Dr Shepherd & Partners Also known as The Filey Surgery

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

We identified a breach of the legal regulations. Although leaders had the experience, capability and integrity to deliver the organisations strategy and manage most risks there were some shortfalls in oversight and monitoring processes. Healthcare staff were administering medicines under directives that had expired, there was no oversight or monitoring of staff competency checks, not all staff had received an annual appraisal and there was no process in place to deliver formal clinical supervision. Some staff said they were not aware of the practice’s vision and strategy moving forward, however, they told us they were committed to delivering high-quality person-centred care to patients. Not all staff said they felt supported, some said this had improved with the introduction of team leaders and feedback from staff regarding the culture of the practice was mixed with some saying the atmosphere had changed or could be better and others reported a good working atmosphere.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Not all staff reported they were aware of the vision and strategy of the service moving forward but were committed to delivering high-quality person-centred care to patients. They reported a lot of staff changes which had been unsettling. Leaders told us that staff had been kept informed of changes at team meetings and that the regular staff newsletter had been restarted. Leaders told us they had dedicated a full team meeting’s agenda on 6 June 2024 to discuss and develop the service’s strategy with staff. Feedback from staff regarding the culture of the practice was mixed with some saying the atmosphere had changed or could be better and others reported a good working atmosphere.

The provider had an appropriate equality and diversity policy in place which staff knew how to access. There were regular team meetings including clinical meetings.

Not all staff said they felt supported, some said this had improved with the introduction of individual team leaders. The practice had completed its own staff survey in 2023 with similar results. An action plan to address this had been developed. However, leaders told us that although some actions had been completed, others had been delayed due to staff changes and recruitment. Leaders had a plan to re-visit the survey results and action plan with staff on 6 June 2024. Staff told us that they had received the training they required for their role. However, not all staff had received an annual appraisal.

Although leaders had the experience, capability and integrity to deliver the organisation's vision and manage most risks there were some shortfalls in oversight and monitoring processes. Healthcare staff were administering medicines under directives that had expired, staff competency checks had been completed, however, there was no management oversight or monitoring of these to support staff development. Not all staff had received an appraisal, some staff not having had one for several years and there was no process in place to deliver formal clinical supervision. The provider did have appropriate policies in place including a recruitment policy and a business continuity plan. Appropriate recruitment checks had been completed for staff in the personnel files we reviewed and we saw induction records had been completed for new staff.

Staff told us they knew how to access the whistleblowing policy and how to contact the freedom to speak up guardian.

The service had an appropriate whistleblowing policy in place. We observed the staff newsletter from April 2024 had included the freedom to speak up guardian’s contact details. The provider used significant events and complaints to review when things had gone wrong and to drive improvement. We saw people had received an apology and were told about any actions being taken to prevent the same thing happening again.

Staff told us they had received equality and diversity training. Leaders told us they took action to prevent and address bullying and harassment and that action to address concerns raised by staff had been taken. Some staff told us their wellbeing had been taken account of, however some staff reported they did not feel able to raise concerns or felt listened to by leaders.

The provider had an Equality and Diversity policy in place. We did not see any discrimination in the recruitment records we reviewed.

The provider was in the process of moving internal documents including practice policies, personnel files and staff training onto a new intranet system. Staff told us they knew how to access practice policies. There were named leads in place for key areas and staff were clear about their roles and responsibilities. Not all staff said they felt listened to or able to raise concerns, some said this had improved with the introduction of the team leaders and some staff said they had the opportunity to raise suggestions or new ideas and others said they did not feel able to raise concerns or that they did not feel their concerns were listened to. Feedback from staff regarding the culture of the practice was mixed with some saying the atmosphere had changed or could be better and others reported a good working atmosphere.

Although there were some gaps in oversight and monitoring of some processes, for example, staff competency checks, lack of formal clinical supervision, delayed appraisals and administering medicines without proper documentation, there were some effective governance and management arrangements in place, for example appropriate recruitment checks of staff, effective arrangements for identifying, managing and mitigating risks, for example, infection, prevention and control audits and information was used effectively to monitor and improve the quality of patient care. For example, rolling medicine audits. However, the provider had not listened to staff feedback or taken timely action from their own staff survey completed in 2023 when some staff reported they did not feel supported or listened to.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.