Shakespeare Road PMS

Updated 10 June 2022

Shakespeare Road PMS is located in Rotherham, South Yorkshire at:

• Shakespeare Road Health Centre, 50 Shakespeare Road, Eastwood, Rotherham, S65 1QY.

The practice has a branch surgery at:

• Ridgeway Medical Centre, 14 Ridgeway, Rotherham, S65 3PG.

During this inspection, we visited the Shakespeare Road Health Centre site only, as the practice had temporarily suspended operations from Ridgeway Medical Centre to allow the site to operate as a COVID-19 treatment and assessment hub.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures; family planning; maternity and midwifery services; and treatment of disease, disorder or injury.

The practice is situated within the NHS Rotherham Clinical Commissioning Group (CCG) and delivers Personal Medical Services (PMS) to a patient population of about 5,700. This is part of a contract held with NHS England.

The practice is part of a wider network of GP practices, and is one of seven practices within the ‘Wentworth 1 PCN’ primary care network.

Information published by Public Health England shows that deprivation within the practice population group is in the second lowest decile (two of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 71.1% White, 20.3% Asian, 3.2% Black, 2.9% Other, and 2.6% Mixed.

The age distribution of the practice population is significantly different from local and national averages, with the practice reporting a larger percentage of young people and a smaller percentage of older people compared with local and national averages.

There is a team of two GPs, who are both partners at the practice. The practice has two practice nurses who provide nurse-led clinics for long-term conditions, supported by a healthcare assistant. The practice manager provides managerial oversight and oversees a team of reception and administration staff.

The practice provides its own extended hours service, where early morning appointments are available. Extended access is provided locally by Connect Healthcare Rotherham CIC, where late evening and weekend appointments are available. Out of hours services are provided by NHS 111.

Updated 10 June 2022

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