Hollyns Health and Wellbeing

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our last inspection in April 2023, we rated this key question as requires improvement due to concerns identified in relation to ineffective management of patients with pre-existing conditions as well as low performance in relation to cervical screening and child immunisations uptake. At this assessment, the rating has changed to good as management of patients with pre-existing conditions had improved. Despite action by the practice to improve cervical screening and child immunisations uptake rate, they continued to be below national targets in some areas. Staff had access to training and learning opportunities to support them in their role. The practice engaged with other services and supported patients to manage their health and wellbeing. Staff made sure patients understood their care and treatment to enable them to give informed consent. Processes were in place to support patients to make informed decisions about their future, and to review patients at the end of their lives.

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.

A review of clinical records showed that the treatment of patients with some long-term conditions including chronic kidney disease was effectively managed. We found there were 1,298 patients on the practice’s asthma register, of which 58 had been prescribed 2 or more courses of rescue steroids. We reviewed records for 3 of these patients and found that 2 had been effectively managed. The third patient had not been appropriately assessed by the pharmacist prior to prescribing of rescue steroids, and had not received a steroid card. After the assessment the practice told us that feedback had been provided to the pharmacy team to review their prescribing processes as this was not in line with practice policy.

In addition, we found that 9 of 450 patients diagnosed with hypothyroidism had not had the required monitoring in the last 18 months. We reviewed 2 records with the practice and were informed that risk assessments were undertaken at clinical meetings where patients did not engage with the practice.

Furthermore, we reviewed records for 2 patients registered with diabetes and with a latest HbA1c of more than 74mmol/l, and found that monitoring was overdue. The practice told us that one appointment had been arranged and that they would ensure the other was made.

Staff were aware of the needs of the local community and checked patients’ health, care, and wellbeing needs during health reviews. The provider had effective systems to identify patients with previously undiagnosed conditions. Patient’s accessibility and communication needs were taken into account, and they were supported accordingly, for example through the use of translation services. Staff could refer patients with specific needs, such as those experiencing poor mental health, to social prescribers and other services.

There was a clinical triage policy in place, and staff had received training in care navigation.

The practice had a palliative care register with 160 patients and these patients were reviewed in monthly meetings and supported to make informed decisions about their future. There were dedicated staff to oversee and support at risk patients, including care home patients.

Clinical staff told us they followed best practice guidance when carrying out their work. They also told us they had access to training and learning opportunities and were supported with their professional development. We saw several examples of this including nurse managers undertaking managerial training, and staff having dedicated study days.

However, as part of our clinical searches we reviewed records for 5 patients prescribed methotrexate (a disease-modifying anti-rheumatic drug) and found all 5 records did not specify the day of the week the medication was to be taken, in line with Medicines and Healthcare products Regulatory Agency (MHRA) guidance. After the assessment the practice told us they would audit all patients on methotrexate and ensure a day of the week was documented in the medication repeat template.

Staff had access to the information they needed to appropriately assess, plan, and deliver patient’s care, treatment, and support. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. Staff and leaders told us how they managed information sharing with other providers, including out of hours teams.

The practice supported patients to manage their health and wellbeing to maximise their independence, choice and control. Patients were supported to live healthier lives and where possible, reduce their future needs for care and support.

Staff supported initiatives to improve population health. This included referral to social prescribers and for mental health and bereavement support, as well as encouraging patients to attend for cancer screening. Leaders were taking steps to improve uptake rates for cervical screening.

There were processes in place to invite patients for relevant health checks. In the last 12 months 2,362 patients were eligible for an NHS health check. Of these,157 had been completed. There were also systems in place to identify patients in need of extra support, for example those with a learning disability. The practice had 127 patients on their learning disability register. Of these, 110 had received a health check in the last 12 months. The practice had also identified 240 patients as carers. Information to support patients was available around the practices, on the practice website and in patient newsletters.

The GP Patient Survey for 2024 showed that 49% of patients felt they had enough support from local services or organisations to manage long-term conditions, compared to the national average of 68%.

The practice’s cervical screening uptake rate in June 2023 was 68%, which was below the 80% national target. More recent and unverified data provided by the practice for April 2025 indicated an uptake rate above 80%.

Data from March 2024 showed that the practice had met the 90% minimum uptake rate for 3 out of 5 routine childhood vaccinations indicators. For the 2 indicators below the minimum uptake rate, 1 (children aged 5 who have received immunisation for measles, mumps and rubella) had declined since March 2023 (from 85.2% to 75.6%), and 1 (children aged 2 who have received a Pneumococcal booster) had improved (from 79.1% to 88.3%).

The practice told us of the steps they took to encourage patients to attend for cervical screening and childhood immunisations, which included sending regular recalls, carrying out opportunistic promotion and testing, and through additional staff recruitment and training. For example, the practice had recruited a women’s, newborn and infant practitioner in November 2023 to focus on increasing childhood immunisation promotion and uptake. The practice website also contained links to websites with information on cervical screening and childhood immunisation.

The practice had also recently enhanced the process for patients to book an appointment for cervical screening by allowing them to book directly via a link sent to them by text message. Where childhood immunisations were declined by patients, this was highlighted with the safeguarding lead and escalated to relevant stakeholders such as health visitors.

Staff we spoke with could outline the systems in place to recall and review patients and understood their role in this process.

Appropriate registers were held to ensure effective monitoring of specific groups such as those receiving palliative care.

Staff told us how they dealt with consent and how they helped patients make decisions about their care, including the use of relevant guidelines and recording consent.

There was a consent policy in place which covered areas such as capacity consent for children. Carers and advocates were involved in consultation processes where required. Processes were in place to support patients to make informed decisions about their future, and to review patients at the end of their lives. Staff also told us how they worked with patients, and their carers, to support them to understand their options regarding Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) decisions. We saw that DNACPR and Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms were completed in line with guidance and with the input of patients, and when necessary, their carers.