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Inspection carried out on 12 November 2019

During a routine inspection

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 www.cqc.org.uk.

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 carried out on 7/08/2019

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Hollins Grove Surgery on 6 March 2019. This was the first inspection of this service for this single-handed GP provider. 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). The full comprehensive report on the 6 March 2019 inspection can be found by selecting the ‘all reports’ link for Hollins Grove Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 7 August 2019 to confirm the practice had carried out their plan to meet the legal requirements in relation to the breach identified within the warning notice.

At this inspection we found:

  • Good progress in meeting the requirements of the warning notice had been achieved.
  • A comprehensive quality improvement plan was being implemented and effective progress was being made in improving service delivery in several areas.
  • The GP provider had brought in a support team to help implement the changes required to develop, introduce and improve systems and processes to ensure comprehensive oversight of both managerial and clinical risk. A strategy of joint working and collaboration with another GP practice was being established.
  • Governance systems had been improved. The introduction of a web based electronic information system supported practice management.
  • Systems to ensure safety were prioritised and established and evidence of shared learning and improvement was available.

As per our published inspection methodology, a further full comprehensive inspection visit will be carried out to monitor the work the practice has started to produce the required improvements to the service.

Details of our findings and the evidence supporting them are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection carried out on 06 March to 06 March 2019

During a routine inspection

We carried out an announced comprehensive inspection at Hollins Grove Surgery on 6 March 2019.

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 requires improvement overall.

We rated the practice as requires improvement for providing safe services because:

  • The practice did not have clear systems and processes to keep patients safe.
  • The practice did not have comprehensive systems in place for the safe management of medicines.
  • The practice did not effectively embed learning and improvements identified when things went wrong. Documentation was not comprehensively maintained so as to effectively monitor trends.

We rated the practice as requires improvement for providing effective services because:

  • There was limited monitoring of the outcomes of care and treatment, with no formalised programme of quality improvement activity or clinical audit.
  • Clinical oversight of the management of patients with long term conditions, or vulnerable groups such as those patients with learning disabilities was lacking.

We rated the practice as inadequate for providing well-led services because:

  • Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
  • While the practice had a vision, that vision was not supported by a credible strategy.
  • The overall governance arrangements were ineffective.
  • The practice did not have clear and effective processes for managing risks, issues and performance.
  • The practice did not always act on appropriate and accurate information.
  • We saw little evidence of effective systems and processes for learning, continuous improvement and innovation.

These areas affected all population groups so we rated all population groups as requires improvement.

We rated the practice as good for providing caring and responsive services because:

  • 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 must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Review the IPC audit process to ensure effective oversight and monitoring by the designated lead for IPC within the practice.
  • Complaints literature should be readily available to patients to make them aware of the practice’s complaints process.

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