16 March 2023
During a routine inspection
We carried out an announced onsite comprehensive inspection at Shakespeare Medical Practice on 16 March 2023. Prior to the onsite inspection, a GP specialist advisor conducted a remote clinical notes search on 7 March 2023.
Following this inspection, we rated the service as requires improvement overall.
Safe - good
Effective – requires improvement
Caring - good
Responsive - good
Well-led - requires improvement
The service was last inspected on 20 December 2017 and rated good overall and good for all key lines of enquiry. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Shakespeare Medical Practice on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this comprehensive inspection to follow up concerns reported to us.
How we carried out the inspection
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.
This included:
- Conducting staff interviews using video conferencing.
- Reviewing staff questionnaires.
- Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider.
- A shorter site visit.
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 found that:
- There were systems in place to safeguard children and vulnerable adults from abuse and staff knew how to identify and report safeguarding concerns.
- Patients received effective care and treatment that met their needs.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- Patients could access care and treatment in a timely way.
- There were gaps in systems and processes to support good governance at the walk-in centre which included the management of complaints, the locum induction process, clinical supervision, and staff communication.
We found breaches of regulation. The provider must:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
- Establish effective systems and processes to ensure staff receive appropriate support and supervision as necessary to enable them to carry out the duties they are employed to perform.
In addition, the provider should:
- Summarise any outstanding patient records to ensure that all information is available for the delivery of safe patient care and treatment.
- Review and update training records for staff to demonstrate they have completed all required training.
- Continue to recruit patients to join the Patient Participation Group to establish a group representative of the practice population.
- Review and improve the system for access to management support for staff working within the walk-in centre.
- Review the whistleblowing policy and include signposting to external agencies in line with the Freedom to Speak Up Policy for the NHS.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services