Claremont Bank 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 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 requires improvement. At this assessment, the rating has changed to good. The provider had made improvements in the following areas: risk management, reviewing and embedding structures, processes, and systems to support good governance and re-establishing a patient participation group (PPG).

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 practice had a shared vision, strategy and culture. The shared core values included quality, and equality in patient centred care, innovation in staff development, integrity, professionalism and compassion. Staff we spoke with demonstrated an understanding of the practice vision and strategy. The mission statement was displayed in the waiting area and included providing high quality, accessible services in a safe, professional, comfortable environment and ensuring patients were the centre of everything they did.

We gained staff feedback through a variety of means including interviews prior to and during our site visit. We also received 16 completed staff surveys. Feedback we received regarding the culture was very positive. Staff told us it was a friendly environment to work in, that the culture was open, transparent, blame free and non-discriminatory. Staff told us they enjoyed working at the practice and there was a strong focus on making sure patients received the best possible care, with all colleagues contributing to a culture where everyone felt valued and respected.

Leaders had developed a succession plan, signed and dated by all partners to ensure continuity, managerial and financial operations of the service. Some of the proposed timelines were discussed with us during our remote interviews and site visit. A Business Development Plan (BDP) for the period 2023-2028 had also been developed. The plan was detailed, included strategic goals and was tailored to meet the requirements of the practice population.

The practice 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 told us their managerial structure was defined as ‘flat hierarchal’, enabling the direct involvement of the team in the decision-making process, enhanced communications and rapid responses to business issues, but ultimately a collaborative working environment, promoting continuous improvement and innovative thinking.

The practice had an experienced workforce which had stabilised since the last inspection. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. Leaders told us they were currently reviewing their management processes, utilising their succession plan, and were looking to develop the job roles of the practice management team. The deputy practice manager had completed the ILM Level 5 in Leadership and Management in February 2025 to support her in her role. A new reception team leader post had also been developed since the last inspection.

Staff told us leaders were approachable and responded to any concerns raised. The practice worked with other practices in their primary care network (PCN) and were engaged with the primary care services within the local area.

The practice fostered a positive culture where people felt they could speak up and their voices would be heard.

The practice had established Freedom to Speak up (FTSU) arrangements in place. There was visual signage displayed of the practice FTSU Guardian and contact information in the reception and admin areas. In addition they had access to a designated FTSU for the member practices of the PCN. Staff were aware of how to raise concerns and felt confident these would be listened to and actioned. Leaders told us the arrangements they had in place helped to promote a transparent and supportive culture within the practice, where staff felt safe to raise concerns and confident that they would be listened to and supported.

The practice had systems and processes to promote diversity and equality in the workplace.Leaders worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Policies and procedures to promote diversity and equality were in place and staff had received training. There were procedures in place to ensure work was equitable across the team.

At the last inspection we found structures, processes, and systems to support good governance were in place but not fully embedded into practice. At this assessment we found improvements had been made. There had been a change in leadership of the practice following the appointment of a new practice manager, a new deputy practice manager, and a change in registered manager.

The practice now had clear responsibilities, roles, systems of accountability and good governance. Staff we spoke with who had lead roles were clear of their roles and responsibilities. The practice now had established governance processes that were appropriate for the service and were used to manage and deliver good quality, sustainable care, treatment and support.

Staff had access to a range of policies and procedures and knew how to locate them. A range of internal meetings were held with staff which provided opportunity for engagement and discussion around concerns, emerging risks, performance and outcomes. Meetings had a set agenda and were recorded and included actions. The GPs met daily over lunchtime to discuss any patient concerns. Staff took patient confidentiality and information security seriously.

Leaders supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Leaders met with staff regularly to complete appraisals and performance reviews.

The practice understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. A range of external meetings were held, including practice managers’ meetings, protected learning time (PLT) events and meetings with stakeholders such as the palliative care team, district nursing team and midwifery team. Leaders told us they had developed an excellent working relationship with the local Integrated Care Board (ICB) and were fully committed to working with them and participated in ICB meetings and groups.

The practice also worked in partnership with West Midlands Training Deanery. They were a host site for GP trainees and were involved in education and mentoring. The practice had links with a local community organisation offering homeless patient support and had met with the manager to discuss patient registration requirements to safeguard this population.

The practice was an active member of the Shrewsbury Primary Care Network (PCN), a group of 11 local GP practices working together to provide a wide range of services to support the health and wellbeing of 104,000 people across Shrewsbury and the surrounding area. The PCN offered extended opening hours offering improved access for patients, home visits and specialist clinics and other services. Leaders were aware of the constraints of the building with the limited space available for patients to see PCN staff at the practice, however patients could access staff within the other PCN practices. The practice manager and one of the GPs were Board members of the PCN and attended monthly meetings. Leaders told us the PCN were very supportive.

Since the last inspection the practice had re-established a patient participation group (PPG) to ensure patient voice influences decisions and promotes transparency. The PPG was supportive of the practice in driving improvements and met on a quarterly basis.A GP partner attended these meetings, which were recorded. The PPG representative told us the practice welcomed feedback and had made changes as a result of this including improvements in the waiting room and toilets to enhance accessibility and the installation of a handrail in the car park area to facilitate easier access for patients. They told us the new practice manager had introduced many changes and improvements and encouraged and promoted membership of the group, that represented the patient population. Information about the PPG was displayed in the waiting area.

The practice focused on continuous learning and improvement. Staff were given opportunities for attending team events, learning and career development. For example a new practice nurse had registered onto the fundamentals of practice nursing course commencing in September to develop essential clinical skills, which combines theoretical knowledge with practical application in a general practice setting. A staff member had been promoted to a new role of a reception team leader.

The practice had developed a quality improvement plan and used learning from significant events and complaints to continually improve the service they provided. The quality improvement plan was detailed, covered a wide range of areas and included both short-term and long-term actions with a colour coded system (red, amber, green) for status reporting.

The practice was an established training practice for GP trainees providing medical education. Systems were in place to support trainees during their placements.

Leaders told us they wanted to provide more in-house services to meet patient demand and expanding patient population however, the constraints of the building did not allow for this. Leaders were in discussions regarding a potential new development and shared the proposals with us. Staff told us a new building would enhance their working environment and provide opportunity for patients to access more services.

Leaders told us they were part of a pilot steering group for artificial intelligence (AI) to help improve staff efficiency and expand roles.