The Shrubberies 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 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 remains the same.

This service scored 75 (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 service had a clear vision, values and strategy focused on patient-centred care, safety, equality, staff wellbeing and continuous improvement. Strategic priorities were monitored through governance, clinical and performance meetings, and the practice's core values were displayed in reception and waiting areas. Leaders understood the needs of their local population and worked with the Primary Care Network, Integrated Care Board and Patient Participation Group to support service development and address local health inequalities. Following review of the 2025 National GP Patient Survey, leaders developed an action plan covering five improvement areas, including digital access, communication, appointment flexibility, mental wellbeing support and long-term condition management. Leaders promoted a culture of openness and engagement. Staff survey feedback had been used to improve communication, well-being, training and team culture. During our assessment, staff spoke positively about leadership and described supportive working relationships. Patient feedback also recognised improvements in the attitude, kindness and consistency of reception staff. The service promoted equality, diversity and inclusion through its governance arrangements. An equality impact assessment had been completed covering all nine protected characteristics, and staff were undertaking Oliver McGowan training to support inclusive care for patients with learning disabilities and autism.

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 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.

The service had clear governance arrangements with named leads across clinical, operational and compliance functions. We were made aware of significant operational challenges that began in 2025, including an extended absence of a senior clinical leader and the departure of the practice manager without a full handover. Despite this, clinical services were maintained, and governance systems remained in place. The service used a governance risk register, business continuity plan, clinical audits, complaints reviews and performance monitoring to identify and manage risks. During 2025–26, 18 audits were completed or in progress, with action plans and re-audit dates in place. Staff could access all required policies and procedures, which were kept up to date and reflected the latest guidance. Leaders held meetings with staff, during which they discussed emerging risks and potential improvements to the service. The service had systems to support learning and improvement, including complaint monitoring, safeguarding oversight and patient survey action plans.

However, some governance records required strengthening. Clinical governance meeting minutes for the preceding three months were not available, appraisal records were not consistently evidenced, and the mandatory training matrix did not accurately reflect completed training. Overall, governance systems were established and functioning, and leaders used available information to monitor risk, performance and service quality.

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.