Shakespeare Road Medical Centre

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

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

The service had a good learning culture and people could raise concerns. Leaders investigated incidents thoroughly. There were enough staff with the right skills, qualifications and experience. Leaders made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes.

Although the service had governance systems and processes to assess and monitor the quality and safety of the service, this was not always effective to address shortfalls in performance relating to infection prevention and control. In particular, we observed cleaning arrangements or outcomes following audits did not always comply with national guidelines.

We have not awarded this service a score for Safe.

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

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff were encouraged to raise concerns when things went wrong. They told us significant events, complaints and examples of feedback were shared and discussed during regular meetings. Staff felt there was an open culture and understood their duty to raise concerns and report incidents. Leaders provided examples of how incidents were investigated and resolved.

There were policies and processes in place to record, investigate and take action from incidents and complaints. These were discussed in monthly governance meetings and minutes were made available to staff who were unable to attend. When things went wrong, staff apologised and gave people support in line with the duty of candour. Learning from incidents and complaints resulted in changes that improved care for people who used the service.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. The service was supported by a cancer care co-ordinator and a social prescriber who were effective in bringing together multidisciplinary teams to support people with complex health and care needs, such as arranging appropriate support via service referrals. The service demonstrated consistent positive feedback from people who engaged in the service’s wellbeing initiatives and further mental health support in relation to their cancer care. We noted examples provided by people, their families and advocates who commended the support these roles provided.

The service worked with other providers to deliver shared care and when people moved between services. There were systems for processing information relating to newly registered people. Referrals and test results were managed in a timely way. Policies and guidance were in place to support workflow and pathways for appointments, referrals, records and correspondence. The service had a system for processing new information and summarisation of notes.

Staff told us they were aware of their role to monitor and manage care when people moved between services, such as outcomes following referral to secondary care, or admission to hospital. A review of the service’s clinical system, which formed part of this assessment, indicated people’s test results were being managed in a timely manner to support transition through services. For example, people residing in one of the service's local care homes who were deemed frail or vulnerable received co-ordinated approach to their care, led by the service's GP. The service demonstrated how they worked with community services such as nursing and mental health teams when planning care and treatment arrangements.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

There were designated leads for safeguarding children and adult at the service. There were multi-disciplinary meetings where safeguarding issues were discussed, and these were attended by clinical and management staff. External stakeholders were invited to safeguarding meetings where relevant, such as community nursing teams and health visitors. Systems were in place to appropriately refer people to the local authorities and information was shared amongst community teams where required. Safeguarding and chaperoning policies were accessible to staff.

Clinical staff members had chaperone responsibilities as part of their role. All staff members had completed Disclosure and Barring Service (DBS) checks to ensure they would be appropriate to undertake this role.

All members of staff were up to date with safeguarding training in addition to the Mental Capacity Act and the Deprivation of Liberty Safeguards which were mandatory in line with the service’s policy.

We reviewed a sample of people’s records as part of our remote clinical searches and saw care plans noted how people were to be supported to remain safe. There were safe systems and processes in place to ensure children had been appropriately followed up with when they failed to attend appointments.

The service worked with people to understand and manage risks. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. The service had maintained emergency equipment and staff were aware of procedures including recognising a deteriorating patient and were trained on relevant actions to take. People were advised on risks related to their condition and actions to take if their condition worsened.

The service had a dedicated workflow team comprised of administrative staff which supported correspondence and patient communications. Staff told us urgent tasks were raised to GPs based on information escalated by Out of Hours and NHS 111 services, particularly, for people who were required to be seen in-hours by the service based on their symptoms and clinical presentation.

Leaders demonstrated the arrangements for reviewing abnormal results were prioritised to ensure people were followed up in a timely way. For example, we observed the service’s pathology clinical system mailbox and identified abnormal results were assigned appropriately. This was either to the requesting clinician or to the duty GP for review on the day via a ‘buddy system’ to prevent delays to care and treatment. Staff were able to describe their roles and responsibilities to manage risks associated with workflow and patient correspondence.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Premises and equipment were maintained in accordance with national guidelines and service policy. This included regular portable appliance testing, equipment calibration and lift servicing and maintenance. Fire safety procedures had been managed in line with the Fire Safety Act 2021. Fire safety measures were in place such as fire extinguisher servicing, emergency lighting servicing and gas safety checks. The service ensured identified actions had been taken following a fire risk assessment to ensure compliance to safety standards. The service had a business continuity plan which was monitored and reviewed regularly.

Staff told us the service assessed health and safety arrangements to support them in their roles in line with The Health and Safety at Work etc. Act 1974. We noted examples of assessments which had been carried out for staff including Personal Emergency Evacuation Plan (PEEP) for emergencies. Workplace equipment to support staff with safe working had been requested and ordered as a result of assessments such as ergonomic chairs, display screen filters and workplace eye tests.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff told us the service ensured staff were supported in their roles, and supervision and development was in place through appraisals. The service demonstrated examples of how cases had been reviewed by a GP supervisor and discussed the quality of care to ensure prescribing was in line with national guidelines.

Staff could discuss clinical queries in relation to their medicine prescribing, care and treatment planning with leaders who they said had an ‘open door’ policy. Regular audits had been carried out to identify themes, trends and learning. There were daily timeslots available for clinicians to seek support with the on-the-day duty GP.

Staff received a formal induction relevant to their role and responsibilities and were supported through ongoing appraisals. There were systems in place to monitor staff training compliance, and all staff had completed mandatory training in line with service policy.

All recruitment and Human Resource (HR) records were kept in-line with service policy and Schedule 3 requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We carried out a review of the provider’s recruitment checks in relation to 3 members of staff and information was available and up to date in line with service policy.

There were staffing arrangements to ensure in the event of an emergency, the risk of unsafe practice was mitigated and prevented lone working.

Although the service had governance systems and processes to assess and monitor the quality and safety of the service, this was not always effective to address shortfalls in performance relating to infection prevention and control. In particular, we observed cleaning arrangements and outcomes following the infection, prevention and control audit, undertaken in July 2025, deemed cleaning standards did not comply with national guidelines. We noted actions had been taken as a result of the audit, including monthly performance reviews with the cleaning contractors. Subsequent improvements had been made to the management of Control of Substances Hazardous to Health (COSSH) risk assessments and Safety Data Sheets (SDS) for all cleaning products stored at the service. The latest cleaning contractor performance review audit conducted in October 2025 identified some improvements to the general cleaning of office areas and toilets, however the flooring in consulting and treatment rooms remained stained and affected by spillages and debris, requiring further improvement. Despite identifying the risk and sharing concerns with the cleaning contractors promptly, the standards of cleaning continue to not meet the NHS national standards of healthcare cleanliness guidelines and service approved ‘Functional Risk’ rating performance.

We also observed inappropriate cleaning mop storage such as ensuring these were off the floor, ventilated, facing upwards, segregated and colour coded, to prevent contamination and bacterial growth. The service rectified this after the on-site visit, ensuring designated mop holders were installed. However, the service was unable to demonstrate mop heads were suitably disinfected and cleaned as part of the cleaning contractor arrangements, as records of cleaning standards were not always kept.

The service had carried out a legionella service assessment in February 2025, which deemed the premises free from the presence of legionella. The service had a water flushing regime in place. There were arrangements to test and record water temperatures to demonstrate the prevention of the growth of legionella bacteria.

The service had a designated infection, prevention and control (IPC) lead and all staff had received relevant training. Risk assessments and audits were completed. Recent examples we noted related to hand hygiene and anti-septic non-touch technique (ANTT).

The service made sure medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

During our remote clinical searches, we noted people who had been prescribed high-risk medicines had been appropriately monitored and reviewed in line with national guidelines.

Patient Group Directions (PGD), a legal document that allows certain healthcare professionals to supply or administer a specific medicine to a pre-defined group of patients without an individual prescription, and Patient Specific Directions (PSD), a written instruction from a prescriber for a medicine to be supplied or administered to one or more named patients, were in place which relevant staff worked to. Prescription stationery was logged and stored securely.

Medicines were stored securely and the service held appropriate emergency equipment and medicines. The service maintained appropriate fridge temperature records where vaccines were being stored, and cold-chain protocols were followed.

Leaders demonstrated there was an effective system to ensure safety alerts were acted upon in a safe way to people. During our remote clinical searches, we noted people who were subject to medicine safety alerts were contacted to inform them on the risks and prescriptions were reviewed appropriately.

There were systems and processes to monitor the quality of medicines reviews which formed part of staff’s clinical supervision and appraisals, to improve the quality of care delivered by clinicians and for learning purposes. The service demonstrated recall systems for people to ensure the monitoring of medicine reviews complied with national guidelines. During our remote clinical searches, we determined people received timely medicine reviews and found documentation included sufficient information to support future care planning from the records we reviewed.