Mayfield 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 the service was managed by a different provider and when we inspected the service, we rated this key question as good. This was the first assessment of the service under the new provider and the rating of this key question has remained the same.

However, due to the governance concerns identified by the assessment, the service was in breach of legal regulation related to good governance.

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 service had a clear vision and strategy for the future which included 4 priorities. These were to become a training practice, increase the boundary area of the service, introduce a joint injection service and increase engagement with the local Nepalese community. Leaders explained these had been chosen to meet the future needs of the population and how they would improve the service and outcomes for the benefit of people. Leaders were aware of the risks to delivering the strategy, including local factors, and had action plans to address these. Staff were aware of the service’s vision and strategy.

Staff we spoke with were focused on ensuring people from deprived communities, those with varying levels of education and understanding and those from the Nepalese community that were potentially at risk of health inequalities did not miss out on healthcare. Data had identified that people from the Nepalese community were particularly at risk of developing long-term illnesses and deteriorating and often did not access healthcare. This was the reason for including improving care and outcomes for this group of people in the service’s vision strategy and a Nepalese-speaking care coordinator had been recruited to support this vision by helping people to navigate the healthcare system and access care.

Equality and diversity were actively promoted within the service and all staff we spoke with confirmed the culture within the service celebrated and valued diversity.

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.

The service had experienced multiple changes in leadership due to a period without a practice manager and before this, several changes in the same role. The role of CQC Registered Manager had also changed several times. Both roles had been recruited to recently with a new practice manager joining in January 2026 and registered manager in December 2025.

Clinical leadership for the service was delivered by a lead GP who reported to the Head of Clinical Services and the Medical Director for the provider which had changed since our last inspection. We were told the service found this arrangement supportive and effective.

Staff told us they had always been able to approach leaders in the service about concerns. Since the new practice manager joined, they had noticed further positive improvement in how easy it was to speak with leaders and how they listened. Staff were optimistic about the future based on their experience so far. This was because there was an open door policy to approach the new management and they felt listened to. For example, we were told found a member of staff had raised concerns related to infection prevent and control processes and changes had promptly been made which led to improvement in the quality of cleaning.

Staff also told us leaders modelled the values of the service. We saw the leadership team worked with other services 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 service had clear Freedom to Speak Up arrangements for all staff and positively encouraged people who may be under-represented and less likely to speak up to do so. The policy also confirmed there was a zero tolerance approach to preventing a person from speaking up. Staff from many roles within the provider were Freedom to Speak Up Guardians (FTSU) and there were arrangements to signpost staff to raise concerns externally if needed.

Staff told us that although FTSU guardians existed they felt comfortable to approach any member of leadership with a concern and believed they would be listened to and appropriate action would be taken.

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 specifically promote diversity and equality were in place and all policies we reviewed had considered the impact of the policy on equality, diversity and people’s human rights.

Leaders acted to positively improve the culture of the workforce and to ensure all staff were valued. They also took steps to ensure staff were representative of the population it served. For example, staff in both clinical and non-clinical roles were representative of the local community.

Leaders told us how they considered whether staff required adjustments and support. Staff gave examples of adjustments made to their roles to support their individual needs, for example, caring responsibilities.

The service did not always have systems of accountability, oversight and good governance. The service had not always responded in a timely or appropriate manner to risk and performance concerns. However, roles and responsibilities of staff were clear and the service was quick to address issues identified.

The service did not always have effective oversight of performance and governance processes. Systems did not always manage or control risks affecting the delivery of care and treatment effectively. They had not always operated as effectively as the service had intended. For example, environmental risks to people and staff using the first floor of the premises had not been identified and fully considered. Governance processes to determine which items of emergency medical equipment should be stocked had not included a risk assessment to support decision making and control the risks with not stocking certain items. Oversight processes had not identified a gap in compliance regarding checks of the stock of emergency equipment.

Recruitment processes were not effective due to incomplete information in staff members’ records.

The system to ensure blank prescription stationery was managed safely had not operated as the service intended because it did not provide assurance that the service could account for stock held.

Systems and processes to manage the quality and safety of care for people prescribed high risk medicines and with long-term conditions had not always operated consistently or effectively. There also was not an embedded or effective system to manage patient safety alerts issued by the MHRA.

Whilst the provider was aware of some of the issues identified during the assessment and was taking steps to improve oversight, such as introducing a new software system to give leaders better oversight of compliance and performance, the service was in a phase of transition. Aspects of the new system were not yet being fully utilised and it was not yet fully embedded. For the concerns identified by the assessment, the provider acted immediately to mitigate the risks and provided evidence of action plans to fully address the issues following our onsite visit.

Leaders and managers supported staff, and all staff we spoke with were clear about their individual roles and responsibilities. Staff could access all required policies and procedures and took confidentiality and information security seriously. Meetings were held with staff, during which clinical, safeguarding, and operational matters were discussed. As well as the clinical meetings, the service held morning huddles for GPs to debrief, seek advice about any clinical cases they were involved with and discuss other immediate matters.

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

The service worked with other services within their primary care network (PCN) to offer extended access, and flu and covid vaccination programmes. Staff spoke passionately about how they championed for people using their service to ensure any risks of health inequalities were reduced.

Established arrangements, including meetings with community healthcare services such as the local hospice and the integrated care team existed. These allowed the staff to discuss the care of those at higher risk of hospital admission and needing support in the community.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged ways of delivering equality of experience, outcome and quality of life for people.

Examples of improvement and innovation activity included how the service had transitioned from hardcopy authorisation of PGDs and PSDs to an electronic system. The service had done this to aid data retention and ease of access to information, but also to ensure environmental benefits by not printing guidance unless required.

The service had introduced a new online request and triage system in response to people’s feedback about their experience when accessing the service. The system improved people’s experiences when booking appointments because once triaged by a clinician they could book an appointment at a time and with a clinician of their choice using the system.