The Care Quality Commission
  • Doctor
  • GP practice

Holsworthy Doctors

Overall: Good read more about inspection ratings

Holsworthy Medical Centre, Dobles Lane, Holsworthy, Devon, EX22 6GH (01409) 253692

Provided and run by:
Ruby Country Medical Group

All Inspections

29 Sept 2020

During an inspection looking at part of the service

This report follows a desktop inspection which was undertaken to follow up on previous concerns found at an inspection in November 2019. We carried out an announced inspection on 19 November 2019 of this service following our annual review of the information available to us including information provided by the practice. At that inspection we focused on the safe, effective and well led domains. We rated the practice as Good overall but requires improvement for providing effective services and requires improvement in all population groups. The practice was rated Outstanding for providing responsive services.

We rated the practice as requires improvement for providing effective services because:

  • Some areas of performance for patient outcomes significantly declined during 2018/19 when patient numbers increased by 4,000, which the practice was aware of and targeting.

We carried out an announced focused desk-based inspection on 29 September 2020 to follow up on areas where we previously suggested the practice should look to improve their services.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we reviewed evidence gathered from the provider remotely

• 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 for providing effective services and good in the population groups older people, families, children and young people, working age people, vulnerable people and people experiencing mental health issues. We rated the population group of people with long term conditions as requires improvement. This is because:

  • The patient outcomes areas of concern identified during our previous inspection had been monitored and improved. However, the practice achievement was below local Devon clinical commissioning group (CCG) and national averages.
  • Data showed some improvement in the target areas of patients with long-term and mental health conditions in September 2020, however, there was also evidence of high exception reporting.

We found that:

  • Staff teams and services continued to work collaboratively with the wider community and stakeholders.
  • Patients with complex needs continued to receiveproactive co-ordinated care, which had been evaluated and improved upon since the last inspection. Innovative and efficient ways to deliver more joined up care in a safe way had been created for people using services in the wider community.

We also found:

  • The practice had improved their systems to monitor and improve performance of reviewing patients with long-term and mental health conditions. However, further improvement and time was needed to see performance in line with CCG and national averages.
  • Improvements had been made to slightly increase the uptake of cervical cancer screening. However, this was still below the national target of 80%.
  • The practice had reviewed arrangements for storing blank prescription stationery across all sites and ensured that improved security was embedded in their systems and processes.

We identified areas where the practice should make improvements;

  • The percentage of patients with cancer, diagnosed within the preceding 15 months, who have a patient review recorded as occurring within 6 months of the date of diagnosis was lower than the national average. The uptake of cervical cancer screening was also lower than the national target.
  • Patients with dementia having an agreed comprehensive care plan’s exception reporting was 29% which was higher than the local CCG of 10% and nationally 8%.

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant that we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what regulatory action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

Dr Rosie Benneyworth MB BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Please refer to the detailed report and the evidence tables for further information.

19 November 2019

During an inspection looking at part of the service

We rated the practice as outstanding overall in December 2014.

We carried out an inspection of this service due to the length of time since the last inspection. Following our review of the information available to us, including information provided by the practice, we focused our inspection on the following key questions:

  • Is the practice safe?
  • Is the practice effective?
  • Is the practice well led?

Because of the assurance received from our review of information we carried forward the ratings for the following key questions:

  • Is the practice Caring? (Good – December 2014)
  • Is the practice responsive? (Outstanding – December 2014)

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 have rated this practice as requires improvement for the following population groups - older people; families, children and young people; and, people whose circumstances may make them vulnerable, People with long term conditions; working age people (including those recently retired and students); and patients experiencing poor mental health (including people with dementia).

We rated the practice as good for providing safe services because:

  • The practice had a clear vision which had quality and safety as its top priority. Comprehensive systems and processes demonstrated that the practice was safe, but prescription security arrangements needed to be fully adhered to.
  • Patients were safeguarded, lessons were learned and communicated widely to support improvement.
  • There was a proactive approach to anticipating and managing risks to people who use the services, which staffs understood and followed.

We rated the practice as requires improvement for providing effective services because:

  • Some areas of performance for patient outcomes significantly declined during 2018/19 when patient numbers increased by 4,000, which the practice was aware of and targeting.
  • Staff teams and services were committed to working collaboratively with the wider community and stakeholders.
  • Patients with complex needs received proactive co-ordinated care, which had been evaluated and improved upon since the last inspection. Innovative and efficient ways to deliver more joined up care in a safe way had been created for people using services in the wider community.
  • The practice provided leadership in creation of the Holsworthy, Bude and Surrounding Villages Primary Care Network sharing best practice, opportunities for resilience and ongoing developments.

We rated the practice as good for providing well led services because:

  • There was a clear ethos of working in partnership to meet the needs of patients, particularly those most at risk of otherwise not having good access to healthcare. Quality improvement was embedded with continuous clinical and non-clinical audit to support the practice to achieve good health outcomes for patients and to continually improve. Performance was closely monitored and actions in place to address gaps found when 4,000 new patients registered at the practice.
  • The practice had demonstrated sustained innovation and improvement since the last inspection. The leadership, governance and culture provided early detection of these gaps and drove, prioritised and was improving the delivery of high-quality person-centred care when we inspected in November 2019. Leaders were not afraid of safe innovation and strove to continually improve the health outcomes for patients. Change was well managed, and innovation was considered and implemented in a safe way.

We found that:

  • The practice had a clear vision which had quality and safety as its top priority. A five-year strategy was in place, monitored and regularly reviewed and discussed with all staff and patient representatives.
  • There was extensive public engagement prior to and after Ruby Country Medical Group had taken over a contract to provide GP services.
  • Concerns raised at these meetings were acted on and explanations provided about the rationale for some changes in service delivery, for example to promote patient safety.
  • Patient satisfaction was high about involvement in decisions about their care and treatment and timely access to services.
  • 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. However, some areas of performance for patient outcomes reduced in 2018/19 relating to patients who transferred from the other practice which closed. The practice had identified the risk to patient outcomes and put immediate actions in place to improve performance for patients with long-term conditions, working age patients (cervical screening) and mental health needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • New premises had been refurbished to provide a branch surgery in Hatherleigh.
  • The practice had reviewed and organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way with near patient testing available on site or at two other locations run by Ruby Country Medical Group.
  • The way the practice was well led and managed promoted the delivery of high-quality, person-centred care.
  • Since the last inspection, the home visiting team service delivery had increased to meet new demands and mitigate community risks following the closure of one of the local practices.
  • There was a training and development culture, which was supportive and encouraged staff development and competencies to extend services for patients in North Cornwall and Devon.

The areas where the provider should make improvements are:

Continue to monitor and improve performance of reviewing patients with long-term and mental health conditions.

Continue to review arrangements to improve the uptake of cervical screening.

Review compliance of blank prescription stationery security across all sites to ensure change is embedded.

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

8 December 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

Holsworthy Doctors was inspected on Monday 8 December 2014. This was a comprehensive inspection.

Holsworthy Doctors practice provides primary medical services to people living in a rural areas in North Devon covering approximately 250 square miles. Transport links within the area are limited. Holsworthy Doctors provides the highest level of area coverage within England. The area is mostly rural, with high percentage of agriculture and mid range deprivation. The practice provides primary medical services to a diverse population and supports patients living in eight adult social care homes in the area. Holsworthy community hospital is situated next to the practice and GPs have responsibility for 10 patient beds there. At the time of our inspection there were 10,700 patients registered at the service. The practice had a higher than national average number of patients of working age and older people, with fewer children and young people in the total practice population.

The practice has 7 full time GP partners; three male and four female GP partners. There are two Advanced Nurse Practitioners (female). The GPs are also supported by five practice nurses (female), four health care assistants (female) and two phlebotomists (female). The practice manager is also a partner, the registered manager with CQC and manages a large team of administrative staff. Holsworthy Doctors is a training practice, with two GP partners approved to provide vocational training for GPs, second year post qualification doctors and medical students. When we inspected there was GP and two second year registered doctors completing training placements at the practice.

Patients who use the practice have access to community staff including social workers, district nurses, community psychiatric nurses, health visitors, physiotherapists, mental health staff, counsellors, chiropodist and midwives.

The practice is rated as OUTSTANDING.

Our key findings were as follows:

  • Patient satisfaction was higher than the national average, 92% compared with 86% in the 2014 GP survey. Fifty nine patients gave feedback at the inspection, in person (34) or in writing (25). All confirmed they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. The practice had a very good skill mix which included two advanced nurse practitioners (ANPs) and was able to see a broader range of patients than the practice nurses.
  • The practice was purpose built and very well equipped to treat patients and meet their needs.

We saw several areas of outstanding practice including:

  • The practice had a strong vision which had quality and safety as its top priority. A comprehensive business plan was in place, which was monitored and regularly reviewed. Progress with this and action plans were discussed with all staff and shared with PPG members. High standards were promoted and owned by all practice staff with evidence of team working across all roles and with external agencies. The practice held registers for every population group and used tools like the Kings Fund predictive model to rate risk so knew which patients could be at risk of unplanned admissions and ensured appropriate support was in place and well co-ordinated by the community team.
  • The practice understood the needs of the patient list and the challenges of the rural location and had developed a responsive service accordingly. There were many examples of this seen at the inspection. The practice hosted specialist clinics at the practice for procedures normally offered at the main hospital (29 miles away) such as diabetic retinal screening (held 3-4 times a year) regular hospital nurse specialist appointments for patients with complex diabetes and leg ulcer treatment. Access for working patients was facilitated through the availability of early morning appointments every day of the week and weekend clinics for flu vaccination were available throughout the Winter months. Patients were able to request repeat prescriptions and appointments online and sms texting was used for appointment reminders and blood test results. The patient list was managed in a way to avoid any barriers, for example patients who moved out of area were able to remain registered with the practice for continuity of care and treatment. Approximately 1482 patient appointments were delivered each month, which far exceeded the 802 expected for the list size. GPs carried out an average of four home visits each per day, travelling up to 15 miles on rural roads to reach patients in need. The practice also provides pre-hospital emergency care to patients until the ambulance or air ambulance service arrives..
  • The practice was innovative in promoting collaborative working with other agencies to improve outcomes for patients. Significant challenges were overcome by the practice, which facilitated well co-ordinated safeguarding and management of patients with complex care needs. Social services were able to use the practice facilities for safeguarding strategy meetings, which had further enhanced working relationships. Patients, particularly women experiencing domestic violence were able to access discreet face to face social care support at the practice once a week. Holsworthy Doctors held monthly multidisciplinary meetings, which included hospital specialists from the palliative care team. The practice knew that it was difficult for patients needing palliative care support to travel to the local hospice approximately 25 miles away, so had facilitated the building of a satellite day hospice on land owned by the practice. Data showed 100% of all patients newly discharged from hospital following an emergency admission were contacted within 24 hours by GPs from the practice to ensure they had appropriate care, treatment and support.
  • The practice significantly improved access to support for patients living with long term conditions and their carers. For example, the Memory Matters programme run by the Alzheimer's society was hosted at the practice. This enabled carers and patients to attend who would otherwise be unable to travel the distance to Bideford or Barnstaple.

Patient participation was achieved in two ways, through a virtual PPG (50 patients) and face to face meetings with representatives from the Patient Participation Group (PPG). Their suggestions had developed into work streams to implement changes at the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice