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Holbrooks Health Team Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 30 September 2021

We carried out an announced inspection at Holbrooks Health Team on 18 August 2021.

The key questions are rated as:

Safe - Requires Improvement

Effective – Requires Improvement

Well-led - Inadequate

Following our previous inspection on 5 January 2016, the practice was rated Good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Holbrooks Health Team on our website at

Why we carried out this inspection

This inspection was a focused inspection to follow up on the information of concern we had received into the Commission.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short site visit

Our findings

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 and Good for the population groups Older People, People whose circumstances make them vulnerable and People experiencing poor mental health. The population groups People with Long-term Conditions, Families, children and young people and Working age people have been rated as Requires Improvement.

We found that:

  • One medicine safety alert had not been acted upon which put patients at risk.
  • The premises was not being adequately monitored and maintained.
  • There were ineffective governance arrangements in place which resulted in risks within the practice not being identified and managed.
  • Improvement was needed in relation to staff support and communication with staff within the practice.
  • Patients with diabetes and Chronic obstructive pulmonary disease (COPD) had not always had their reviews in an effective way.
  • Good infection prevention and control processes were in place and these were adequately overseen to ensure patient safety.
  • The practice had improved the management structure and staff felt supported in their roles.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
  • Since the new partner joined the service in April 2021, there were newly embedded systems in place to ensure that significant events and incidents were recorded, and that learning was shared as a result of these.
  • There were good systems in place to safeguard vulnerable patients.

We found two breaches of regulations. 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.

The areas where the provider should make improvements are:

  • Review COPD and diabetes patients in order that they have appropriate and timely reviews of their care and treatment at the practice.

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


Requires improvement


Requires improvement






Checks on specific services

People with long term conditions

Requires improvement

Families, children and young people

Requires improvement

Older people


Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable