Shakespeare Road PMS

We carried out an announced inspection at Shakespeare Road PMS between 28 April and 9 May 2022. Overall, the practice is rated as requires improvement:

• Safe – requires improvement
• Effective – requires improvement
• Caring - good
• Responsive - good
• Well-led – requires improvement

Why we carried out this inspection

This inspection was a comprehensive inspection, and was our first inspection of this location since their registration with CQC.

How we carried out the inspection

Throughout the pandemic, CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting staff interviews using video conferencing
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider
• Reviewing patient records to identify issues and clarify actions taken by the provider
• Requesting evidence from the provider
• A short site visit
• Circulating an electronic staff questionnaire.

Our findings

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as Requires Improvement overall.

We found that:

• The practice had clear systems, practices and processes to keep people safe and safeguarded from abuse.
• Staff had the information they needed to deliver care and treatment.
• Staff worked well together and with organisations.
• Staff treated patients with kindness and compassion, and respected their privacy and dignity. Staff helped patients to be involved in decisions about their care and treatment.
• The practice organised services to meet patients’ needs.
• People were able to access care and treatment in a timely way.

We found one area of outstanding practice:

• The practice employed several staff who spoke multiple languages, including languages spoken commonly by the practice’s local communities. To support this, the practice had introduced a dedicated weekly clinic whereby GP appointments with a face-to-face interpreter were available. This allowed patients who did not speak English, or who preferred to speak in their primary language, the ability to access services easily and equally.

We found one breach of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients

Although not a breach of regulations, the provider should:

• Improve the uptake of childhood immunisation and cervical screening.
• Develop a programme of quality improvement and clinical audit that is aimed at improving the quality of patient care.
• Improve the accuracy and oversight of staff training records.
• Improve processes to collect and review patient feedback.
• Improve systems to identify carers.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care