Archived: Matlock and Ashover Practice Also known as Imperial Road Surgery

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.

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