During an assessment under our new approach
The Hollies Surgery is a GP practice and delivers service to approximately 12,500 patients under a contract held with NHS England. The National General Practice Profiles states that 96.8% of the practice population are from a White background, 1.7% from a mixed background, 2% from an Asian background and 1.1% from a Black background. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 9th decile (9 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
The practice was last assessed in March 2024. We reviewed 9 quality statements and rated the practice as requires improvement overall. In this assessment, we reviewed all quality statements under the safe, effective, caring, responsive and well-led domains.
We found the practice did not have a proactive and positive culture of safety. We found safeguarding procedures did not always keep people safe and protected from harm. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. Leaders at the practice could not demonstrate staff received adequate training and regular appraisals to maintain high-quality care. From our review of clinical searches, we found the provider did not have effective systems to manage patients prescribed high-risk medicines subject to medicines safety alerts or those patients living with long term health conditions.
People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. However, our clinical record searches showed care was not based on latest evidence and good practice.
We found people were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. However, staff wellbeing was not always supported.
People were involved in decisions about their care and the service provided information people could understand. Patient feedback and results from the National GP Patient Survey showed that there was difficulty in accessing the service and obtaining appointments.
Leaders and staff did not demonstrate evidence of a a shared vision and culture. Leaders were not always visible and available to help staff develop in their roles. We found there were shortfalls in governance and management systems. Staff wellbeing and development was not always supported. Managers worked with the local community to deliver care but the service did not always focus on learning and improvement.
We found breaches of regulations and have served the practice with a warning notice under regulation 12 safe care and treatment and regulation 17 good governance under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.