The Care Quality Commission
  • Doctor
  • GP practice

Holly House Surgery

Overall: Good read more about inspection ratings

12 Avery Hill Road, New Eltham, SE9 2BD 0844 477 0975

Provided and run by:
Welling Medical Practice

All Inspections

28 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of the practice on 8 September 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 legal requirements in relation to the breach of regulation 12(1)(2)(b)(d)(h) Safe care and treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We undertook this desk-based focussed inspection on 28 April 2016 to check that they had followed their plan and to confirm that they now met the legal requirements. This report covers our findings in relation to those requirements and also where additional improvements have been made following the initial inspection. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Holly House Surgery on our website at www.cqc.org.uk.

Overall the practice is rated as Good. Specifically, following the focussed inspection we found the practice to be good for providing safe services, however they were still Requires improvement for responsive services. As the practice was now found to be providing good services for safety, this affected the ratings for the population groups we inspect against. Therefore, it was also good for providing services for older people; people with long-term conditions; families, children and young people; working age people (including those recently retired and students); people whose circumstances make them vulnerable and people experiencing poor mental health (including people with dementia).

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

  • Risks to patients were assessed and well-managed, including those related to infection control, health and safety and responding to emergencies.

However there were areas of practice where the provider should make improvements:

  • Ensure that clinical staffing levels are appropriately planned and monitored.
  • Ensure compliance of the premises with the Equality Act 2010.
  • Improve access to pre-bookable appointments and appointments with a named GP for continuity of care, particularly for patients from vulnerable groups and those with long-term conditions.
  • Ensure that complaints are responded to in an appropriate manner.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

8 September 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Holly House Surgery on 8 September 2015. Overall the practice is rated as requires improvement.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

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

  • There were arrangements for identifying, recording and managing risks and implementing mitigating actions.
  • Most risks to patients were assessed and well managed, with the exception of those relating to infection control and responding to emergencies.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • Data showed that patient outcomes were average or above for the locality. Some clinical audits had been carried out, with evidence that they were driving improvement in performance to improve patient outcomes.
  • Most patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • The practice was equipped to treat patients and meet their needs, although not all areas of the practice were accessible to those with physical disabilities.
  • Urgent appointments were available on the day they were requested. However, patients said that they had difficulty accessing an appointment with a named GP.
  • Information about services and how to complain was available and easy to understand.
  • Policies and procedures were in date and were accessible for staff.
  • There was a clear leadership structure and staff felt supported by management. The practice sought feedback from staff and patients, which it acted on.
  • The practice had an established and active patient participation group (PPG).
  • There was evidence of learning and improvement within the practice from incidents, complaints, audits and risk assessments, but these were not always linked together to identify themes. Action points were not always monitored effectively to demonstrate that improvements in the practice had been successful.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider must:

  • Ensure that the practice has systems in place to be able to appropriately respond to emergencies, including access to a defibrillator and basic life supporting training for all staff.
  • Ensure there are adequate infection control processes in place to include infection control training for staff, adequate cleaning processes and monitoring of the control of substances hazardous to health (COSHH).

In addition the provider should:

  • Improve access to pre-bookable appointments and appointments with a named GP for continuity of care; particularly for patients from vulnerable groups and those with long-term conditions.
  • Ensure that patients, including those from vulnerable groups, are given sufficient information to be involved in treatment and care planning.
  • Ensure compliance of the premises with the Equality Act 2010.
  • Ensure that the practice has a clear incident reporting policy for staff to refer to.
  • Ensure that health and safety assessments are thoroughly documented.
  • Ensure that clinical staffing levels are appropriately planned and monitored.
  • Ensure that systems are in place to monitor and improve the quality of medical records.
  • Ensure that complaints are responded to in an appropriate manner.
  • Ensure that there are systems in place to monitor actions taken as a result of learning and improvements, to demonstrate that changes in the practice have been successful.
  • Ensure that induction processes are robust, to include mandatory training for all staff and ensure that systems are in place to maintain up to date employment checks for existing members of staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice