The Hollies Surgery in Benfleet is a Doctors/GP specialising in the provision of services relating to diagnostic and screening procedures, family planning services, maternity and midwifery services, services for everyone, surgical procedures and treatment of disease, disorder or injury. The last inspection date here was 15th June 2017
The Hollies Surgery is managed by The Hollies Surgery.
Contact Details:
Address:
The Hollies Surgery 41 Rectory Road Benfleet SS7 2NA United Kingdom
Letter from the Chief Inspector of General Practice
We first carried out a comprehensive inspection at The Hollies Surgery on 28 January 2016 where the practice received a rating of requires improvement overall. The practice received requires improvement for providing safe, effective and well-led services and good for providing caring and responsive services. As a result the practice was issued with a requirement notice for improvement.
We then carried out a further focused inspection on 1 September 2016 to follow up on improvements and found that suitable improvements had not been made. The practice remained at requires improvement overall. The practice was rated as requires improvement for providing safe and effective services and inadequate for providing well-led services. As a result the practice was issued a warning notice and were to be compliant by March 2017.
A focused follow up inspection was carried out on 7 March 2017 to review the issues highlighted within the warning notice and we found that the practice had made the necessary improvements and were found to be compliant. As a result we carried out our most recent inspection on 4 May 2017 to follow up on areas of improvement and conduct a ratings review.
The full reports for the January 2016, September 2016 and March 2017 inspections can be found by selecting the ‘all reports’ link for The Hollies Surgery on our website at www.cqc.org.uk.
At our 4 May 2017 comprehensive inspection we found improvements had been made, overall the practice is now rated as good.
Our key findings across all the areas we inspected were as follows:
There was an effective system in place for reporting and recording significant events. Staff confirmed discussions had been held and lessons learnt. We found evidence to demonstrate how learning had been shared and changes embedded into practice.
Patient safety and medicine alerts had been appropriately responded to.
Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
We found the practice had developed multiple quality improvement processes to monitor their medicines however, we found one area relating to patients being treated for thyroid conditions where appropriate reviews had not been undertaken.
All staff had received a Disclosure and Barring Service (DBS) check and an appraisal within the last 12 months.
We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.
We found that staff had a clear understanding of key issues such as safeguarding, Mental Capacity Act and consent.
All practice policies and protocols were practice specific, updated and reviewed.
The practice had identified 172 patients as a carer which was 1.2% of their patient list.
Information about how to complain was available and easy to understand. Complaints were responded to at the time of reporting where possible. Learning from complaints was shared with staff.
The practice had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to it.
The practice worked closely with their clinical commissioning group (CCG) to provide essential primary care to vulnerable adults within a domiciliary setting.
The practice proactively sought and valued feedback from staff and patients, which it acted on. The patient participation group was active.
There was a clear leadership structure and staff felt supported by management. The practice held regular staff, clinical and partner meetings.
The practice had reviewed their national GP survey results and were implementing action plans to address the appointment availability issues that were raised.
The practice had good facilities and was well equipped to treat patients and meet their needs.
Actions the provider SHOULD take to improve:
Improve the system for reviewing patients taking prescribed thyroid medicines.
Letter from the Chief Inspector of General Practice
On 28 January 2016, we carried out a comprehensive announced inspection. We rated the practice as requires improvement overall. The practice was rated as requires improvement for providing safe, effective and well-led services. The practice was then re-inspected on 01 September 2016 and we found that sufficient improvement had not been made. Therefore the overall rating remained as requires improvement. A rating of requires improvement for providing safe and effective services and an inadequate rating for well-led was given. The practice was rated as good for providing caring and responsive services.
As a result of this inspection and due to repeat issues from the previous inspection, a warning notice was issued to the practice. The previous reports can be found by selecting the ‘all reports’ link for The Hollies Surgery on our website at www.cqc.org.uk.
The practice was required to be compliant with the warning notice by February 2017. We conducted a focused inspection on 07 March 2017 to establish whether they were complaint with the warning notice.
We previously found that:
The provider did not have effective systems or processes to assess, monitor and mitigate the risks to the health, safety and welfare of patients, particularly in relation to patients at risk of stroke. The system of audit was ineffective in identifying and managing risks to patients.
Staff were acting in a clinical role without relevant risk assessments or disclosure and barring service checks in place.
Policies were incomplete or not being adhered to, including those relating to needle stick injury and Health and Safety.
There were limited opportunities for non-clinical staff to give their feedback to identify where improvements to services may be required. Non-clinical staff were not routinely invited to practice meetings.
Non-clinical staff did not all receive regular appraisal.
The practice was required to be compliant with the warning notice by March 2017. At our focused inspection on 07 March 2017 we found;
The system of audits was effective for assessing and monitoring patients at risk of stroke.
There were procedures in place for monitoring and managing risks to patient and staff safety. There was a health and safety policy available with a poster in reception, which identified local health and safety representatives.
The practice has mitigated previous risks by ensuring all clinical staff members had received a Disclosure and Barring Service (DBS) check.
The learning needs of all staff were identified through a system of appraisals, meetings and reviews of practice development needs.
Weekly practice meetings were held and open to all staff members. These meetings had several standing items on the agenda. Staff told us there was an open culture within the practice and they had the opportunity to raise any issues at team meetings and felt confident and supported in doing so.
The practice presented us with 13 audits, two of which were clinical audits which related to medicine management. The audits were aligned to national guidance, performance had been assessed, and learning was evident with improved clinical outcomes.
The practice had complied with the warning notice. However, the practice will remain rated as requires improvement until a further inspection in 2017 has been undertaken.
Action the service SHOULD take to improve:
Improve the monitoring of blood pressure in relation to patients suffering from hypertension and those with diabetes.
Letter from the Chief Inspector of General Practice
We carried out an announced follow up inspection at The Hollies Surgery on 1st September 2016 to check whether improvements had been made, following the rating of requires improvement at our previous inspection of 28th January 2016. At our earlier inspection, the practice was rated as requires improvement overall, with requires improvement for safe, effective and well-led. It was rated as good for providing caring and responsive services.
As a result of our inspection of 28th January 2016, the practice were issued with a requirement notice for improvement. This was in relation to the governance at the practice, as the provider was not monitoring or assessing the services they provided. Following that inspection, the provider submitted an action plan to inform us of how they intended to make the required improvements.
At our most recent inspection, we found that many of the required improvements had not been made, and therefore the practice continues to be rated as requires improvement overall. It is now rated as requires improvement for providing safe and effective services, and inadequate for providing well-led services.
Our key findings across all the areas we inspected were as follows:
Sufficient action had not been taken to meet the requirement notice issued at our earlier inspection.
The provider had failed to implement their own action plan. This action plan detailed what action would be taken to achieve compliance with the regulations. Continued breaches were identified at our focused inspection of 1 September 2016, in spite of the assurances given.
There was still no health and safety risk assessments completed, despite this being identified as required in the provider’s health and safety policy. We were assured in the practice’s action plan that this policy had been reviewed to ensure this reflected the requirements of the practice.
In their action plan, the provider told us that lessons would be learnt from the last inspection and audits would ensure sustained and immediate improvement. This was not the case. Audits did not consistently improve patient’s outcomes.
One audit did not effectively identify and manage patients at risk of stroke, despite the risks to these patients being identified at earlier inspection.
Not all clinical staff had a Disclosure and Barring Service check in place to ensure they were suitable to carry out their role.
Electronic patient records were not updated to provide an up to date account of patients’ health. Records were inconsistent in establishing how many patients were at risk of stroke
Not all non-clinical staff received a regular appraisal, despite this issue being identified in our last report.
A minutes secretary had been put in post and meetings were now being recorded. However, there continued to be an absence of regular staff meetings to enable all staff to provide their feedback about how the practice was managed.
Some steps had been taken to implement a practice patient survey for the purpose of obtaining and acting on patient feedback.
Action the provider MUST take to improve:
Mitigate the risks associated with staff acting in a clinical role by ensuring relevant staff have a disclosure and barring service check in place.
Improve the leadership and governance at the practice so that risks to patients are identified and mitigated and health outcomes for patients are improved, particularly in relation to patients at risk of stroke.
Complete a health and safety risk assessment to mitigate risks to patients, staff and visitors to the practice.
Ensure there is a system to assess, monitor and improve the quality of services provided by ensuring staff receive a regular appraisal and have the opportunity to provide their feedback at practice meetings.
Action the provider SHOULD take to improve:
Discuss and document new clinical guidance at practice meetings.
Progress actions to obtain and act on patient feedback.
Letter from the Chief Inspector of General Practice
We first carried out a comprehensive inspection at The Hollies Surgery on 28 January 2016 where the practice received a rating of requires improvement overall. The practice received requires improvement for providing safe, effective and well-led services and good for providing caring and responsive services. As a result the practice was issued with a requirement notice for improvement.
We then carried out a further focused inspection on 1 September 2016 to follow up on improvements and found that suitable improvements had not been made. The practice remained at requires improvement overall. The practice was rated as requires improvement for providing safe and effective services and inadequate for providing well-led services. As a result the practice was issued a warning notice and were to be compliant by March 2017.
A focused follow up inspection was carried out on 7 March 2017 to review the issues highlighted within the warning notice and we found that the practice had made the necessary improvements and were found to be compliant. As a result we carried out our most recent inspection on 4 May 2017 to follow up on areas of improvement and conduct a ratings review.
The full reports for the January 2016, September 2016 and March 2017 inspections can be found by selecting the ‘all reports’ link for The Hollies Surgery on our website at www.cqc.org.uk.
At our 4 May 2017 comprehensive inspection we found improvements had been made, overall the practice is now rated as good.
Our key findings across all the areas we inspected were as follows:
There was an effective system in place for reporting and recording significant events. Staff confirmed discussions had been held and lessons learnt. We found evidence to demonstrate how learning had been shared and changes embedded into practice.
Patient safety and medicine alerts had been appropriately responded to.
Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
We found the practice had developed multiple quality improvement processes to monitor their medicines however, we found one area relating to patients being treated for thyroid conditions where appropriate reviews had not been undertaken.
All staff had received a Disclosure and Barring Service (DBS) check and an appraisal within the last 12 months.
We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.
We found that staff had a clear understanding of key issues such as safeguarding, Mental Capacity Act and consent.
All practice policies and protocols were practice specific, updated and reviewed.
The practice had identified 172 patients as a carer which was 1.2% of their patient list.
Information about how to complain was available and easy to understand. Complaints were responded to at the time of reporting where possible. Learning from complaints was shared with staff.
The practice had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to it.
The practice worked closely with their clinical commissioning group (CCG) to provide essential primary care to vulnerable adults within a domiciliary setting.
The practice proactively sought and valued feedback from staff and patients, which it acted on. The patient participation group was active.
There was a clear leadership structure and staff felt supported by management. The practice held regular staff, clinical and partner meetings.
The practice had reviewed their national GP survey results and were implementing action plans to address the appointment availability issues that were raised.
The practice had good facilities and was well equipped to treat patients and meet their needs.
Actions the provider SHOULD take to improve:
Improve the system for reviewing patients taking prescribed thyroid medicines.
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