Hollyhurst Medical Centre

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating has remained the same

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Managers encouraged staff to raise concerns when things went wrong. During clinical and non-clinical staff meetings, we saw staff discussed and learnt from issues relevant to their work. Staff felt there was an open culture, and that safety was a priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Health and safety risk assessments and audits had been undertaken and some risks identified had been addressed. However, at the last inspection several issues with the environment and fire safety at the Elvaston Road Branch were identified and an action plan put in place for the provider to resolve these. Most works had been completed; although, on the day of the assessment we saw the fire door seals had not been installed and the wooden shelving unit in reception which was partially blocking a fire exit had not been removed. Our walk around also highlighted an exposed wire and broken wall socket in the main corridor, thought to be a telephone wire and socket which staff said had been like that for some time. We brought this to the attention of the provider who confirmed it would be fixed.

There was a fire safety risk assessment in place but, these issues were not identified in an action plan and therefore progress was not easily monitored. We fed back the 2 outstanding and 1 new issue to the provider who confirmed they would address these immediately.

The redecoration of Elvaston Road practice was in progress on the first floor which is solely used by staff but the ground floor which had the patient facilities had not been started. The provider confirmed it was part of the designated work by the decorator so would be completed shortly.

We saw regular contracts were in place to ensure the premises and equipment were maintained. The practice manager had an online system which was coded red, amber, green, to ensure required maintenance and calibration was highlighted before it was due and then completed.

Clinic rooms were all on the ground floor and had appropriate flooring and equipment. Appropriate emergency equipment and medicines were accessible to staff.

There was a business continuity plan in place which was monitored and reviewed.

The service did not always make sure there were enough qualified, skilled and experienced staff.

Clinical supervision had not changed since the previous inspection. As such, there was no evidence of appropriate clinical supervision and oversight taking place in a structured and timely manner on a 1:1 basis for all roles of clinical staff.

Most staff raised concerns about staffing. Staff surveyed commented that there were insufficient nursing and administrative staff to cover sickness and annual leave. The provider confirmed locum nursing staff were recruited for longer periods of annual leave when there was sufficient notice however, we found the practice nurse was on planned 10 days annual leave at the time of inspection, which was not covered by locum staff. This impacted on the availability of appointments for patients as the wait time was more than two weeks for a nurse or a healthcare assistant. However, patients had access to nurse appointments on Saturdays through the Primary Care Network. After the provider had received the draft report, they sent us evidence to suggest that the practice nurse was available on 6 and 11 November. This did not reflect the evidence we collected on the day of the site visit.

When there was no availability of a nurse or a healthcare assistant and an urgent blood test was required for their patient, doctors confirmed they would take the blood test themselves.

Likewise, administration staff spoke of workload pressures particularly when covering sickness and annual leave. They described times when the workload was overbearing particularly with the volume of scanning of letters and correspondence required.

However, we saw there were a range of clinical and non-clinical roles within the practice. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Staff told us they had received relevant training for their role, and they had access to annual appraisals when development and training was discussed.

Safe recruitment practices were followed. We sampled recruitment checks for staff and saw that checks had been undertaken prior to employment. For example, proof of identification, references, qualifications and registration with the appropriate professional body. Relevant vaccinations were in place for staff which was an improvement from the previous inspection.

We saw all staff who required a disclosure and barring service (DBS) check had one recorded, including those acting as chaperone. These were monitored by management.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The practice had a designated infection, prevention and control lead which was the practice nurse and all staff had had relevant training. Cleaning schedules were in place and followed.

Risk assessments and audits were completed, including hand hygiene and actions taken to mitigate risks.

Since the last inspection all clinic room sinks had been fitted with elbow operated taps as part of the providers action plan. The mould identified at Elvaston Road had been removed and we saw the wall had been replastered. The nurse’s clinic room at Elvaston Road does not have handwashing facilities within the room however, the risk has been assessed, and measures were in place to minimise the risk when the sink outside of the room is used by nursing staff.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. The provider was previously inspected in June 2024 and this included remote clinical searches of the clinical system. The recent results showed little change to the 2024 results.

In our clinical searches for the monitoring of medicines, which are used to treat heart failure and high blood pressure, the results showed 25%, or 10 out of 39 patients had not been monitored at the required 12-month time scale, since their last check. The practice completed searches on patient records to identify those who had not received monitoring checks. They acted upon this and invited patients for monitoring however, no further measures were taken when the patient failed to respond and were non-compliant. We found the medication could be prescribed beyond the review date. This was a recurring theme, throughout the clinical searches.

For the monitoring of medicines, which are used to treat neuropathic pain and occasionally used for epilepsy, just over half of patients equating to 71 patients out of a total of 124 had not been reviewed in the last 12 months. This result was slightly worse than the previous inspection in 2024 when we found 66 patients had not been reviewed in the last 12 months. Of the 2025 data, a sample of 5 patients showed the oldest review dating back to 2020 and some were 2022.The risk is that this medication is addictive and reviews take place to ensure there is clear ongoing evidence of patient benefit. These reviews are typically completed by a GP.

There were 65 patients out of a total of 441 patients with diabetes who’s latest HbA1c was greater than 75mmol/l and they had not had a full annual review. These results were slightly improved from the previous year’s inspection when 81 patients out of a total of 435 patients with diabetes who had HbA1c as greater than 75mmol/l and they had not had a full annual review. The risk is that there could be some deterioration or complication of diabetes which could be missed, and possibly their treatment may be suboptimal. These reviews are nurse led.

There were 7 patients out of a total of 237 with hypothyroidism who had not had thyroid function test monitoring for 18 months or more. This was similar to the previous inspection in 2024 when there were 6 patients out of a total of 239 patients with hypothyroidism who had not had thyroid function test monitoring for 18 months or more. A sample of 5 patient records reviewed for the 2025 inspection showed one was reviewed that day and one had been short scripted, however 3 others had not been short scripted to encourage them to attend the practice for a review. Infrequent reviews can risk patients being under or over treated for their hypothyroidism.

National Institute for Health and Care Excellence guidance advises that patients should be reviewed within 48 hours of an acute exacerbation of asthma and their regular treatment should be stepped up if needed to improve the control of symptoms. For the purpose of our clinical searches this is extended to 7 days. We found there was no consistency in follow up for patients within the timeframe. This was despite the system displaying a prompt to remind the clinician that the review is required. There is a risk of these patients deteriorating due their asthma and not being seen in a timely manner.

For the inspection in June 2024, we noted in the clinical searches of the practice patient records system 44% or 14 patients with a learning disability who were due an annual review had not had one. During this inspection the result had improved slightly however there were 31% or 9 patients who had not had one. This means patients were not being monitored and reviewed in line with the latest guidance.

However, we saw where people did attend for monitoring appointments, staff involved them in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms.

Staff received regular training, and felt confident managing the storage, administration and recording of medicines. We saw staff had the appropriate authorisations to administer medicines under Patient Group Directions (PGD). Staff managed prescription stationery appropriately and securely.

Staff stored medicines securely and at appropriate temperatures. There were no controlled drugs at the practice.

Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks, mostly received recommended monitoring.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.