Background to this inspection
Updated
13 August 2020
Dr RW Shelly & Partners is located at Stokewood Surgery, Fair Oak Road, Fair Oak, Eastleigh, SO50 8AU. There is a pharmacy located next to the practice. The practice also has a branch site located at The Old Anchor Surgery, Riverside, Bishopstoke, Eastleigh, SO50 6LQ.
The provider is registered with CQC to deliver the Regulated Activities at both sites for:
- Diagnostic and screening procedures
- Family planning
- Maternity and midwifery services
- Surgical procedures
- Treatment of disease, disorder or injury.
Dr RW Shelly & Partners is situated within the West Hampshire Clinical Commissioning Group (CCG) and provides services to approximately 17,600 patients under the terms of a personal medical services (PMS) contract. This is a contract between general practices and NHS England for delivering services to the local community.
The provider is a partnership of GPs which registered with the CQC in 2013. The practice consists of seven GP partners, six salaried GPs, two nurse practitioners, four practice nurses, and five health care assistants. Alongside the clinical team, a practice manager is supported by a reception manager, a facilities manager and a data manager who lead a team of receptionists, administrators and medical secretaries. The practice is a GP training practice and, at the time of inspection, had one GP Registrar attached to the practice. The practice is part of a GP Federation so an extended access service to GP services outside core hours is provided through this arrangement. Out of hours services are accessed by calling NHS 111. Details of these arrangements are listed on the practice’s website.
There are higher than average number of patients over the age of 65, and fewer patients aged under 18 years than the national average. The National General Practice Profile states that 97% of the practice population is from a White background. Information published by Public Health England, rates the level of deprivation within the practice population group as ten, on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest. Male life expectancy is 82 years compared to the national average of 79 years. Female life expectancy is 84 years compared to the national average of 83 years.
The practice has been inspected before in November 2014, and April 2019. The full reports for the practice can be found by searching Dr RW Shelly & Partners and using the “all reports” tab on our website .
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