Hollybrook Medical Centre

Updated 22 June 2022

Hollybrook Medical Centre is located in Derby at:

Hollybrook Way
Littleover
Derby
DE23 3TX

The practice has a branch surgery at:

Sinfin Health Centre
Arleston Lane
Sinfin
Derby
DE24 3DS

Both sites were visited as part of this inspection.

The provider Aspiro Healthcare is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning, maternity and midwifery services, treatment of disease, disorder or injury and surgical procedures. These are delivered from both sites.

The practice is situated within the Derby and Derbyshire Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of about 22,330. This is part of a contract held with NHS England.

The practice is part of Derby City South Primary Care Network, a wider network of seven GP practices that work collaboratively to deliver primary care services.

Information published by Public Health England reports the deprivation ranking as 6. The lower the number, the more deprived the practice population is relative to others. The age profile demonstrates a significantly lower proportion of older patients compared to the local and national averages, a similar number of working age patients compared to local and national averages, and a higher proportion of young people compared to the local and national averages:

• The percentage of older people registered with the practice is 13.6% which is significantly lower the CCG average of 20.3%, and the national average of 17.6%.
• The percentage of working age people registered with the practice is 61.3% which is similar to the CCG average of 60.2%, and the national average of 62.4%.
• The percentage of young people registered with the practice is 25% which above the CCG average of 19.4%, and the national average of 20%.

The National General Practice Profile indicates that the practice ethnicity as 67.7% white, 22.4% Asian, 3.7% mixed race, 3.9% Black and 2.2% other groups. There are slightly more female patients registered at the practice compared to males.

There is a team of twelve GPs who provide cover at both practices. The GPs are supported by a multidisciplinary team including Advanced Clinical / Nurse Practitioners; practice nurses and a health care assistant; a physician associate; medicines management team led by a senior clinical pharmacist and including clinical pharmacists and pharmacy technicians; first contact physiotherapists and social prescribers. Clinical staff are supported by the practice team led by the Head of Operations and GP Partner.

The main site is open between 8am and 8pm Monday and Thursday, 8am to 6.30pm Tuesday, Wednesday and Friday and 8.30am to 12.30pm alternate Saturdays. The branch site is open 8am to 6.30pm Monday to Friday. The practice offers a range of appointment types including telephone and face to face appointments which can be booked in advance and via online booking.

Out of hours services are provided by Derbyshire Health United via NHS 111.

Updated 22 June 2022

We carried out an announced inspection at Hollybrook Medical Centre on 12 and 17 May 2022. This was the first inspection since registration with the Care Quality Commission. Overall, the practice is rated as good and good in all key questions except responsive, which was rated as requires improvement.

Why we carried out this inspection

This inspection was a comprehensive inspection undertaken as part of our routine inspection programme.

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
• Spoke with staff from a local care home, the community matron and members so the patient participation group by video conferencing
• A short site visit to both sites

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 rated the practice as good for providing a safe, effective, caring and well-led service. This was because:

We found that:

• Staff told us they felt supported and valued in their work.
• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.
• Staff had the skills, knowledge and experience to carry out their roles. There was a system in place to monitor compliance with staff training. Staff were encouraged and supported to develop their skills and knowledge.
• Systems were in place to assure the provider of the competency of staff working in advanced roles.
• Staff generally dealt with patients with kindness and respect, although this was not always the case. Staff involved patients in decisions about their care.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
• The provider recognised the deficits in the service and implemented an improvement plan. This included the proposed merger, development of the whole staff team and better of use of technology to interact with patients and monitor practice performance.

We rated the practice as requires improvement for providing a responsive service because:

• Feedback from patients indicated that they experienced difficulties getting through to the practice by telephone and accessing care.
• Patients could not always access care and treatment in a timely way.

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

• Provide non-clinical staff with the appropriate level of children’s safeguarding training.
• Ensure gaps in employment history are clearly recorded.
• Ensure that all patients with asthma who had been prescribed rescue steroids are offered a follow up review after the exacerbation of their asthma.
• Continue to improve the update of specific childhood immunisations and cervical cancer screening.
• Continue to monitor and improve telephone access and availability of appointments.
• Further development engagement with the patient participation group (PPG).

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