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Inspection Summary

Overall summary & rating


Updated 17 December 2019

We carried out an announced comprehensive inspection at Hollins Grove Surgery on 12 November 2019.

We had previously inspected the practice in March 2019 where the practice was rated as requires improvement overall, (Safe and Effective rated as requires improvement and Well led rated as inadequate). We issued a warning notice for breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Good Governance). We undertook a focused inspection of the practice in August 2019 to monitor the actions implemented to meet the legal requirements in relation to the breach identified within the warning notice. That inspection noted improvements in complying with the breach of regulations. The full reports for the inspections in March and August 2019 can be found by selecting the ‘all reports’ link for Hollins Grove Surgery on our website at

We carried out our most recent inspection in order to ensure the practice had implemented appropriate improvements.

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, with population group Families, children and young people population group rated as requires improvement.

We rated the practice as requires improvement for services provided to Families, children and young people because:

  • Data showed immunisation and vaccination achievement was significantly below the world health organisation target of 95%.

We rated the practice good for providing safe, effective, caring, responsive and well led services because:

  • A comprehensive quality improvement plan had been implemented and effective progress and achievement made in improving service delivery in many areas.
  • The practice systematically reviewed the service it provided and recognised and used opportunities provided by feedback, significant events and complaints to improve.
  • We found systems had been implemented to ensure significant events, patient safety alerts, responding to test results and recruitments checks had all improved.
  • Safeguarding records had improved although some coding issues remained.
  • The management of medicines had improved, although we found structured annual reviews for patients prescribed regular medicines were not yet in place. The GP was implementing a plan to improve this.
  • The practice had recruited three clinical pharmacists and another practice nurse to assist them in meeting the needs of their patient population.
  • A strategy of joint working and collaboration with another GP practice was established. This provided support and resilience.
  • 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.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The areas where the provider should make improvements are:

  • Update children’s safeguarding records so that people, including parents, grandparents and other adults are coded and linked to the record.
  • Implement action to ensure children receive immunisations as required.
  • Continue to implement the practice plan to provide structured medicine reviews to patients.
  • Continue training the practice nurse to enable improvements in reviews of long-term conditions.
  • Provide enhanced training to the lead for infection prevention and control.

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

Inspection areas










Checks on specific services

People with long term conditions


Families, children and young people

Requires improvement

Older people


Working age people (including those recently retired and students)


People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable