Shoreditch Park Surgery

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 the service’s leadership, management and governance assured high-quality, person-centred care and promoted an open and fair culture. At our last assessment, we rated this key question as Good. At this assessment, the rating changed to Requires Improvement.

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 transparency, equity, equality, human rights, diversity, inclusion and engagement. Staff and leaders understood the challenges and the needs of people and their communities.

The practice had a clear shared vision of providing equitable, compassionate care and maintaining continuity with a regular clinician.

Leaders and staff described an open, non-hierarchical culture where staff felt able to raise concerns, suggest improvements and access development opportunities. The practice manager told us the practice has an informal, open-door approach to staff feedback.

Priorities and progress were reviewed through weekly clinical and partners’ meetings and annual partner and whole-team away days.

Patient and staff feedback, significant events, local population needs and engagement with Primary Care Network and Integrated Care Board partners informed service planning.

Equality and diversity were promoted through training and inclusive working practices.

Leaders had identified strategic risks, including succession planning, and were recruiting clinicians who supported the practice’s values and model of care.

Staff described an open culture in which they felt comfortable raising any concerns directly with leaders, and the practice manager told us the practice operated an informal, open-door approach to staff feedback.

However, staff told us regular whole-team meetings were difficult to maintain.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service did not have effective systems of accountability and governance. Leaders did not always act on the best available information about risk, performance and outcomes.

Staff understood their individual roles and described leaders as approachable. However, oversight of key workforce and organisational risks was not always effective.

The provider's own systems had not identified gaps in staff recruitment records, detailed in the Safe and effective staffing quality statement, and there was no formal recruitment policy or documented assurance of pre-employment checks completed for agency and Primary Care Network staff.

Staff training was managed reactively and role-specific training requirements and renewal frequencies had not been fully defined. One GP partner's fire safety training had lapsed since September 2016 due to a platform configuration error, corrected once identified, and the practice manager was unable to confirm which mandatory training courses individual staff members were enrolled in.

Appraisal and supervision were not consistently completed or recorded for nursing and administrative staff.

The practice did not have an effective system to monitor policy reviews, or actions arising from audits, risk assessments and external reviews.

Records did not consistently identify responsible leads, completion dates or whether completed actions had reduced the identified risks and an accessibility audit completed in June 2026 had no action plan at the time of our assessment.

The frequency of portable appliance testing was not supported by a documented risk assessment, and the business continuity plan was reviewed reactively, following incidents or organisational changes, rather than on a scheduled cycle.

The practice began addressing some of these shortfalls during and after the assessment. However, the provider's systems had not identified the extent of the concerns and did not provide assurance that risks were consistently assessed, monitored and mitigated. The practice had failed to establish and operate effective systems and processes to assess, monitor and mitigate risks relating to the health, safety and welfare of people using the service and others who may be at risk. This was a breach of Regulation 17(2)(b) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.