The Hollies Medical Practice

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm.

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

The service was in breach of legal regulation in relation to Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 47 (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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service. Managers encouraged staff to raise concerns when things went wrong. We saw that during clinical and management meetings issues were discussed with staff telling us that if any learning needed to be shared then this was done electronically. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when people moved between services. Referrals and test results were managed in a timely and systems were in place to ensure urgent referrals were monitored and actioned as necessary.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff we spoke with told us they were confident to report any concerns and knew who the practice safeguarding leads were.Safeguarding policies were in place and known to staff, with the majority of staff up to date with their safeguarding training and some were working through the modules. The practice maintained a list of vulnerable people and acted on concerns. Safeguarding discussions took place during management and clinical meetings. We reviewed minutes of these meetings and people’s needs were discussed and actions agreed.

The service did not always understand and manage risks.

Emergency equipment was available but effective systems were not in place for checking the expiry dates of consumables. During our site visit, we identified two expired oxygen cylinders that had not been flagged by the provider. The provider subsequently confirmed that replacement cylinders had been ordered.

Of the four self-inflating bags stored with the emergency equipment, two were expired and two lacked expiry dates. While on site, staff investigated and found that one bag indicated no expiry date. Following our visit, the provider contacted the manufacturer to verify manufacturing and expiry dates and ordered two new bags.

Emergency medicines and equipment were stored in a consulting room, within a suite of treatment rooms with narrow spaces in which to readily manoeuvre the emergency trolley. The precise availability should be determined locally, but should consider immediate and available use and accessible for prompt use.

Staff could recognise a deteriorating patient and knew of action to take. The layout of the building meant there were 3 separate waiting areas for people. We spoke to the provider about how they managed the oversight of people in the waiting areas. They had an explanation of how they did this, but this had not been risk evaluated and there was no direct oversight by any staff members of the 3 waiting areas.

People were advised on risks related to their condition and actions to take if their condition deteriorated.

The practice had sourced additional equipment in order to aid diagnosis and speed up the results process. For example, they had access to a centrifuge machine, which separates blood components.

The service did not always detect and control potential risks in the care environment.

Following the onsite inspection, the provider implemented measures to address identified risks. Notably, there was no mercury spill kit, or evidence of risk evaluation for the mercury. The liquid nitrogen in use had not been evaluated, and corded blinds in clinical rooms posed unassessed hazards. After the inspection, the provider submitted risk assessments and confirmed arrangements for mercury disposal.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken with risks identified. Some of these had been actioned, with a couple outstanding. The provider informed the outstanding actions had been assigned and were waiting to be actioned by the relevant person.

The provider leased space from the building owners and operated a ground-floor practice within a large health centre. There had been a partial refurbishment in 2023/2024, and the provider’s business plan detailed talks were still ongoing with the relevant organisations around a full refurbishment.

The premises are equipped with automatic doors and level access, facilitating entry for individuals using mobility aids and those with prams. Designated parking was provided directly outside the health centre.

The practice employed a range of clinical and non-clinical roles. Mandatory training was largely up to date, and staff learning and development were appropriately managed. Staff reported receiving supervision; however, documented clinical supervision was not consistently in place for all clinical personnel, including non-medical prescribers. Following the inspection, the provider confirmed that a protocol will be implemented to ensure supervising clinicians formally record supervision.

Appraisals were not fully up to date across all staff groups. The provider advised that a structured schedule had now been established to ensure timely completion.

Not all staff had received vaccinations against infectious diseases relevant to their job roles, as required by the UK Health Security Agency. The provider had conducted risk assessments for those staff members who had not been vaccinated and was in the process of referring them to the newly procured occupational health service commissioned by the local Integrated Care Board.

Safe recruitment procedures were observed and adhered to.

We identified several concerns in this area. There was cleaning contract in place held by the owners of the building.

Although an infection prevention and control audit was in place, it was not consistently effective in identifying and mitigating risks. It also lacked clear guidance on required actions and assigned responsibilities, resulting in risks not being adequately managed.

During our onsite visit, we observed clinical waste stored in inappropriate bags, creating a risk that infectious waste could be disposed of as household waste. Staff attributed this to a shortage of bags; however, we found no evidence that the issue had been reported or escalated. Some sharps bins were found to be incorrectly stored or full, requiring corrective action. One sharps bin was overfull and stored in a carpeted room and another sharps bin was stored at below waist level.

Additionally, some rooms and furnishings did not provide an environment conducive to minimizing infection risks. For example, chairs and desks in consultation rooms were not designed for effective cleaning and could become potential sources of infection. The provider informed us 12 of the 23 consultation rooms have been subject to a full or partial refurbishment.

The provider had an infection prevention and control policy; however, it lacked guidance on managing notifiable diseases. Following our feedback, the provider implemented a notifiable disease protocol to ensure staff understand the required actions when such cases arise.

The service did not ensure the safety of medicines and treatments or confirm that they met each person’s needs, abilities, and preferences.

Our clinical searches identified potential patient risks related to legacy safety alerts from the Medicines and Healthcare products Regulatory Agency (MHRA). Our clinical searches highlighted that 19 people were prescribed a combination of medicines that were discouraged in an MHRA drug safety update from December 2014. We reviewed 5 people’s records and found they were at potential risk of harm from interactions between these medicines. We informed the provider, who confirmed these people have since been reviewed.

Our clinical searches identified gaps in medicine reviews, with insufficient detail to confirm that all medications had been assessed for safety and appropriateness. We identified patients who were very overdue medication reviews.

Patients prescribed disease modifying antirheumatic medicines (DMARDs) for autoimmune conditions were all monitored by secondary care. The practice was not prescribing the medicines, but records did not have alerts to highlight that these people were taking medicines which could make them immunocompromised.

For medicines requiring monitoring, our clinical searches and patient records reviews identified 6 people who were prescribed a medicine to treat diabetes contrary to the manufacturers instructions as they had very poor renal function. Additionally, some people were overdue for medication or long-term condition reviews. The provider confirmed these cases would be addressed within a specified timeframe.

Medicines were stored securely and at appropriate temperatures.

Staff managed prescription stationery appropriately and securely.

The provider had completed a stock check for emergency medicines and vaccines; however, this process was not auditable. After our feedback, the provider committed to implementing a stock control sheet to ensure auditability. Additionally, two recommended emergency medicines were not held, and no rationale was documented. The provider later supplied documentation confirming these considerations.

The provider had undertaken prescribing audits that focused on improving care and treatment.