Our view of the service
Date of Assessment: 30 June 2025 to 1 July 2025. South Norwood Hill Medical Centre is a GP practice and delivers service to 6750 under a contract held with NHS England. The National General Practice Profiles states that the ethnic make up of the patient population is 43.76% White, 32.68% Black, 10.53% Asian, 8.89% Mixed and 4.14% Other. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 4th decile 4 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
We carried out this assessment to follow up on breaches found in our last inspection during November and December 2022, at which time the practice was rated at requires improvement for Safe, Effective, Responsive and Well-Led.
We saw evidence during this assessment that the provider had made improvements across all areas. It is now rated Good for delivering Safe, Effective, Responsive and Well-Led care. The rating of Good for Caring was not reviewed at this assessment and remains unchanged.
SAFE: The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe, although arrangements around medical emergencies could have been improved in relation to staff not having face to face training. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. There were enough staff with the right skills, qualifications, and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes.
EFFECTIVE: People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people took decisions in people’s best interests where they did not have capacity.
RESPONSIVE: People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care.
WELL-LED: 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.
Since the last inspection, the practice had made improvements and is no longer in breach of regulation 17 (Good Governance).
People’s experience of this service
People were positive about the quality of their care and treatment. Recent survey results, including from the National GP Patient Survey and the NHS Friends and Family Test, showed people were satisfied with services. There was an active patient participation group (PPG) who represented the views of people using the service. Representatives from the PPG described how managers made positive changes because of feedback, such as implementing a new phlebotomy service at the practice and increasing evening and weekend appointment availability.
We asked the practice to share details on the practice website of CQC Give Feedback on Care process. Give Feedback on Care allows patients to comment directly to CQC on the care they have received. We received 4 positive comments from patients via Give Feedback on Care forms. Patients’ comments included “my experience at the practice has been exceptional,” and “staff customer service is great.”