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Dr R W Shelly & Partners Good Also known as Stokewood Surgery

Inspection Summary


Overall summary & rating

Good

Updated 13 August 2020

We previously carried out an announced focused inspection at Dr RW Shelly & Partners, known as Stokewood Surgery, on 25 April 2019 as part of our inspection programme. The inspection was carried out following an annual regulatory review of information available to us. The inspection looked at the Effective, Responsive and Well-led domains. We rated the practice as Good overall, however we found a breach of regulations and rated Well-Led as Requires Improvement. You can read the full report by selecting the ‘all reports’ link for Dr RW Shelly & Partners on our website at .

We were mindful of the impact of the Covid-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what type of inspection was necessary and proportionate, this was therefore a desk-based review. On 21 July 2020, we commenced the desk-based review to confirm that the practice had carried out its plan to meet the legal requirements in relation to the breach of regulations that we identified at our previous inspection in April 2019.

We found that the practice is now meeting those requirements and we have amended the rating for this practice accordingly. The practice is now rated Good for the provision of Well led services. We previously rated the practice as Good for providing Safe, Effective, Caring and Responsive services.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we reviewed the information sent to us by the provider
  • information from our ongoing monitoring of data about services and
  • information from the provider.

We have rated Well-Led as Good because:

  • The practice demonstrated it had improved its monitoring process of its safety alerts. The practice had implemented a log to formally document the actions taken in response to safety alerts.
  • The practice demonstrated it had revised its significant event policy and identified a significant event lead clinician to lead its investigations into such events.
  • We reviewed four examples of significant events since our last inspection, and we found these had been appropriately addressed. Learning had been identified from all four events and shared with staff.
  • The practice told us it now invited all staff to attend its significant review meetings. The practice told us this had been positively received by staff and that it had promoted a more open, no blame culture.


Although not part of the practice’s previous regulatory breach, the practice demonstrated it had also made improvements since our last inspection in the areas of:

  • Arranging and monitoring its internal clinical audit programme.
  • Confirming formal arrangements for the clinical supervision of nurse practitioners.

Whilst we found no breaches of regulations, the provider should:

  • Arrange formal training for its significant event lead to support the practice’s root cause analysis processes of significant events.

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

Inspection areas

Safe

Good

Effective

Good

Caring

Good

Responsive

Good

Well-led

Good
Checks on specific services

People with long term conditions

Good

Families, children and young people

Good

Older people

Good

Working age people (including those recently retired and students)

Good

People experiencing poor mental health (including people with dementia)

Good

People whose circumstances may make them vulnerable

Good