We carried out an announced comprehensive inspection at Hollins Grove Surgery on 6 March 2019.

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.

We have rated this practice as requires improvement overall.

We rated the practice as requires improvement for providing safe services because:

• The practice did not have clear systems and processes to keep patients safe.
• The practice did not have comprehensive systems in place for the safe management of medicines.
• The practice did not effectively embed learning and improvements identified when things went wrong. Documentation was not comprehensively maintained so as to effectively monitor trends.

We rated the practice as requires improvement for providing effective services because:

• There was limited monitoring of the outcomes of care and treatment, with no formalised programme of quality improvement activity or clinical audit.
• Clinical oversight of the management of patients with long term conditions, or vulnerable groups such as those patients with learning disabilities was lacking.

We rated the practice as inadequate for providing well-led services because:

• Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
• While the practice had a vision, that vision was not supported by a credible strategy.
• The overall governance arrangements were ineffective.
• The practice did not have clear and effective processes for managing risks, issues and performance.
• The practice did not always act on appropriate and accurate information.
• We saw little evidence of effective systems and processes for learning, continuous improvement and innovation.

These areas affected all population groups so we rated all population groups as requires improvement.

We rated the practice as good for providing caring and responsive services because:

• 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.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Review the IPC audit process to ensure effective oversight and monitoring by the designated lead for IPC within the practice.
• Complaints literature should be readily available to patients to make them aware of the practice’s complaints process.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care