The Hollies Medical Practice

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

At our last assessment, we rated this key question as good. At this assessment, the rating has changed to requires improvement.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not ensure that people received effective care and treatment.

The provider had some systems in place to identify people with previously undiagnosed conditions. However, our clinical searches identified 25 people had a potential missed diagnosis of diabetes. We sampled 5 patient records and found 3 people had appointments to be followed up, and 2 people has a potential missed diagnosis of diabetes, but still needed repeat tests to confirm, which had not yet been arranged.

Further review of patient records in relation to our clinical searches found the total number of people with diabetes who had a raised HbA1c > 75mmol/l suggesting poor diabetic control was 183 out of a total number of 1110. We sampled 5 people’s records and found people were overdue their annual diabetic review and medication reviews. In addition, people were not actively followed up in a timely manner after having their medicines adjusted nor having follow up checks to make sure readings had improved.

Feedback from people using the service was predominantly positive. People reported active involvement in the assessment of their needs and expressed confidence that staff understood their personal circumstances. Staff demonstrated awareness of local community requirements. Reception teams utilised digital flags within care records to identify specific needs, such as extended appointment times or interpreter support. Clinical staff employed standardised templates during care reviews to ensure consideration of wider health and wellbeing. Where social needs were identified, such as isolation or housing challenges, and staff referred people to a social prescriber.

The practice did not always follow legislation and current evidence-based good practice and standards.

There was a recall system in place to manage long term conditions, however the systems in place were not always working effectively. For example, the total number of people with asthma who have been prescribed 2 or more courses of rescue steroids was 62 out of a total number on asthma register of 997. We sampled 5 people’s records and found people were overdue their annual asthma reviews and medicine reviews, had not always had an adequate assessment when they had presented with an acute exacerbation, had sometimes not been issued the dose of steroids recommended in national guidance, had not had their preventer treatment adjusted following an exacerbation, and had not being followed up within 48 hours after exacerbations or admission for an exacerbation in line with NICE guidance. We also found people had not always issued with steroid cards when appropriate.

Our clinical searches identified 19 people out of 507 had not had monitoring of their hypothyroidism done in the last 18 months. We reviewed 5 sets of records and found 4 people had not had blood test monitoring done since 2023 and one person had not had it done since 2020. Monitoring should be undertaken annually. Adequate measures had not been taken to encourage people to attend, as 4 people were still getting more than one month of medicines on each prescription. People were also overdue medication reviews and blood pressure checks.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The practice had produced a spreadsheet for all staff with various easily accessible information on it, including room allocation lists and staff contact numbers. The practice worked with other services to ensure continuity of care, for example with palliative care and end of life needs. Local care homes had access to the care coordinator who acted as liaison between them and the clinical team. Where the practice had come across issues with other services, they had raised these concerns with the appropriate organisations.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff focussed on identifying risks to peoples’ health, including those receiving palliative care and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

The practice had achieved 4 out of the 5 recommended minimum uptake for all childhood immunisations. For the one that was not met, practice leaders acknowledged this has been a recurring challenge and identified several contributing factors. They confirmed that processes were in place to monitor children who do not attend scheduled appointments.

The practice did not meet the national targets for cervical screening. Women aged 25 to 49 years who had an adequate screening test within the last 3.5 years as a percentage of the eligible population was 66.2%, compared to the expected 80%. Women aged 50 to 64 years who had an adequate screening test within the last 5.5 years as a percentage of the eligible population was 72.5%, compared to the expected 80%.

Leaders advised that reminder letters are routinely issued to people to encourage attendance and stated they would consider implementing a more targeted campaign to improve uptake.

The practice had completed a range of quality improvement audits. However, evidence of appropriate follow-up actions to address identified issues was not always clear.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. Capacity and consent were recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation. Chaperone posters were displayed in the practice informing people this was available to them. The practice had a policy in place around consent.