Letter from the Chief Inspector of General Practice

We carried out an announced inspection of this practice on 3 December 2015. Breaches of legal requirements were found. After the comprehensive inspection the practice wrote to us to say what they would do to meet the following legal requirements set out in the Health and Social Care Act (HSCA) 2008:

• Regulation 17 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 Good governance.

• Regulation 18 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 Staffing.

We undertook this comprehensive inspection on 14 December 2016 to check that they had followed their plan and to confirm that they now met legal requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Hollyhurst Medical Centre on our website at

www.cqc.org.uk

. The practice was rated as good overall following this inspection.

Our key findings at this inspection on the 14 December 2016 were as follows:

• The practice had addressed the issues identified during the previous inspection.

• Staff understood and fulfilled their responsibilities to raise concerns, and report incidents and near misses.

• Risks to patients were assessed and well managed.

• Outcomes for patients who use services were good.

• Patients’ needs were assessed and care was planned and delivered following best practice guidance.

• Staff were consistent and proactive in supporting patients to live healthier lives through a targeted approach to health promotion. Information was provided to patients to help them understand the care and treatment available.

• 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 system in place for handling complaints and concerns and responded quickly to any complaints.

• Patients we spoke with raised no concerns regarding making an appointment.

• The practice had good facilities and was well equipped to treat patients and meet their needs.

• There was a leadership structure in place and staff felt supported by management. The practice sought feedback from staff and patients, which they acted on.

• The practice was aware of and complied with the requirements of the Duty of Candour regulation.

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 Hollyhurst Medical Centre on 3 December 2015. Overall the practice is rated as requires improvement.

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

• Non-clinical risks to patients, such as health and safety, were assessed and well managed.
• Significant events were recorded, investigated, however we had concerns about how learning from them was shared with staff.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles.
• The practice could not demonstrate they had an effective system for clinical audit or that they used audits successfully to improve quality.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• Patients said they were able to get an appointment with a GP when they needed one, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice sought feedback from patients, which they acted on.
• Staff said managers were approachable; however there were no formal staff meetings, other than monthly clinical meetings.
• The lead GP in the practice had the experience, but not the capacity to run the practice effectively. The salaried GPs did not receive an appraisal or clinical supervision from the provider.

The areas where the provider must make improvements are:

• Ensure that there is an effective system for clinical audit and that audits are used successfully to improve quality.

• Ensure there is appropriate support and appraisal for salaried GPs.

The areas where the provider should make improvements are:

• Consider sharing the learning from significant events and complaints formally with staff and carry out an annual review of significant events and complaints to ensure there are no patterns or trends.

• Record the numbers of the pre-printed prescription stock which has been distributed in the practice in accordance with national guidance.

• Implement a checking regime for the emergency equipment to ensure items included in it are in date and fit for use.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

This practice is rated as Good overall. (Previous rating December 2016 – Good)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Hollyhurst Medical Centre on 21 August 2018 as part of our current inspection programme.

At this inspection we found:

• The practice had systems in place to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes. However, the fire risk assessment for the branch surgery at Elvaston Road was basic and lacked the necessary details.
• 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.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There was a focus on continuous learning and improvement at all levels of the organisation.

There were areas where the provider should make improvements:

• Improve and strengthen the current fire risk assessment in respect of the branch surgery.
• Familiarise all staff with the practice business continuity plan.
• Continue to recruit patient participation group members and seek their views in relation to the running, development and performance of the practice.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.