The Southall 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 in January 2015, we rated this key question as good. At this assessment in July 2026, the rating remains the same. However, we found some minor governance issues relating to the oversight of medicines, staff training, clinical oversight and appraisal.

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 people and their communities. The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges. For example, the practice had a young and new partner who had joined the management to ensure continuity of adequate governance and patient care and safety. The practice operated a no- blame culture and staff told us that there was good leadership and staff were supportive.

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.

The service fostered a positive culture where people felt they could speak up and their voices would be heard. The service had established Freedom to Speak up arrangements with the local primary care network. Staff were aware of how to raise concerns internally and externally. Staff knew that the leaders were open and could be approached with any of their concerns.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Policies and procedures to promote diversity and equality were in place. We saw an example of where reasonable adjustments was made for staff who needed them.

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 acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. Clinical leads deputised for each other and the administrative management also provided additional support to the team. Staff we spoke to were clear on their individual roles and responsibilities. However, we found 2 clinical staff members who had not completed the required yearly training. We also found that a member of the nursing team had not completed required training but was being supported to complete them as soon as possible. Leaders did not have complete oversight of all clinical and administrative tasks related to actions completed by the clinical pharmacists and health care assistants. The oversight of patient group directions (PGDs) and patient specific directions (PSDs) was not always efficient. A member of staff told us they had never had an appraisal. Staff told us they could access all required policies and procedures. Staff took patient confidentiality and information security seriously.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The service 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 and voluntary organisations. The service engaged with the patient population, including the patient participation group (PPG) to improve service delivery.

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 contributed to safe, effective practice and research. The service was proactive in improving the quality of the service received by the patient population through audits of systems and clinical audits. The practice operated a family practice ethos and the doctors at this location had been there for a long time and were aware of the needs of the patient population and how to improve the quality of care.