Shakespeare Road PMS

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

At our previous assessment we rated the practice as requires improvement for the well-led domain. We found that, the practice did not have clear and effective processes for managing risks, issues and performance, and did not always act on appropriate and accurate information. At this assessment we found that this had been improved and strengthened. This included having regular practice and clinical meetings, clear and robust infection prevention and control processes and a high mandatory training compliance.

We found that leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. They worked with and identified several different local services in the community that patients could be signposted to. There was a culture of continuous improvement with staff given time and resources to try new ideas.

This service scored 79 (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 and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff feedback we received was positive about the culture of the practice. Staff told us they felt involved and were able to contribute to the shared direction of the practice. We saw that there was a stable workforce in place and that staff turnover was low.

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.

Staff told us leaders in the practice were approachable and responded to any concerns raised. We saw that the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

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

The practice had established Freedom to Speak up arrangements with other practices in the primary care network. Staff were aware of how to raise concerns, and fed back to us that they would feel confident to do so if they needed to. Staff were also given training on freedom to speak up and whistleblowing.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff told us they felt supported, were treated equally, and were free from bullying and harassment.

Policies and procedures to promote diversity and equality were in place. We saw that staff had completed mandatory training on equality and diversity.

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 share this securely with others when appropriate.

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

The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

We found that the practice was at the heart of its local community. The service clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborate for improvement.

The practice had analysed the need of their patient population and as a result they produced a “Community Resources” book that was used to signpost patients to local services. These services were made up of bereavement, carers, cost of living, mental health, debt and money, dementia, domestic abuse, eating disorder, gambling, housing, health and fitness, drug and alcohol and free food services.

The practice had also identified that a high number of patients were non-English speaking. They were able to offer translators to patients when required, they also employed a number of staff who were multilingual and were able to assist patients by speaking in their own language. They also held a clinic every two weeks which was attended by a Slovak interpreter.

The provider worked with other practices within their primary care network (PCN) to offer extended access outside of normal opening times and provide flu and covid vaccination programmes. Patients could also be given appointments through an overflow service ran by the Primary Care Network (PCN). These included doctor and nurse appointments as well as physiotherapy and social prescribers.

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. They actively contribute to safe, effective practice and research.

The practice had a quality improvement plan in place to help drive improvements in services.All staff were encouraged to put forward and test out new ways of working.