You are here

Dr P J P Holden & Partners Good Also known as Imperial Road Surgery

Reports


Inspection carried out on 4 December 2019

During an inspection to make sure that the improvements required had been made

Dr P J P Holden & Partners received a previous comprehensive inspection in December 2018 as part of the Care Quality Commission’s inspection programme. The overall rating for the practice was ‘good’, however, the practice was rated as ‘requires improvement’ for providing safe services because:

  • Clinical coding was not always used on safeguarding records which meant that access to some information, including an up-to-date practice safeguarding register was not readily accessible.
  • The practice could not evidence that all staff had appropriate immunisation status, or a risk assessment in place to minimise any impact of not having been vaccinated.
  • We found that rates of incident reporting were low, and some events had not been reported through the significant event reporting process to ensure wider learning. Evidence of completed actions was not always available.

The practice was rated as good for all population groups except for people experiencing poor mental health (including people with dementia) as some indicators relating to mental health had exception reporting rates above local and national averages.

The practice was asked to develop an action plan to address the areas of concern that were identified during our inspection.

The full comprehensive report from the inspection in December 2018 can be found by selecting the ‘all reports’ link for Dr P J P Holden & Partners on our website at

This inspection was an announced focused inspection carried out on 6 December 2019 to review the actions taken by the practice since our previous inspection. This report covers our findings in relation to actions taken by the practice since our last inspection in respect of the safe domain.

Overall the practice remains rated as ‘good’. The practice is now also rated ‘good’ for providing safe services, and ‘good’ for the population group of people experiencing poor mental health (including people with dementia).

Our key findings were as follows:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Coding for safeguarding records had been reviewed and improved to ensure greater consistency and accurate information.
  • The practice provided evidence of staff immunisation status. An improved system ensured any new staff had this reviewed as part of their induction.
  • The practice had revised its processes to ensure events and near misses were used to promote learning, and had evidence that these were discussed and appropriately actioned.
  • Exception reporting rates for mental health indicators had decreased and the practice was monitoring their QOF performance more comprehensively.
  • In addition, the practice had improved patient satisfaction with access to appointments, and had strengthened their approach to quality improvement processes, including audit. We also observed that the exception reporting rates for some Quality and Framework (QOF) indicators relating to mental health had reduced in the latest published QOF data (2018-19).

Details of our findings and the evidence supporting our rating is set out in the evidence table.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care.

Review carried out on 13 November 2019

During an annual regulatory review

We reviewed the information available to us about Dr P J P Holden & Partners on 13 November 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 18 December 2018

During a routine inspection

We carried out an announced comprehensive inspection at Dr P J P Holden & Partners on 18 December 2018 as part of our inspection programme.

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.

The overall rating for this practice was good. All population groups were rated as good with the exception of people experiencing poor mental health. This was rated as requires improvement because levels of exception reporting were higher than local and national averages

We found that:

  • The practice mostly 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. There was some evidence of lower satisfaction rates with regards to access to appointments, but we observed that the practice was taking action to address this.
  • The way the practice was led and managed promoted the delivery of good quality, person-centred care.

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

  • Clinical coding was not always used on safeguarding records which meant that access to some information, including an up-to-date practice safeguarding register was not readily accessible.
  • The practice could not evidence that all clinical staff had appropriate immunisation status, or a risk assessment in place to minimise any impact of not having been vaccinated.
  • We found that rates of incident reporting were low, and some events had not been reported through the significant event reporting process to ensure wider learning. Evidence of completed actions was not always available.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way (Please see the specific details on action required at the end of this report).

In addition, the provider should:

  • Review the need for a second audit cycle to provide evidence of outcomes achieved in improving the quality of care.
  • Review levels of clinical exception reporting and consider how to evidence where levels are high, for example, by a supporting audit.
  • To continue to improve patient feedback in relation to accessing appointments.

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

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Inspection carried out on 08 October 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We inspected this practice on 08 October 2014, as part of our new comprehensive inspection programme. The practice had not previously been inspected.

We found the practice to be good in safe, caring and responsive areas we inspected, and outstanding in effective and well-led. The overall rating is outstanding. 

Our key findings were as follows:

Patients expressed a high level of satisfaction about the care and services they received.

Systems were in place to keep patients safe and to protect them from harm.

Patients were asked for their views, and their feedback was acted on to improve the service.

Patients were treated with kindness, dignity and respect.

The practice worked in partnership with other services to meet patients’ needs in a responsive way.

Staff were supported to share best practice, acquire new skills and further develop their knowledge to meet patients’ needs and provide high quality care.

The culture and leadership empowered staff to carry out lead roles and innovative ways of working to meet patients’ needs, and drive continuous improvements. The leadership and governance arrangements also ensured the delivery of high-quality person-centred care.

We saw several areas of outstanding practice including:

The practice had links with local schools and had provided several presentations to pupils about health issues. Pupils from a local school had designed the new logo for the practice.

The leadership enabled staff to drive continuous improvements and carry out lead roles and innovative ways of working to meet patients’ needs. For example, the community matron regularly visited patients in their own home and local care homes in response to their needs, and held quarterly meetings with the practice manager and care home managers to review their needs.

The practice provided medical support to a local drug misuse service, and was helping to change perceptions about people who had a drug dependencyThe practice worked pro-actively with relevant services, which had enhanced their safeguarding links and holistic approach to supporting families and patients who had a drug dependency.

The Patient Reference Group were actively involved in recruiting senior staff including the current practice manager. 

In addition the provider should:

Complete a competency assessment to evidence that the health care assistant has been assessed competent to carry out specific health checks and delegated tasks.

 

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice