Hollyhurst Medical Centre

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our previous inspection in September 2022 the practice was rated Requires Improvement at providing an effective service. At this inspection we rated effective as good as there had been some improvements although there were still some issues with completions of annual asthma reviews and annual health checks for people with a learning disability. The practice had a strategy in place for improving these however there were still gaps in both types of annual review completions. We found staff involved people in decisions about their care and treatment and provided them with advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this. We saw that the most recently available data showed that childhood immunisations were above with national targets, however cervical screening were below these. Audits were completed however the quality and effectiveness of these meant it was difficult to compare findings and monitor any improvements in outcomes.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Our assessment raised no concerns in this area, and we received no specific feedback from patients on this.

The provider assessed the needs of its population in terms of appointment availability. Leaders told us they set staffing levels to ensure the wait for routine appointments was 8 - 10 days. Staff holiday and sickness cover was provided by existing staff and regular locums to maintain this level of access to appointments. Staff and leaders told us they reviewed patient feedback with access and acted accordingly.

The provider accessed social prescribing link workers via the primary care network (PCN). Social prescribing is a key component of Universal Personalised Care. It is an approach that connects people to activities, groups, and services in their community to meet the practical, social and emotional needs that affect their health and wellbeing. The provider had a system in place to ensure people were invited back regularly for their annual health checks, however the result from our clinical searches shows that this is not working effectively to ensure all reviews are completed annually. In relation to outcomes, we saw from data from NHS Digital - Cervical Screening Programme Coverage Statistics that for the percentage of persons eligible for cervical cancer screening who were screened adequately within 3.5 years for persons aged 25 to 49, and within 5.5 years for persons aged 50 to 64, at 30/6/2023 the practice had achieved 77.2% - the expected percentage was 80%. Child immunisations were above the 90% minimum vaccination rate recommended by the World Health Organisation (WHO). The practice has provided further data for cervical screening up to 07/01/2025 which shows for the percentage of persons eligible for cervical cancer screening who were screened adequately within 3.5 years for persons aged 25 to 49, and within 5.5 years for persons aged 50 to 64, the practice had achieved 87% and 92% for the respective age groups well above the expected percentage of 80%. This additional data has not yet been verified or published.

We received no specific feedback from patients on this.

The leaders at the practice told us they carried out regular audits.

We looked at 4 clinical audits in detail. All audit summaries were non-specific and appropriate action plans were not included. In 2 of the 4 clinical audits reviewed, results had not improved from the initial audit cycle, and yet no action plan had been created to address this. In the 2 remaining audits, the documented findings did not reflect the aim of the audits, with no specific figures being included. Repeated audit cycles were therefore unable to be compared with previous findings to monitor improvement.

Our assessment raised no concerns in this area and we received no specific feedback from patients on this.

Leadership told us they cooperated across services to support people. There was a procedure for staff to follow to action incoming letters and discharge summaries. Staff commented that the process could sometimes fall behind, particularly when staff were absent or on annual leave. However, they did confirm important clinical information such as test results were prioritised at all times.

We received no comment in this area from stakeholders.

We saw examples of recent multi-disciplinary team meetings where for example, safeguarding and palliative care were discussed. Recent deaths were discussed to assess if there was any learning for the practice to learn from going forward.

Our assessment raised no concerns in this area, and we received no specific feedback from patients on this.

Staff and leaders told us they supported people to live healthier lives. They were also proud to be a veteran accredited practice to support serving and veteran patients. For example, with mental health and drug and alcohol issues using military charities and NHS services.

The practice supported national priorities and initiatives to improve the population’s health, for example, stop smoking campaigns and tackling obesity. We found patients could access appointments with a variety of clinicians in a timely manner. Social prescribers were available to support patients with a wide variety of their needs including diet, exercise and mental health as well as advice on housing and finance.

We received no specific feedback from patients on this.

We discussed our clinical searches with the lead GP. Innovative action was taken to improve patient care recently with training provided for a GP to fit contraceptive devices. The outcome was to provide local support to patients and saving the patients travelling further afield for such a service.

The clinical searches of the practice patient records system showed there were 557 tasks outstanding of which 241 were classed as high priority. We queried this during our site visit and established that there is no system to regularly monitor or audit this system. Since the inspection the practice audited the online tasks, and we have received further data for the week ending 23 August to show tasks for staff totalled between 187 to 224.

At the time of the inspection the clinical searches of the practice patient records system showed 44% of patients with learning disability who were due an annual review had not had one. There were 32 patients with a learning disability registered with the practice. Therefore, 14 patients had not had their annual review. The Practice has since provided further data which states 3 patients were incorrectly classified as having a learning disability and 3 patients had had an annual review which was not captured by the search as having been completed. The updated information results in 24% or 7 patients out of 29 patients not having completed their annual learning disability health review.

Patients were given the opportunity to provide feedback and they knew how to make a complaint. The provider displayed feedback forms and information on how to make a complaint in the practices. We reviewed patient surveys and any feedback from patients or carers however there was no specific feedback from patients on consent to care and treatment.

We spoke with the practice leaders about consent. They explained that patients provided signed consent for all minor operations. For all non-surgical procedures, consent was 'implied'. Implied consent refers to instances where the consent of the patient can be implied without them having to take positive actions, such as attending specific appointments. We saw examples of documented implied and verbal consent for non-surgical procedures.

The provider did not provide sufficient evidence to demonstrate they had considered an effective policy of consent nor was there evidence they monitored clinicians to ensure they were meeting best standards of practice. We requested an example of written patient consent for a surgical procedure, which the practice did not provide. However, we received evidence where informed consent was recorded and the principles of the Mental Capacity Act and Best interests process were followed and documented clearly for patients who lack capacity when undergoing cervical screening and prostate examinations.