The Care Quality Commission
  • Doctor
  • GP practice

Holmhurst Medical Centre

Overall: Good read more about inspection ratings

12 Thornton Side, Watercolour, Redhill, Surrey, RH1 2NP (01737) 647070

Provided and run by:
Holmhurst Medical Centre

Important: The provider of this service changed - see old profile

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Holmhurst Medical Centre on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Holmhurst Medical Centre, you can give feedback on this service.

27 April 2023

During an inspection looking at part of the service

We carried out an announced inspection at Holmhurst Medical Centre on 27 April 2023 to inspect the key question of well-led only. Overall, the practice is rated as Good.

The key questions are rated as:

Safe – Good carried over from last inspection

Effective – Good carried over from last inspection

Caring – Good carried over from last inspection

Responsive – Good carried over from last inspection

Well-led – Good

At our previous inspection in March 2022, the practice was rated Good overall and in all of the key questions with the exception on well-led which was rated as Requires Improvement.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Holmhurst Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

The practice had been previously rated as Good but with Requires Improvement in well-led in March 2022. This inspection was to follow up a breach of regulation 17 as identified in our previous inspection. The previous ratings for safe, caring, effective, and responsive, which were rated as Good, are carried forward.

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:

  • Requesting evidence from the provider
  • A short site visit to the practice

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 Good overall.

At our last inspection well-led was rated as Requires Improvement because:

  • Staff comments were mixed in regard to the culture of the practice.
  • Significant events, complaints and MHRA alerts were not always centrally recorded or readily available in regard to the information required. For example, to evidence the action taken, communication with patients, staff members or the wider learning.
  • Medicine reviews and non-urgent referrals were completed in the required time frames. However, staff told us that they felt undertrained in this area.

At this inspection we found:

  • We received comments from 13 staff members. All were positive with the culture of the practice. The practice had found ways to ensure staff could speak up without fear of retribution.
  • Significant events, complaints and MHRA alerts were centrally recorded and information required was readily available.
  • Staff told us that they had received addition training for medicine reviews and non-urgent referrals. They also told us they could ask for support if required.

Whilst we found no breaches of regulations, the provider should:

  • Embed regular reviews of complaints and significant events to look for trends and themes.
  • Further implement ways to communicate practice information to all staff.
  • Further implement ways to communicate with abusive patients.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

23 February 2022

During an inspection looking at part of the service

We carried out an announced inspection at Holmhurst Medical Centre between 21 March and 24 March 2022. Overall, the practice is rated as Good.

The key questions are rated as:

Safe - Good

Effective - Good

Caring – Good carried over from last inspection

Responsive – Good carried over from last inspection

Well-led – Requires Improvement

At our previous inspection on 12 November 2019, the practice was rated Requires Improvement overall and for the safe and well-led key questions. Caring, effective and responsive were rated as Good.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Holmhurst Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

The practice had been previously rated as Requires Improvement in November 2019. This inspection was to follow up breaches of regulations 12, and 17 as identified in our previous inspection. The previous ratings for caring and responsive, which were rated as Good, are carried forward.

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 using video conferencing
  • 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 to the practice

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 Good overall.

We found that:

  • 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 way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
  • There was adequate monitoring of patients who were prescribed medicines.
  • The practice was monitoring staff immunisations and risk assessments had been undertaken to mitigate any risks associated with a lack of immunisation.
  • Although the provider did have a system in place to record and act on safety alerts, we identified one alert which had been issued in the past that had not been acted on.
  • Staff recruitment files contained all of the required information.
  • Medicine reviews and non-urgent referrals were completed in the required time frames. However, staff told us that they felt undertrained in this area.
  • Staff training was up to date, which included safeguarding, basic life support, infection prevention and control, and sepsis.
  • Patient Group Directives (PGDs) had been signed by all of the nurses and the authorising GP.
  • The practice held a spread sheet of all ‘Two Week Wait referrals. These were dated as to when the GP asked for the referral, the date it was sent and the received date from the organisation sent to.
  • Staff comments were mixed in regard to the culture of the practice.
  • Significant events, complaints and MHRA alerts were not always centrally recorded or readily available in regard to the information required. For example, to evidence the action taken, communication with patients, staff members or the wider learning.

The provider Must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

The provider should:

  • Review and continue to monitor cervical smear screening to meet the Public Health England screening rate target.
  • Review and improve child immunisation rates to meet World Health Organisation (WHO) targets.
  • Continue to review staff immunisation status and record centrally.

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

13 Nov 19

During a routine inspection

We carried out an announced comprehensive inspection at Holmhurst Medical Centre on 13 November 2019 as part of our inspection programme.

We had previously carried out an announced comprehensive inspection at Holmhurst Medical Centre in October 2016 and a follow up inspection in October 2017. The practice was last rated as Good overall and Good in all domains. All of the practices’ previous reports can be found by selecting the ‘all reports’ link for Holmhurst Medical Centre on our website www.cqc.org.uk

We carried out an inspection of this service following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a change to the quality of care provided since the last inspection. Following our review of the information available to us, including information provided by the practice, we focused our inspection on the following key questions:

  • Is it Safe
  • Is it Effective
  • Is it Caring
  • Is it Responsive
  • Is it Well led

We have rated this practice as requires improvement overall with safe and well led being requires improvement and effective, caring and responsive being good. All of the population groups have been rated as good.

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 rated the practice requires improvement for providing safe and well led care because:

  • Some of the systems and processes in place to keep patients safe required improvement. For example: not all Patient Group Directives had been signed by all of the nurses or had an authorising signature, the practice was not monitoring the ‘two week wait’ referrals and so had no method of ensuring that referrals had been completed or tracking of the outcomes. 
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care. However, the practice did not have a written strategy on how it was planning to achieve their priorities. There was a limited virtual Patient Participation Group and the practice had not considered other ways for patients to advise the practice on the patient perspective and provide insight into the responsiveness and quality of services. The practice had not reviewed or investigated why three of the patient survey results were lower than the national and clinical commissioning group average and so were unable to evidence if appropriate action had taken place to improve. The practice did not have a systematic programme of clinical and internal audit, that enabled it to demonstrate continuous improvement.

We rated the practice good for providing effective, caring and responsive care because:

  • 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.
  • There was a clear leadership structure and staff felt supported by management.
  • Staff worked well together as a team and all felt supported to carry out their roles. There was a strong team ethos and culture of working together for a common aim.

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 and continue to monitor cervical smear screening to meet the Public Health England screening rate target.
  • Review and improve child immunisation rates to meet World Health Organisation (WHO) targets.
  • Continue to review staff immunisation status and record centrally.
  • Ensure that written risk assessments are completed if staff are allowed to start work before the practices own DBS check has been completed.

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 October 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Holmhurst Medical Centre on 26 October 2016. The overall rating for the practice was good. The full comprehensive report on the October 2016 inspection can be found by selecting the ‘all reports’ link for Holmhurst Medical Centre on our website at www.cqc.org.uk. The practice sent to us an action plan detailing what they would do to meet the legal requirements in relation to the following:-

  • Ensuring that effective communication took place between staff teams, and ensuring that all staff were involved in the review of issues relating to the quality of service, such as significant events and that meetings are held regularly.

Additionally we found that:

  • The practice needed to review national patient survey data in relation to GP and nurse consultations and take action to improve this.

  • The practice needed to monitor patient satisfaction in relation to accessing appointments and monitoring the effect of changes made to the appointment system.

  • The practice needed to take action to ensure all administrative staff received annual appraisals and up to date training.

This inspection was an announced focused inspection carried out on 6 October 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 26 October 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection..

Overall the practice is now rated as good.

Our key findings were as follows:

  • Regular monthly practice meetings were held where significant events were discussed. These were minuted and made available to all staff groups. Other meetings were held by staff groups, for example, nurse and administrative staff, where relevant issues were discussed.

  • The practice had undertaken annual appraisals appropriately and evidence was seen that all relevant training was up to date.

  • The practice had mixed reviews for patient satisfaction in relation to GP and nurse consultations. For example, results from the national GP patient survey released in July 2017 showed:

    90% of respondents said they had confidence in the last GP they saw or spoke to in comparison to the local clinical commissioning group (CCG) average of 96% and the national average of 95%.

    78% of respondents said the last nurse they saw or spoke to was good at explaining tests and treatment in comparison to the CCG and national average of 90%.

  • The practice had mixed reviews for patient satisfaction in relation to accessing appointments. For example:

    60% of respondents said the last appointment they got was convenient in comparison to the CCG average of 82% and the national average of 81%.

    However, the friends and family test data documented from July 2017 to October 2017 showed 907 responses of which 739 (81%) showed that people were either extremely likely or likely to recommend the practice to their friends and family. This was in comparison to the CCG average of 81% and national average of 77% captured in the national GP patient survey for that question.

    The practice had been affected by staffing issues for a period of time that might have impacted in lower satisfaction scores within the two previous national GP patient surveys. The practice has since rectified their staffing problems and this has resulted in improvement in the area captured by the friends and family test.

    However, there were also areas of practice where the provider should make improvements.

    Importantly, the provider should:

  • Continue to monitor patient satisfaction levels in all areas that show low satisfaction in the national GP patient survey and continue to take action to improve these areas.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

26 October 2016

During a routine inspection

We carried out an announced comprehensive inspection at Holmhurst Medical Centre on 26 October 2016. Overall the practice is rated as good.

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

  • There was an effective system in place for reporting and recording significant events.
  • However, not all staff were involved in discussions about incidents and therefore the practice could not be assured that lessons were always shared to make sure action was taken to improve safety in the practice.
  • 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. However, there were some gaps evident in administrative staff appraisals and training due to recent changes to the staff teams. The practice had plans in place to address this.
  • Patients told us they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Responses from the GP patient survey showed the practice was lower than average in relation to some aspects of GP and nurse consultations and accessing services.
  • Patients had experienced some difficulties in relation to accessing appointments and the practice was addressing this by offering more on the day ‘sit and wait’ appointments.
  • 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 patients and staff, which it acted on.
  • 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 provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvements are:

  • Ensure that effective communication takes place between staff teams, ensuring that all staff are involved in the review of issues relating to the quality of the service such as significant events and that meetings are held regularly.

In addition the provider should:

  • Review the results of national survey data in relation to GP and nurse consultations and take action to improve this.
  • Continue to monitor patient satisfaction with accessing services in relation to survey data and recent changes to the appointment systems.
  • Continue to take action to ensure all administrative staff receive annual appraisals and up to date training.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice