raised.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. All staff we spoke with were aware of how to raise concerns internally and externally. During our site visit, we saw posters for Freedom to Speak up on sign boards.

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. Adjustments had been made to ensure all staff were valued. Staff we spoke with told us that staff were given equal opportunity. They told us that management was supportive and had open door policy. Staff also told us that the practice always promoted equality and diversity.

The service had responsibilities, roles, and systems of accountability. They used these to manage and deliver good quality, sustainable care, treatment and support. 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.

However, we did find some areas of governance needed improving. The systems in place to identify gaps in staff recruitment and training were not effective. The systems in place to ensure patients on specific high-risk medicines were monitored appropriately was not failsafe. The systems in place to identify potential missed diagnosis of diabetes was not effective. Medicine reviews were not always comprehensive in terms of what was documented in the patient record.

Following our inspection, the service provided evidence that they were following up all of the shortfalls identified.

The service understood their duty to collaborate and work in partnership. They shared information and learning with partners and collaborate for improvement. The practice held bi-monthly meetings with Sphere Primary Care Network (PCN).

The service focused on continuous learning, innovation and improvement across the organisation. We saw an example of an audit focusing on incoming calls during Bank Holidays with learning identified and actions put into place.

To support patients and their families, the service had a dedicated Carers’ Corner within the waiting room. This was an ongoing awareness tool, promoting services to patients to access information. Some of this information included: local and national support services, advice for young carers and guidance on financial and wellbeing support.