The Hollies Medical Practice

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture

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 Regulation 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 62 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The practice had a mission statement in place and feedback from staff regarding the culture within the practice was positive. Staff told us they felt supported by leaders and it was a friendly and positive environment to work in. Staff appreciated the flexibility around different teams supporting each other during busy periods.

The practice had a business plan in place which included succession planning.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us leaders in the practice was approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The practice had established Freedom to Speak up arrangements with other practices in the primary care network. Staff were aware of how to raise concerns and told us they felt confident to do so if necessary.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Policies and procedures to promote diversity and equality were in place. Staff we spoke with told us they felt supported in their roles. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support staff who had additional requirements had been put in place.

Leaders and managers provided appropriate support to staff, who demonstrated a clear understanding of their roles and responsibilities. Regular practice meetings were held to review clinical concerns and emerging risks. Staff had access to all required policies and procedures.

Governance arrangements were in place; however, these were not consistently effective. Although there were some risk assessments, we identified deficiencies in infection prevention and control audits, environmental risk assessments, and risk assessments relating to emergency medicines not held by the practice.

Clinical searches highlighted further gaps in governance, including insufficient monitoring of patient recalls and inconsistent application of patient safety alerts and not always following national guidance.

At the time of inspection, the provider’s registration details were incorrect. Corrective action had been initiated, and the update process remained ongoing following our visit.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The provider collaborated with other practices in the Primary Care Network (PCN) to deliver extended access services. They actively participated in PCN engagement meetings to enhance service delivery and address local health needs. The practice worked with community health teams, such as the Learning Disability team, to maintain accurate patient registers. The practice was organising a ‘Winter Wellness Fayre’ on behalf of the PCN. This event was to support local people with a range of services and support including health education, community support and mental health services.

We found that there were some missed opportunities to drive learning and improvement within our clinical searches and the governance system findings. There were missed opportunities to promote learning and improvement, such as embedding and applying lessons from legacy MHRA patient safety alerts. Clinical searches revealed gaps that required the provider to ensure staff adhered to legislation, evidence-based best practices, and current standards. Additionally, learning should be reinforced through documented clinical supervision, so that any identified knowledge gaps lead to targeted training, which is then implemented and evaluated.

The practice was a GP training facility supporting both GP registrars and medical students. Staff were offered opportunities for professional development and career progression through training. A new phone system had been introduced, allowing people to request a call-back rather than wait