Updated 18 June 2026
Date of Assessment: Shadbolt Park House Surgery. Shadbolt Park House Surgery is a GP practice and delivers services to approximately 7,020 patients under a contract held with NHS England. According to the latest available data, the ethnic make-up of the practice area is approximately 74% White, 16% Asian, 4% Mixed, 1.5% Black and 4.5% Other. Information published by the Office for Health Improvement and Disparities shows deprivation within the practice population group is in the 10 decile (10 of 10). The lower the decile, the more deprived the practice population is relative to others.
This was a focused assessment. We undertook this assessment due to the length of time since our last assessment. We assessed 10 quality statements from across all 5 key questions. This assessment considered the demographics of the patients using the practice, the context the practice was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
Staff kept the premises clean and took appropriate steps to prevent and control the spread of infection. However, systems for monitoring infection prevention and control were not always effective. For example, the infection prevention and control (IPC) audit contained inaccurate information and recorded that staff had completed mandatory IPC training when practice records showed this had not been completed. Leaders did not have effective oversight of staff immunisation status.
Staff supported patients to live healthier lives, monitoring their care and treatment to ensure they received positive and consistent outcomes.
Staff treated patients with kindness, empathy and compassion, and respected their privacy and dignity.
Patients could access care, treatment and support when they needed it. Leaders and staff were alert to discrimination and inequality that could disadvantage groups of people who used the practice and sought ways to address any barriers.
The practice had a clear vision and staff reported positive working relationships and good teamwork. However, governance and oversight systems were not operating effectively. Leaders had not ensured that risks were consistently identified, monitored and managed, with gaps identified in health and safety risk assessment and oversight, infection prevention and control arrangements, mandatory training, staff immunisation records, recruitment records and appraisal processes. As a result, leaders could not demonstrate effective oversight of risk, performance and compliance.
We found a breach of Regulation 17 Good Governance. We have asked the provider for an action plan in response to the concerns found at this assessment. We plan to carry out a full comprehensive assessment within the next 12 months.