Background to this inspection
Updated
15 November 2021
Shelley Manor & Holdenhurst Medical Centre is situated in Bournemouth and comprises of two sites. We visited the main site Shelley Manor during our inspection on the 27 September 2021.
Shelley Manor Medical Centre.
Beechwood Avenue,
Bournemouth,
BH5 1LX.
The practice has a branch surgery at:
199 Holdenhurst road.
Boscombe,
Bournemouth,
BH8 8DE.
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures. These are delivered from both sites.
The practice offers services from both a main practice and a branch surgery. Patients can access services at either surgery.
The practice is situated within the NHS Dorset Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of about 25,300. This is part of a contract held with NHS England.
Information published by Public Health England rates the level of depravation within the practice population group as third on a scale of one to ten. Level one represents the highest levels of depravation and level ten the lowest. The practice age profile showed the practice had a lower than average number of patients over the age of 65 years. For example, 13.7% compared with the national average of 17.4%.
The practice has ten partners, five salaried GPs, a clinical pharmacist, a pharmacy technician, two advanced nurse practitioners, three practice nurses, two healthcare assistant and one phlebotomist. The clinical team are supported by a practice business manager and an operational manager. There are also administration and reception staff teams.
Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered a choice of either the main GP location or the branch surgery.
Updated
15 November 2021
We carried out an announced inspection at Shelley Manor & Holdenhurst Medical Centre on 27 September 2021. Overall, the practice is rated as Good.
Safe - Good
Effective - Good
Well-led - Good
At our previous inspection on 4 November 2020, the practice was rated Requires Improvement overall and for all key questions apart from caring and responsive which were rated Good. This was a focused inspection of safe, effective and well-led domains only. The ratings from the other two domains (caring and responsive) from our previous inspection for these key questions have been carried through to contribute to the overall rating for the practice.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Shelly Manor & Holdenhurst on our website at www.cqc.org.uk
Why we carried out this inspection.
We undertook this inspection as part of our published methodology for providers who have a rating of requires improvement overall and breaches to regulations. At our previous inspection we identified a breach in Regulation 17 HSCA (RA) Regulations 2014 Good governance. This inspection was to see whether improvements had been made in the requirement notice and also to look at the key questions rated as requires improvement from the previous inspection.
How we carried out the inspection
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included:
- Conducting staff interviews using video conferencing
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider
- Reviewing patient records to identify issues and clarify actions taken by the provider
- Requesting evidence from the provider
- A short site visit
- A discussion with members of the patient participation group
Our findings
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 found that:
- A new computer system had been purchased to improve the governance processes. This included centralising documents, policies and risk assessments. The new system was accessible to all staff and ensured required updates were being monitored in the relevant timeframes.
- Staff reported the culture had improved, citing being more involved and engaged with the service. Staff felt able to raise concerns and confident their voice was heard and acted upon.
- The practice provided care in a way that kept patients safe and protected from avoidable harm.
- Patients received effective care and treatment that met their needs.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
- The practice’s quality assurance processes remained effective in identifying areas for improvement. A system error negatively impacting the practice’s data had been identified and the practice promptly resolved this. The effectivess of the action taken had been measured and improvements noted.
Whilst we found no breaches of regulations, the provider should:
- Review the service level agreement with the third-party infection prevention and control contractor. This is to provide reassurance that required actions had been completed adequately.
- Consider further ways to engage and support hard to reach patients with long term conditions. Continue to monitor and reduce exception reporting where possible.
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