The Shaftesbury 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.

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 service had a shared vision, strategy and culture. This was based on compassion, quality, integrity, collaboration, inclusivity, and innovation. Leaders we spoke with mentioned the practice wanted to work in partnership with the patients which was fundamental to their role.

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 fostered a positive culture where people felt they could speak up and their voice would be heard. Staff were aware of how to raise concerns as they had an internal freedom to speak up guardian; however, they did not know who to speak to external to the practice if needed, as the practice did not formally have an arrangement in place for this.

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 which included an equality and diversity policy.

The service did not always have clear systems of good governance. Managers held regular practice meetings with staff however during our on-site visit, we saw that this was not clearly recorded as to which actions arose from these meetings as well as which significant events were discussed. We were, however, presented with final versions of these minutes after the on-site visit which showed the significant events and the learning which arose from them.

Staff managed prescription stationery appropriately and securely. However, we found evidence of uncollected prescriptions which had not been disposed of after 6 months. The practice have demonstrated, after the on-site visit, a new prescription policy in place to improve the process that was seen. Medicines were stored securely and at appropriate temperatures, however we did find scope for improvements such as ensuring the maximum temperature alert for the fridge was in line with guidance. We found no appropriate risk assessments for emergency medicines that were not stored on-site; however, this was completed by the end of the on-site visit.

During our on-site visit, we found that there were gaps in training and recruitment files for some locum staff. We found that there were gaps in training files for some salaried staff. This was actioned after the on-site inspection, and we saw evidence that staff were now all up to date with their required training and recruitment files.

We found an example of a child not being contacted following a Did Not Attend (DNA) appointment for childhood immunisation. We also found patient notes not being correctly updated following DNA appointments for smear test appointments. The practice as a result of the inspection, created a Did Not Attend Policy as well as specific policies for Smears DNA and Child Immunisations DNA.

We found that the practice did not have a practice safeguarding register for vulnerable adults although they did have one for children. Some staff we spoke to, other than the safeguarding lead, did not fully understand safeguarding procedures.

The practice understood their duty to collaborate and work in partnership. They held regular meetings with community stakeholders to review service provision and identify areas for improvement. The practice was part of the Harrow Collaborative Primary Care Network (PCN), which collaboratively worked together to improve patient care and service delivery. The practice provided services to a local care home with 30 residents.

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. Over the last 12 months, the practice had undertaken various non-clinical audits and quality improvement activities which included patient access audits to assess appointment booking and availability. The practice worked with the local council, surgeries and the ICB to identify and address the needs of deprived families. An example of this was being part of a pilot with Optivita Early Years. The project aimed to target support for families with children under five to improve health and well-being in later years.