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

Reports


Inspection carried out on 21 Jul 2020

During an inspection looking at part of the service

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 carried out on 25 April 2019

During an inspection looking at part of the service

We carried out an announced focused inspection at Dr RW Shelly & Partners on 25 April 2019. We decided to undertake an inspection of this service following our annual regulatory review of the information available to us. This inspection looked at the following key questions:

  • Are services at this location effective?
  • Are the services at this location responsive to patients’ needs?
  • Are the services at this location well-led?

The practice’s annual regulatory review did not indicate that the quality of care had changed in relation to Safe and Caring. As a result, the ratings from the practice’s previous inspection from 2014 still stand in those key questions.

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 good overall.

We rated the practice as good for providing effective and responsive services because:

  • Patients received effective care and treatment that met their needs
  • Complaints were addressed in a timely way and learnt from.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • Patient feedback was mainly positive about the services provided by the practice.

We rated the practice as requires improvement for providing well-led services because:

  • The overall governance arrangements were ineffective, especially in relation to oversight of safety alerts and the investigations of significant events.
  • The practice was unable to demonstrate that its nurse practitioners were receiving appropriate formal clinical supervision.

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Review the formal arrangements for the nurse practitioners to receive clinical supervision in line with the practice’s newly revised policy.
  • Review how clinical or non-clinical audits are identified and undertaken in order to drive improvement from within the practice.
  • Continue to respond to patient feedback, especially in relation to patient satisfaction with appointment times and access to appointments.
  • Review the arrangements for the patient participation group to provide feedback to the practice.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGPChief Inspector of Primary Medical Services and Integrated Care

Inspection carried out on 18 November 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection of Stokewood Surgery, Fair Oak Road, Fair Oak, Hampshire, SO50 8AU on 18 November 2014. Overall the practice is rated as good.

This practice has a branch surgery at Old Anchor Surgery, Riverside, Bishopstoke. Eastleigh. SO50 6LQ. We did not inspect the branch surgery.

We found that Stokewood Surgery is a good practice overall with a strategy and track record of continuous improvement for care and responded to the needs of patients living in the area. The practice was rated as good in the population groups we looked at.

Our key findings were as follows:

  • Patients were complimentary about the care and support they received from staff.
  • Staff told us they were committed to providing a service that put patients first.
  • The practice responded to the changing needs of the different populations groups that used the practice.
  • The practice had undertaken major internal refurbishment of the ground floor.
  • The practice joined the Wessex GP Educational Trust in 2012. The Wessex GP Educational Trust (WGPET) was formed in 1990 to provide funding for educational events run by GP Tutors. It continues to fund a wide range of events from one hour lectures to week-long refresher courses throughout the Wessex Deanery.
  • The partners have weekly meetings with the community care team and community matron.
  • The practice was above the national average for satisfaction with phone access, opening hours and reported good overall experience of making an appointment.
  • The practice showed good child immunisation percentages, which were above the percentage receiving vaccinations across the rest of the Clinical Commissioning Group.
  • The practice showed a better than average result in areas such as maintaining a register of all patients in need of palliative care or support irrespective of age and maintaining a register of patients aged 18 or over with learning disabilities.

We saw areas of outstanding practice including:

•The practice employed a medicines adviser who worked closely with patients and pharmacists to improve efficiency in prescribing.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice