During an assessment under our new approach
Date of Assessment: 13 May 2026. Shere Surgery/Dispensary is a GP practice and delivers services to approximately 8,000 people under a contract held with NHS England. The practice is also a dispensing practice for eligible patients. According to the latest available data, the ethnic make-up of the service area is approximately 96% White, and 4% Asian, Mixed, Black and Other. Information published by the Office for Health Improvement and Disparities shows deprivation within the service population group is in the 9 decile (9 of 10). The lower the decile, the more deprived the service population is relative to others.
This was a focused assessment. We undertook this assessment due to the length of time since our last assessment. We assessed 10 quality statements from across all 5 key questions. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
Staff kept facilities clean and maintained equipment appropriately to ensure people were kept safe. They assessed and managed the risk of infection well and took steps to control the risk of it spreading. There were enough staff with the right skills, qualifications and experience. There were arrangements in place for identify risks however we found there were not clear action plans in place to implement mitigating actions.
Staff supported people to live healthier lives, monitoring their care and treatment to ensure they received positive and consistent outcomes.
Staff treated people with kindness, empathy and compassion, and respected their privacy and dignity.
People could access care, treatment and support when they needed it. Leaders and staff were alert to discrimination and inequality that could disadvantage groups of people who used the service and sought ways to address any barriers.
The service had a clear strategy, which considered the needs of the people who used their service and the wider community. Staff understood their individual roles and responsibilities. Systems and processes were not always operating effectively as leaders intended. Leaders did not always account for the actions and performance of staff through effective governance processes. We found gaps in recording of action plans resulting from risk assessments, staff training records, staff immunisation records and a lack of monitoring of prescription stationary.
We found a breach of Regulation 17 good governance.We have asked the provider for an action plan in response to the concerns found at this assessment.