Hollyhurst Medical Centre

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

At our previous inspection, the practice was rated good in providing well-led services. At this assessment we have rated the practice as requires improvement for providing a well-led service. There was a breach of regulation as we were concerned with the lack of effective systems and processes in place. The practice failed to demonstrate clear oversight of governance arrangements to ensure risks to patients, staff and visitors to the practice were considered, managed and mitigated appropriately. These include a lack of clinical supervision; effective audit process; infection prevention and control and fire risk assessments. Staff were positive about being part of a team and well supported by leaders. However, we found some staff thought communication and frequency of team meetings could be improved to share learning and enhance understanding.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders told us that staff were involved in developing the practice vision and values statement, which was reviewed annually, and displayed within the practice. When surveyed, most staff agreed that the practice had a clear vision for the future. However, all staff told us that they were not involved in strategic planning for the practice. Non-clinical staff also reported a lack of team meetings to share learning and updates, as well as to assist team building. Staff did provide positive feedback about those in leadership.

We received a copy of the practice’s business plan for 2023 to 2028. The plan details the providers purpose, core values and mission statement together with an outline of the staffing, premises and communication systems. Patient care key areas for improvement are clearly identified together with the short, medium and long term goals of the service, however succession planning is not covered

Leaders told us they focused on staff wellbeing for example managing workloads, providing flexible working hours and arranging reasonable adjustments where necessary. Leaders also arrange team social events. Staff felt supported and guided by their leadership team they told us the leaders were approachable and made time for staff.

The General Medical Council registration was in place for the Doctors who were all suitably qualified and experienced. The roles of staff and leaders were clear, and they understood their responsibilities and accountabilities. There was inclusive recruitment however there was little evidence of succession planning for the future.

Staff were aware of how and when to contact the freedom to speak up guardian.

The Provider had made arrangements via their primary care network to provide an independent freedom to speak up guardian who worked at a neighboring practice.

Leaders supported staff and told us they had an open-door policy which staff we spoke to confirmed. Staff told us they felt they could approach leaders at any time if they required support. Staff told us they have completed equality, diversity, and inclusion training, records also confirm this training was completed by all staff.

The provider had a diverse workforce in place. All staff received equality, diversity, and inclusion training as part of their mandatory training.

Leaders supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Leaders met with staff annually to complete appraisals. Leaders told us there were systems in place to maintain continuity of service in unexpected events. A business continuity plan was in place, that covered a wide range of scenarios and mitigation. Leaders told us there were processes in place to securely store records electronically. The practice has a family and friends feedback system in place, to gather monthly data to drive improvement. Some staff reported poor communication and inadequate meetings in terms of frequency and outcomes. Non-clinical staff told us leaders did not hold regular staff meetings to share information, changes in policies and learning from incidents. Leaders explained they were aware of this, and it was due to the varied working hours of non-clinical staff, however they plan to improve this.

Staff received annual appraisals, which were in date. For Primary Care Network staff clear guidance was in place for supervision arrangements within the Network. However, there was no record of locum Doctors or salaried GP’s clinical supervision. The supervision for the nonmedical prescriber consisted of an annual audit followed up at appraisal rather than reaudited in close succession to verify learning and improvement. The provider had systems, processes, and policies in place for the practice, which staff had access to. However, we found evidence some were ineffective and insufficiently embedded. For example: There was a clinical supervision policy, but this did not refer to how frequently clinical supervision should occur and there was no evidence that supervision had been completed on a regular basis. Audits were completed but the quality, effectiveness and frequency varied which restricted the ability to use these to make improvements. Some audits identified issues but there was no evidence of action plans. Leaders had identified issues with infection prevention and control at the Elvaston Road surgery. However, they had failed to rectify issues in a timely manner. The provider had no evidence that a regular fire safety audit was carried out and any findings acted upon immediately as part of their assurance process. We identified a large number of outstanding clinical and non-clinical tasks assigned to staff on the practice’s clinical system. There was no management oversight of task workloads and risk per staff member or their timely completion; reliance was on the staff member to raise the issue with leaders if their workload was too heavy. Leaders held regular clinical staff meetings during which they discussed clinical concerns and emerging risks. Leaders recorded and shared any actions. Nonclinical staff meetings were less regular with only 2 meetings evidenced in the last 12 months.

People were able to access support at the practice rather than be referred elsewhere. For example, a mental health worker was available through the primary care network clinics. The practice did not have a Patient Participation Group which had be the case since the Covid Pandemic in 2020.

There was evidence staff worked closely with the Primary Care Network (PCN) and we had examples of multidisciplinary team working, for example with the end of life pathway. Freedom to speak up was provided for staff at PCN level at a nearby practice.

We spoke with the Integrated Care Board who did not have any specific concerns in this area. Dr Singh had been recently appointed as the Clinical Director with the Primary Care Network.

There was evidence of multidisciplinary team working involving external professionals to provide specialist support to patient groups with specific needs. The provider also worked closely with the local primary care network which provided additional roles attending the practice such as a mental health worker, physiotherapist and clinical pharmacist as well as a Digital officer. The Digital Officer role was to help with the communication of information and guidance to patients such as through the screens in the waiting areas and the practice Facebook page.

There was no Patient Participation Group at this practice. Since the COVID pandemic, leaders had attempted to relaunch this but were not successful due to limited engagement from the community. Within the last year, the practice recognised the need for more local sexual health services and had introduced a new service to fit contraceptive devices.

Leaders carried out regular audits, however the frequency was inconsistent, limiting learning opportunities, and some did not have action plans for improvement. Patient feedback was generated on a monthly basis from the friends and family test, and we saw the majority of feedback was positive. Negative feedback was investigated, and we saw evidence of learning.