Shakespeare Road Medical Centre

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive - We looked for evidence that the service met people’s needs through good organisation and delivery.

This is the first inspection for this service since its registration with CQC. This key question has been rated as Good.

People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood their options.

We have not awarded this service a score for Responsive.

Find out about when we will not publish a key question score and what we look at when we assess Responsive.

The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs. Care plans reflected physical, mental, emotional, and social needs of people including those related to protected characteristics under the Equality Act. Our review of clinical records demonstrated people were supported to understand their condition and were involved in planning for their care needs and in decisions about their care.

The service had an exceptional understanding of the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity. The service had tailored its provision to meet the diverse needs of its community, for example, building relationships with community groups to promote the uptake of screening programmes. For example, people were signposted to initiatives such as diabetes prevention scheme, sleep-based therapies and mental health self-referrals.

The service ensured longer appointments were available for those with additional needs. The service took proactive steps to identify and remove barriers so that people could access care and support when they found it difficult to use services. For example, the service ensured people who were recognised as a military veteran were invited to annual reviews, as part of their recognised accreditation. The service provided staff with additional training to understand military service-related health needs, including referrals, and prioritising access for related conditions, such as mental-health support.

The service identified demographics of the local area who had registered. As a result, the service facilitated community engagement events which commenced from February 2024 in collaboration with ActionHampshire to improve communication barriers for Nepalese community members. Over 80 people attended these sessions, demonstrating the effectiveness of outreach efforts. The project aimed to disseminate service provision information and encourage participation through translator and interpreter services. For example, cancer screening awareness information was provided to ensure people were aware of how to access services and the importance of prioritising their health and wellbeing. Educational information produced by medical professionals was provided as a result of these sessions and this was made available on the service website.

The service supplied appropriate, accurate and up-to-date information tailored to individual needs.

The service made reasonable adjustments to meet individual needs in line with the Accessible Information Standard. People were given clear and accessible information about their care and treatment. The service used multiple formats, including large print, braille, and translated materials, to meet diverse needs. Staff supported people to use digital tools such as the NHS App, while care navigators assisted those at risk of digital exclusion by triage request forms on their behalf. People were informed as to how to access their care records. There were arrangements to ensure confidentiality at the reception desk and a separate telephone hub operated by an administrative team to prevent sensitive information being inappropriately shared or overheard.

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result The service identified themes from a review of complaints and learning was shared with staff. The service actively sought feedback through the Friends and Family Test, online surveys, and via the GP National Patient Survey. Feedback was reviewed at governance meetings, and learning was shared with staff. Examples showed that changes had been made following patient input, such as improving telephone access and developing patient education initiatives. During our assessment, we reviewed a sample of complaints and noted these were investigated and responded to appropriately in line with service policy. Where appropriate, people were provided with an apology and signposted to the Parliamentary and Health Service Ombudsman.

The service was exceptional at ensuring people could access the care, support and treatment they needed when they needed it. National GPPS data showed higher than average positive results for accessing the service. Feedback from people collected by the service was also positive in relation to accessing services which suited their needs. For example, online, in person, by telephone and could also submit medical or admin requests online via the practice website. The service offered extended access arrangements outside of normal working hours in collaboration with North Hampshire Urgent Care (NHUC), on Saturday mornings and weekday evenings. The service carried out a 2-cycle audit in relation to extended access arrangements and the quality of consultations delivered through NHUC. The initial audit in May 2025 reviewed 75 people and identified 31% of consultations required further quality review. However, following targeted feedback with clinicians, this improved significantly to 16% of 75 consultations in the reaudit in August 2025. The service assisted in providing quality improvements to ensure collaborative partnership working for people to access services outside of normal working hours.

We saw evidence of audits completed in relation to access performance, such as appointment capacity and demand data, appointment waiting times and ‘Did Not Attend’ (DNA) rates to assess performance. The service had also reviewed audits of telephone access data which included the total number of inbound calls daily; queue waiting times and call abandonments. This also helped provide oversight to rota management and staffing arrangements to meet access demand. The service made changes to the administrative telephone staff rotas and staff support during busy periods of the day and during different days of the week through identifying trends.

Staff and leaders were innovative in how they listened to information about people who are most likely to experience inequality in experience or outcomes. Staff and leaders actively used this information to provide exceptionally tailored care, support and treatment in response to this.

Feedback provided by people using the service, via feedback surveys as well as to CQC through ‘give feedback on care’, was overall positive. For example, we saw feedback themes which highlighted people were well informed and involved in decisions about their care and staff treated people equally, without discrimination.

Leaders proactively sought ways to address any barriers to improving people’s experience and worked with local organisations, including within the voluntary sector, to address any local health inequalities. Staff understood the importance of providing an inclusive approach to care and made adjustments to support equity in people’s experience and outcomes. Staff used appropriate systems to capture and review feedback from people using the service, including those who did not speak English or have access to online services.

We received feedback from Patient Participation Group (PPG) members who told us there were ongoing efforts to assist with a project to ensure information for people on the service’s website was consistent and accessible. As a result of PPG engagement, there was an action plan in place to implement regular social media information on service updates and local initiatives accessible to the local community.

The service was part of the Safe Surgeries programme, led by the charity Doctors of the World (DotW) in the UK, which is an initiative to ensure that people in the community, including ethnic minority groups, migrants, and other vulnerable populations, can access primary healthcare without facing barriers. We noted examples of how the service supported people who are not registered such as ethnic minorities or with no fixed abode and travellers. This addressed health inequalities which disproportionately affect these demographics through an emphasis on non-discriminatory registration and staff training for awareness.

People were given exceptional support to plan for important life changes, so they could make informed decisions about their future, including at the end of their life.

The service demonstrated an exceptional commitment to supporting people to plan for important life changes, including at the end of life. Staff worked proactively with people and other healthcare professionals to ensure care was personalised and sensitive to individual needs and preferences. People were given enough time and information to make informed decisions about their future care, and staff consistently respected their wishes.

Our remote review of clinical care records showed people residing in local care homes were consistently supported on a routine basis and people had additional access to acute care with the service if required. Records we reviewed highlighted a comprehensive holistic approach involving local community services.

There was a proactive approach to anticipatory care planning, led by one of the senior GP’s. The service identified patients approaching the end of life early and initiated comprehensive anticipatory care plans. These plans were developed collaboratively with people and their families, ensuring that decisions about treatment escalation, DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) orders, and preferred place of care were clearly documented and shared with relevant services. Conversations were handled sensitively and revisited regularly to reflect changing circumstances. There was a process in place to ensure the palliative care register was accurate so staff could provide more appropriate and patient-focussed care to people. People on the service’s palliative care register were reviewed in monthly multi-disciplinary meetings. Clinical staff had completed appropriate training on documenting people’s preferences for emergency care.

The service offered emotional and practical support to carers, including signposting to bereavement services and providing information about benefits and community resources. Feedback from families highlighted staff were compassionate and responsive. The service audited care plans and acted on findings to improve quality. For example, they introduced a system to flag people who might benefit from early discussions about future care, which led to more timely interventions and improved patient satisfaction.

The service had plans to meet future demand and improve patient experience. Recruitment was ongoing for clinical and administrative roles, and succession planning was supported by the provider.