Hollybrook Medical Centre

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