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

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating remains 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 shared vision and values statement, which was displayed within the practice. Although staff fed back to us that they felt that they were consulted by the management at the practice, almost all of those completing a questionnaire said they did not contribute towards the practice vision or strategy of the organisation.

The practice understood the challenges and the needs of people and their communities and that the patient numbers were increasing. Staff told us that many patients joining the practice were complex cases which needed additional monitoring and reviews.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. However, leaders did not always demonstrate they had the capacity and capability to ensure that the organisational vision could be delivered, and risks were well managed.

Leaders told us they focused on staff wellbeing for example, providing flexible working hours and arranging reasonable adjustments where necessary. Leaders also arrange team social events.

Staff told us leaders in the practice were approachable, supportive and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The practice had established Freedom to Speak up arrangements with another practice through the primary care network. The arrangements were detailed for staff in the Whistleblowing Policy. Staff were aware of how to raise concerns and confident to do so. Overall staff felt their views and suggestions were actively taken on board and gave us examples of this.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Leaders supported staff and had an open-door policy.

Policies and procedures to promote diversity and equality were in place. Staff told us they could approach leaders at any time if they required support. We saw staff had completed equality, diversity, and inclusion training.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Clinical supervision had not changed since the previous inspection when the provider was in breach of regulation. At the last assessment there was a clinical supervision policy, but it omitted detail of the frequency and structure of clinical supervision to direct staff and there was no evidence supervision had been completed.

During this assessment the policy remained unchanged and there was no evidence of appropriate clinical supervision and oversight taking place. This included for the locum and salaried GP’s, the practice nurse, the advanced nurse practitioner and the health care assistant. The policy gave no timelines or framework to guide staff, of their roles and responsibilities for regular clinical supervision to be undertaken by a suitably trained or experienced colleague on a 1:1 basis and be documented. We noted staff did have day to day support for issues arising in the practice.

The practice held regular clinical staff meetings and less frequent administrative staff meetings however there was not an all-staff practice meeting. Clinical and non-clinical staff raised this with us in our staff questionnaires as a way to help their understanding of roles and to feel part of a team working as a more cohesive unit.

For the previous assessment the practice had identified issues with infection prevention and control and fire safety at the Elvaston Road surgery. We noted some works had been completed however, there were unfinished tasks. The risk assessment had not clearly identified actions and their progress, to help oversight. These included shelves in the staff reception area partially blocking a fire door, incomplete fire door seals, redecoration of the ground floor and a new issue of a broken wall socket and exposed telephone wire. However, these issues were being worked on and due to complete imminently.

During this assessment we noted cover arrangements were not in place for practice nurse annual leave. This resulted in a delay of more than 2 weeks for an HCA or Nurse appointment at either site. The HCA was also due to be on leave in the next week or so and no cover had been arranged. 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.

Administration staff also raised concerns about workloads at times being overwhelming, particularly the scanning of correspondence at Hollyhurst Medical Centre. Additionally, we noted there were 203 patient records not summarised on the clinical system dating back to February 2022. These had been risk assessed to ensure Managers that the information not uploaded was not urgent.

However, at the last inspection in June 2024, we identified a large number of outstanding clinical and non-clinical tasks assigned to staff on the practice’s clinical system. There had been no management oversight of task workloads and their timely completion. However, the practice had implemented improvements with a system of regular oversight now in place and embedded. We checked task numbers at a couple of time points during the assessment and saw they had reduced significantly.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Leaders met with staff annually to complete appraisals. Competency assessments of patient consultation records were also completed on nursing staff prior to their annual appraisal. The provider had established governance processes that were mostly appropriate for their service. Staff could access all required policies and procedures.

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.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The provider worked with other practices within their primary care network to offer extended access. Staff had made adjustments to improve coordination of their service with community healthcare services.

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 holds a Veteran Friendly accreditation. This is a recognized program run by the Royal College of General Practitioners (RCGP) and NHS England for providing better care for veterans.

Freedom to speak up was provided for staff at PCN level at a nearby practice

The practice did not have a Practice Participation Group which had been the case since the Covid Pandemic in 2020.

The service focused on learning, and improvement across the organisation and local system.

Leaders told us they supported the development of their staff and encouraged creative ways of delivering improved care, experience and outcomes for patients. Clinical staff told us they discussed and learned from complaints, incidents and audits. We saw nonclinical staff reviewed some complaints and incidents during meetings which were noted in the minutes.

The advanced nurse practitioner was undertaking menopause training to become a menopause champion to enhance patient care.

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.