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