The Care Quality Commission
  • Doctor
  • GP practice

Holly Tree Surgery

Overall: Good read more about inspection ratings

42 Boundstone Road, Wrecclesham, Farnham, Surrey, GU10 4TG (01252) 793183

Provided and run by:
Holly Tree Surgery

All Inspections

During an assessment under our new approach

Date of Assessment: 15 July 2026. Holly Tree Surgery is a GP practice and delivers services to approximately 6,060 people under a contract held with NHS England. According to the latest available data, the ethnic make-up of the service area is approximately 93.8% White, 2.9% Asian, 2.2% Mixed, 0.7% Black and 0.5% Other. Information published by the Office for Health Improvement and Disparities shows deprivation within the service population group is in the 10th decile (10 of 10). The lower the decile, the more deprived the service population is relative to others.

This was a focused assessment. We undertook this assessment due to the length of time since our last assessment. We assessed 10 quality statements from across all 5 key questions. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.

Systems and processes related to the safe recruitment of staff, infection prevention and control and safe environments were not always effective and required strengthening and improvement because they did not always follow national guidance or best practice. Not all staff were up to date with their mandatory training. However, there were enough staff with the right skills, qualifications and experience. Facilities were kept clean and staff maintained equipment appropriately to ensure people were kept safe.

Staff supported people to live healthier lives, monitoring their care and treatment to ensure they received positive and consistent outcomes. The service’s childhood immunisation results were above the national target for all 5 indicators.

Staff treated people with kindness, empathy and compassion, and respected their privacy and dignity. Feedback from people using the service was generally very positive about how they were treated, listened to and consulted with.

People could access care, treatment and support when they needed it. Leaders and staff were alert to discrimination and inequality that could disadvantage groups of people who used the service and sought ways to address any barriers. This included making changes in response to feedback from people such as the location where extended access appointments were delivered from.

The service did not have clear and effective governance processes related to the assessment and management of risk and performance within the service. Although we found the service was developing a vision and strategy which considered the needs of the people who used their service and the wider community after the formation of a new partnership. Staff understood their individual roles and responsibilities. Leaders accounted for the actions, behaviours and performance of staff through clear and effective governance processes.

We found 1 breach of regulation in relation to good governance. We have asked the provider for an action plan in response to the concerns found at this assessment.

17 July 2020

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Holly Tree Surgery on 6 November 2019 to follow up on breaches of regulation found in a previous inspection. We rated the practice as Good overall, however we found a further breach of regulation and rated Well led as Requires Improvement. You can read the full report by selecting the ‘all reports’ link for Holly Tree Surgery on our website at .

We were mindful of the impact of the Covid-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what type of inspection was necessary and proportionate, this was therefore a desk-based review. On 17 July 2020, we carried out the desk-based review to confirm that the practice had carried out its plan to meet the legal requirements in relation to the breach of regulations that we identified at our inspection in November 2019.

We found that the practice is now meeting those requirements and we have amended the rating for this practice accordingly. The practice is now rated Good for the provision of Well led services. We previously rated the practice as Good for providing Safe, Effective, Caring and Responsive services.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we reviewed the information sent to us by the provider
  • information from our ongoing monitoring of data about services and
  • information from the provider.

We have rated Well led as Good because:

  • After the last inspection the practice had reviewed their arrangements for monitoring waiting times for the “sit and wait” system for GP appointments. They had undertaken an audit of waiting times in March 2020 to establish any areas of risk.
  • Due to COVID-19, the “sit and wait” service had been temporarily suspended in March 2020 and a new system of telephone consultations was commenced. This had enabled reception staff to identify priorities of care and treatment, where previously this had not been undertaken for the “sit and wait” system (due to confidentiality in the reception and waiting area).
  • The practice had sent a health questionnaire to all staff (including new starters) to determine if any reasonable adjustments were required to their work. The COVID-19 pandemic had resulted in some staff requiring to shield at home and not enter the workplace. They were given flexibility in working from home with remote access.
  • Risk assessments of the practice and dispensary had been carried out to identify any risks to security.
  • There had been two further infection prevention and control (IPC) audits carried out since the last inspection. The audits highlighted continuing concerns with the standards of cleaning and the practice was in regular communication with the contract cleaners to improve this outcome.

The practice had also made improvements since the last inspection in the following areas:

  • The practice had commenced, and was in the process of, collecting information about staff immunisation status to inform them of any risks to patients, visitors or staff. They had reviewed the guidance in “the Green book” and had commenced with gaining clinical staff information first. We saw a spreadsheet of staff immunisations and where gaps were being followed up by the practice.
  • The practice had implemented a system to support collecting informal verbal complaints and other feedback. They had placed books in the reception area, in all clinical rooms, with the medical secretaries and in the dispensary for staff to write in, to capture feedback that was not a formal complaint. The system had only been in place since March 2020 (at the start of the COVID-19 pandemic) and there had been no reported informal verbal complaints or feedback for the practice team to review for themes or trends.
  • The practice had developed a system to recall patients on the learning disabilities register for annual health checks. A member of staff was responsible for undertaking the searches, contacting the patients and sending out an “easy read” patient information leaflet to request information from the patient (or their carer) before the appointment. The system was implemented in April 2020, but due to the restrictions in GP services with the COVID-19 pandemic, had been put on hold. The practice was looking to commence recall for patients on the learning disability register from August 2020.

The areas where the provider should make improvements are:

  • Continue to monitor and review consent seeking processes to ensure accurate records are kept and consent is gained in line with guidance.
  • Continue to collate staff immunisation status to inform any risks to patients, visitors or staff.
  • Continue to include and engage with staff groups to improve communication.
  • Continue to monitor and maintain oversight of cleaning standards and any related infection control issues.

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

6 November 2019

During a routine inspection

We carried out an announced comprehensive inspection at Holly Tree Surgery on 6 November 2019 as part of our inspection programme. At this inspection we followed up on breaches of regulations identified at a previous inspection on 6 November 2018.

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.

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

  • The practice had not consistently identified areas that required a review, such as monitoring of waiting times for the sit and wait service. Staff induction processes were not established and there were no records of staff health status to determine if reasonable adjustments should be applied. We also identified some infection control governance concerns, which required a review.
  • The practice had not identified or assessed potential risks to patient safety and we found concerns with practice premises and security and patient prioritisation processes.

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

  • The practice had clear systems, practices and processes to keep people safe and safeguarded from abuse.
  • Staff training was organised and maintained throughout the year and clinicians could demonstrate they used evidence based practice.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised services to meet patients’ needs. Patients could access care and treatment at a time that suited them.

The areas where the provider must make improvements are:

  • 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:

  • Develop a system for monitoring consent seeking process.
  • Continue to collect staff immunisation status information, to keep staff and patients safe.
  • Identify correct storage processes for maintaining the cold chain when transporting refrigerated medicines outside the practice.
  • Implement a system to support how verbal complaints and feedback from patients can be documented and reviewed to identify any themes and trends.
  • Improve complaint responses to include details of the health ombudsman.
  • Develop a system for undertaking health checks for patients on the learning disability register.

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

During a routine inspection

This practice is rated as requires improvement overall. (Previous rating June 2016 – Good)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We carried out an announced comprehensive inspection at Holly Tree Surgery on 6 November 2018 as part of our inspection programme.

At this inspection we found:

  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • The practice had an active Patient Participation Group who had undertaken a patient survey between September and December 2017 regarding the walk-in appointment system. Results were positive.
  • Patient feedback received during patient interviews and via comments cards were unanimously positive regarding the care and treatment received at the practice.
  • The practice had successfully recruited two GPs within the last 12 months.
  • There were shortfalls regarding staff training, recruitment processes, support via appraisals and communication via team meetings.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it. Access to the practice was particularly rated highly.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.
  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

The areas where the provider should make improvements are:

  • Review the system to monitor actions taken, following safety alerts.
  • Review arrangements to undertake and record regular staff meetings and review arrangements for staff to access meeting minutes.
  • Review arrangements to imbed policies and procedures so that they are understood by all staff.
  • Review information for patients contained in the patient information folder.

You can see full details of the regulations not being met at the end of this report.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

12 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Holly Tree Surgery on 12 May 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Improvements were made to the quality of care as a result of complaints and concerns.
  • The practice held daily walk-in clinics instead of an appointment system. Comments we received and patients we spoke with told us they were always able to get on the day appointments and thought this service worked well. Appointments with the nurse or healthcare assistants could be booked in advance as well as specific services with the GP. For example, contraception services or minor surgery.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

We saw areas where the provider should make an improvement:

  • Review the frequency of internal meetings. Ensure staff who may benefit from attending are invited to do so.

  • Review the recording of minutes or actions from meetings held to ensure the dissemination of information to staff not present and to support shared learning.

  • Review future succession planning.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice