The Care Quality Commission
  • Doctor
  • GP practice

Shelley Manor & Holdenhurst Medical Centre

Overall: Good read more about inspection ratings

Beechwood Avenue, Bournemouth, Dorset, BH5 1LX (01202) 309421

Provided and run by:
Shelley Manor & Holdenhurst Medical Centre

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Shelley Manor & Holdenhurst Medical Centre on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Shelley Manor & Holdenhurst Medical Centre, you can give feedback on this service.

27 September 2021

During a routine inspection

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

04 November 2020

During an inspection looking at part of the service

In light of the current Covid-19, CQC has looked at ways to fulfil our regulatory obligations, respond to risk and reduce the burden placed on practices by minimising the time inspection teams spend on site.

In order to seek assurances around potential risks to patients, we are currently piloting a process of remote working as far as practicable. This practice consented to take part in this pilot and some of the evidence in the report was gathered without entering the practice premises.

We carried out the remote elements of inspection through the GP focused inspection pilot (GPFIP) on 12 October 2020. This was in response to intelligence we received to suggest an increase in risk to patients at the practice. We reviewed information relating specifically to the concerns raised in the intelligence we received. We collected evidence from remote staff interviews and a remote review of systems and processes. Following the GPFIP we held an internal review of the information we collected and determined that we were unable to gain sufficient assurances that systems and processes were in place to ensure patient and staff safety.

Following the internal review, we decided to undertake a short notice announced focused onsite inspection on 4 November 2020. We visited the main location Shelley Manor as part of this inspection. We did not visit the Holdenhurst site.

This inspection looked at the following key questions:

  • Is the practice safe?
  • Is the practice effective?
  • Is the practice well led?

Because of the assurance received from our review of information we carried forward the ratings for the following key questions:

  • Is the practice caring? (Good - December 2018)
  • Is the practice responsive? (Good – December 2018)

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 requires improvement overall.

We rated safe, effective and well- led as requires improvement and the following population groups as requires improvement: People with long term conditions, families children and young people and working age people (including those recently retired and students) because:

  • We found some gaps in the recording of actions taken to mitigate risks and overall governance was not effective.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm. However, some safeguarding procedures and processes lacked consistency and staff were unable to access the most up to date procedures.
  • Some outcomes for people who use services were below expectations compared with similar services.
  • Staff were not always aware of, support, or did not understand the vision and values, or had not been fully involved in developing them.
  • Staff satisfaction was mixed, and some staff reported they did not feel actively engaged or empowered.
  • Staff did not always raise concerns as they were not always taken seriously, appropriately supported, or treated with respect when they did make them.

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.

The areas where the provider should make improvements are:

  • Review the infection prevention and control audits to ensure they are fully completed, and the practice can demonstrate that required actions have been taken to mitigate risk. Continue to review arrangements to improve the uptake of cervical screening.
  • Raise awareness of the significant event (SEA) processes to ensure there is consistent documentation of risks, actions, change and embedding for safe governance.
  • Consider further ways to engage and support hard to reach families in the community including making them aware of healthcare immunisation available for their children.
  • 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

12 and 13 December 2018

During a routine inspection

We carried out an announced comprehensive at Shelley Manor & Holdenhurst Medical Centre on 12 and 13 December 2018 as part of our inspection programme.

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 and good for all population groups. (Previous rating not applicable, first inspection since the practices merged).

At this inspection we found:

  • 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.
  • Feedback from patients about the staff, care and treatment was positive.
  • Patients told us that they were able to get an appointment, but there were difficulties in getting through on the telephone. This had improved but further improvement was needed. This was an area that the practice were focussing on getting right for patients. Patients reported that they were able to access care when they needed it.
  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services and participated in external groups to ensure they understood the local changes and challenges.
  • The practice worked effectively with other practices in the locality.
  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice recognised where systems and processes had worked well and improved their processes where appropriate.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Medicines and prescribing were effectively managed.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation. There was evidence of systems and processes for learning, continuous improvement and innovation.

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

  • Continue to review the systems and processes for health and safety checks to demonstrate that health and safety is maintained.
  • Continue to monitor and reduce exception reporting where possible.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

31 August 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Shelley Manor Medical Centre on Wednesday 31 August 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.

  • The practice employed a nurse for all “vulnerable Elderly” patients. The aim was to respond to the needs of housebound, vulnerable and isolated older patients who were at risk of unplanned admissions and reduce the need for residential care.

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

  • The practice had a proactive system for identifying carers. The practice had identified 2.3% of the practice population as carers. The ongoing support included links to local services

  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

We saw one area of outstanding practice:

The practice had a GP who was a medical adviser to a nationally recognised charity and had been actively involved in writing the Management and Care Guidelines, including GP guidelines, for Rett Syndrome (a rare condition that affects the development of the brain and causes severe physical and mental disability). These guidelines were distributed to over 4,500 families registered with this syndrome.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice