We carried out an announced comprehensive inspection at Holly Bank Surgery on 13 June 2017. The full comprehensive report on the June 2017 inspection can be found by selecting the ‘all reports’ link for Holly Bank Surgery on our website at www.cqc.org.uk.

At our previous inspection in June 2017 we rated the practice as ‘good’ overall but as ‘requires improvement’ for the key question of safety. This was because improvements were needed to demonstrate staff suitability for their roles and responsibilities. We made this judgment because we found there were gaps in employee records included identity checks and Disclosure and Barring service checks. We issued a requirement notice as this was a breach of regulation.

This announced inspection visit was carried out on 6 March 2018 to check that the provider had carried out their plan to meet the legal requirements in relation to the breach. This report covers our findings in relation to that and additional improvements made since our last inspection.

The findings of this inspection were that the provider had taken action to meet the requirement notice issued as all required checks and associated records had been obtained and were held on staff personnel records.

The key question of safety is now rated as good. Overall the practice continues to be rated as good.

Our key findings were as follows:

• All required information and employment checks were available for each person employed.

The provider had also made a number of improvements to the service in response to recommendations we made at our last inspection. These included:

• A review of the level of clinical staffing had been carried out and this had been increased.

• The system in place for identifying and acting upon significant events had been improved to ensure all events were captured appropriately.

• Information provided to patients about the complaints process had been reviewed and updated.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Holly Bank Surgery on 13 June 2017. Overall the practice is rated as good but requires improvement for providing safe services. Our key findings across all the areas we inspected were as follows:

• There were systems in place to reduce risks to patient safety. For example, infection control practices were carried out appropriately and there were regular checks on the environment and on equipment used.

• Systems were in place to safeguard people who used the service against the risks of harm or abuse. However, some of these required improvement. For example, staff who acted as chaperones had not always undergone appropriate checks.

• Significant events were not always documented and managed appropriately.

• Systems were in place to deal with medical emergencies and all staff were trained in basic life support.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.

• Clinical audits had been carried out but there was no programme of audit demonstrating improvements in outcomes for patients.

• Feedback from patients about the care and treatment they received from all staff including clinicians was very positive.

• Patients told us they were treated with dignity and respect and they were involved in decisions about their care and treatment.

• Data showed that outcomes for patients at this practice were generally similar to outcomes for patients locally and nationally.

• Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.

• Patients generally told us they could get an appointment when they needed one. The majority of GP appointments were provided as on the day appointments with routine appointments only being booked in advance for vulnerable patients or working patients.

• The practice was located in a purpose built building and had good facilities, including disabled access. It was well equipped to treat patients and meet their needs.

• Information about services and how to complain was available. This required review to ensure patients were provided with accurate information. Complaints had been investigated and responded to in a timely manner.

• There was a clear staff structure and all staff had been in post for a number of years and they understood their roles and responsibilities. However, staffing levels were not sufficientto ensure the safety and sustainability of the service in the longer term. The provider was aware of this and had plans in place to address the concerns.

• The provider sought patient views about improvements that could be made to the service. This included the practice having and consulting with a patient participation group (PPG).

Areas where the provider must make improvement:

• Ensure specified information is available regarding each person employed linked to their roles and responsibilities.

Areas where the provider should make improvements:

• Review staffing to ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed within the service.

• Improve the system in place for identifying and acting upon significant events.

• Develop a clinical auditing programme that demonstrates improvements in outcomes for patients.

• Review the information provided to patients about the complaints process.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice