Dr Jefferies and Partners

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 looked for evidence that service leadership, management and governance assured high-quality person-centred care, supported learning, innovation, and promoted an open fair culture. Although the practice had an overarching governance framework, we found gaps in its management and oversight. In particular we found concerns around safe environments, infection prevention and control. At our last inspection, we rated this key question as good. At this assessment, the rating has changed to requires improvement.

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.

The practice 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. We saw that policies were reviewed and updated regularly and staff had easy access to them. Leaders informed us they regularly communicated with outside bodies like the wider PCN, Integrated Care Board (ICB), and GP Federation to ensure that the practice ran smoothly.

The practice had inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. We saw examples where there were gaps of oversight from the leadership team in process for infection prevention control, emergency medicines and fire equipment which we found on the day of the site visit, please see above see prior sections. Although the leadership team took corrective action on the day of the site visit to resolve the issues identified, these were not identified prior to the inspection, the practice lacked adequate systems and process to oversee these areas.

Leaders and staff told us there was an open culture, and leaders were approachable and responded to any concerns raised. The practice offered flexible working arrangements where possible. The leadership team worked with other practices in the organisation and PCN and were engaged in the development of primary care services within the local area. Staff we spoke with were aware of those with lead roles in the practice.

The practice fostered a positive culture where people felt they could speak up and their voice would be heard. There was a whistle blowing policy in place and this was regularly reviewed and updated. The practice had established Freedom to Speak up arrangements within the primary care network. Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to a positive effect

The practice valued diversity in their workforce. They worked 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. All staff had completed equality and diversity training. Practice leaders encouraged teamwork and inclusivity and supported this through staff events. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support disabled staff were in place.

There were governance structures in place to support staff, and all staff we spoke with were clear about their individual roles and responsibilities. The practice had appointed designated leads for both clinical and non-clinical areas, including health and safety, recruitment and infection prevention control. However, these arrangements required improvement. The service had clear responsibilities and systems of accountability, however governance processes needed strengthening to ensure risks were identified and actioned, as we identified concerns during the site visit. This indicates the practice had gaps in having robust systems and processes in place to identify the issues found on the day of inspection.

The practice understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement. The practice worked with other practices within their PCN to offer extended access. Staff had made adjustments to improve coordination of the service with community healthcare services, including regular established meetings centred on the care of those at higher risk of hospital admission. The practice was involved in meetings with other healthcare providers in the local area to develop the way care was delivered.

The practice 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 and innovative call centre system and process. Despite concerns raised on the day of inspection leaders were responsive, accountable and took the necessary steps to rectify any concerns raised on the day of the inspection immediately while we were still on site and provided evidence for this. The practice had a quality improvement plan in place to help drive improvements in services, this focussed on access, childhood immunisations, cervical screening and data.