Shakespeare Road Medical Centre

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

Well-led - We looked for evidence that service leadership and management assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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

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.

We have not awarded this service a score for Well-led.

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

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 had contributed to the development of the service’s vision and strategy, which was kept under review.

Staff told us there was an improving team culture and they felt supported by GPs and senior leaders. They told us they were able to contribute to discussions about service improvements such as feedback and complaints. All staff we spoke with were proud to work for the service and an emphasised prioritising providing a positive experience for people.

The service’s mission statement and values were available and accessible to staff. Positive learning culture was demonstrated through meeting minutes which showed performance, incidents, updates to evidence-based care and education sessions were routinely discussed.

There were effective processes and systems for leaders to share their vision, practical experience and support with colleagues. This was achieved formally through governance meetings and clinical discussions.

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 at the service were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the service. Leaders regularly reviewed feedback such as via the Friends and Family Test and the National GP Patient Survey. The service demonstrated actions had been taken to improve patient experience.

Leaders promoted staff development, with opportunities for continuous professional development (CPD) and career progression. Recognition schemes and awards were in place to celebrate staff achievements.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The service had established Freedom to Speak up arrangements in place as well as a whistleblowing policy. Staff also had access to an Employee Assistance Programme and support from occupational health services.

There were mechanisms for staff to raise concerns, while most staff felt confident their views were listened to, some survey responses indicated further work was needed to ensure all staff felt their concerns would be welcomed. Where constructive feedback trends were identified, leaders told us there were plans in place to review staff wellbeing and these areas were placed on the service’s improvement plan. The service had set up new ways to support staff. For example, there was a forum where staff could share feedback and concerns informally. Additionally, there were extra communication channels to share updates about services, learn from experiences, and identify positive feedback through staff bulletins.

We reviewed the service’s incident management systems and processes, which demonstrated when something went wrong, people received a timely apology and were told about any actions being taken to prevent the same happening again.

There was a zero-tolerance policy in relation to the abuse of staff with mechanisms in place to protect people and minimise the likelihood of reoccurrence.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Policies and procedures to promote diversity and equality were in place. Adjustments had been made to ensure all staff were valued. For example, there were reasonable adjustments in place to support the risks posed to the health and safety for workplace display screen equipment, working whilst pregnant and movement and handling, although a small number reported delays in receiving ergonomic equipment.

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 act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

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

There were clear governance arrangements. Risks were recorded on a risk register and discussed at governance meetings. The service had a business continuity plan in place and had been tested following a significant incident in June 2025. Guidance was available to staff for the preparation of major incidents. Staff were able to demonstrate how working arrangements had been adjusted due to past risks or incidents.

Information was stored securely in line with digital security standards with relevant information available in line with privacy, consent notices and general data protection regulations. This included how people’s data was used, choices regarding consent and how to protect online data through notices within the service, registration forms or online via the service’s website.

However, although the service had oversight of the health and safety risks posed to people in relation to infection, prevention and control, performance to cleaning standards had not improved to meet NHS standards, despite examples of control measures in place. The service was working with external contractors for quality assurance purposes to minimise the risks posed to people.

The service understood their duty to collaborate and work in partnership, to ensure services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff had made adjustments to improve coordination of their service with community healthcare services, centred on the care of those at higher risk of hospital admission.

The service worked collaboratively with the local Integrated Care Board and participated in neighbourhood health projects. There were strong links with community services, including social prescribing schemes, carers’ support, and cancer care coordination to provide extra support for a variety of people with more complex needs such as those who were vulnerable and assessed as frail. The practice engaged with its Patient Participation Group and local community initiatives to improve health outcomes.

Community providers shared positive feedback about their experience working with the service, such as community mental health and nursing teams. They highlighted a collaborative approach to monitoring and delivering care tailored to people's needs. This included support for individuals with poor mental health and those receiving end-of-life care. The service worked with healthcare partners in the development and review of locally agreed clinical pathways. Feedback on outcomes following referrals were shared with both the service and the relevant healthcare providers.

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 service had a program of quality improvement audit activity and routinely reviewed the effectiveness and appropriateness of the care provided. For example, there was a clear plan for conducting clinical and non-clinical audits. Outcomes and learning were shared with staff to ensure future recommendations were implemented.