Hollyns Health and Wellbeing

Updated 2 June 2023

Hollyns Health and Wellbeing is located in Bradford at:

4 Glenholme Park

Pasture Lane

Clayton

Bradford

West Yorkshire

BD14 6NF

The practice has a branch surgery at:

Allerton Health Centre

Belldean Road,

Bradford

West Yorkshire

BD15 7WA

Both sites were visited as part of this inspection activity.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury, family planning and surgical procedures. These are delivered from both sites.

The practice offers services from both a main practice and a branch surgery. Patients can access services at either surgery.

The practice is situated within the NHS West Yorkshire Integrated Care Board and delivers Personal Medical Services (PMS) to a patient population of 12,920.

Information shows that deprivation within the practice population group is in the second lowest decile (2 of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 23% Asian, 72% White, 1% Black, 3% Mixed, and 1% Other.

There is a team of 3 GP partners who provide cover at both practices and an advanced nurse practitioner who is also a partner. There are 3 further salaried GPs and 2 further female advanced clinical practitioners (ACPs), a clinical practitioner, and a trainee ACP. The practice has a team of 5 nurses and 3 healthcare assistants. The GPs are supported at the practice by a team of patient services administrators, and additional administration staff. The business development, enterprise and finance manager, operations manager and the care co-ordinator provide managerial oversight. Additional support to the practice is provided by pharmacists and pharmacy technicians from their local Primary Care Network

Hollyns Health and Wellbeing is open between 8am to 6pm Monday to Friday at the Glenholme Park site, and between 8am to 6pm Monday to Thursday and 8am to 1pm on Friday at the Allerton Health Centre. The practice offers a range of appointment types including book on the day, face to face, telephone consultations, online consultations and advance appointments.

The practice works with a local GP federation, Trust Primary Care, and is a member of the Bradford North West Primary Care Network (PCN) which provides extended hours access appointments 7 days per week at several locations across the locality. Appointments are available between 6.30pm and 9.30pm on weeknights and from 10am to 2pm at weekends. Patients can be referred to a range of health professionals including GPs, nurses, phlebotomy services and physiotherapists.

Out of hours support can be accessed by calling the surgery telephone number or contacting the NHS 111 service. The out of hours provider is Local Care Direct Limited.

Updated 2 June 2023

We carried out an announced follow up comprehensive inspection at Hollyns Health and Wellbeing on 24 and 25 April 2023. Overall, the practice is rated as requires improvement.

Safe - requires improvement.

Effective - requires improvement.

Caring – good.

Responsive - requires improvement.

Well-led – good.

Following our previous inspection on 22 and 23 June 2022, the practice was rated requires improvement overall. The key question of safe was rated as inadequate, and the ratings for the provision of effective, responsive and well-led services was requires improvement. The rating for the provision of caring services was good.

As a result of the June 2022 inspection we issued the provider with warning notices for breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 for Regulation 12: Safe care and treatment and Regulation 15: Premises and equipment. We issued a requirement notice for breaches of Regulation 17: Good governance.

During this inspection, undertaken on 24 and 25 April 2023 we saw some improvements had been made, although we found some issues regarding the provision of safe care and treatment, and that planned refurbishment work had not been completed. We also identified some additional concerns in respect of medicines management, supporting patients with specific health conditions, childhood immunisation and cervical screening rates, and poor patient satisfaction with access to services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Hollyns Health and Wellbeing on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up concerns and breaches of regulation from a previous inspection.

The inspection included:

• All key questions.
• A review of the breaches of Regulations 12, 15 and 17.
• A review of progress on actions we told the provider they should take in relation to improving uptake rates for cancer screening programmes, developing ways to improve patient satisfaction regarding the practice, and ensuring staff kept up to date with training, including training relating to safeguarding and mental capacity.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• Undertaking visits to the main site and branch surgery.

Our findings

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 found that:

• There were systems in place to safeguard children and vulnerable adults from abuse and staff we spoke with knew how to identify and report safeguarding concerns.
• Leaders reviewed the effectiveness and appropriateness of the care the service provided.
• There was a programme of quality improvement, this included clinical audit.
• Staff had the skills, knowledge and experience to deliver effective care.
• The practice had an understanding of the needs of the local population and delivered services to meet these needs.
• The practice operated effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Leaders and managers in the practice demonstrated they had the capacity and skills to deliver high-quality, sustainable care.
• We saw that the provider had taken concerted action to rectify the majority of issues highlighted during our previous inspection in June 2022.
• Staff including GP trainees were positive about the level of support they received at work.

We found a breach of regulation. The provider must:

• Ensure care and treatment is provided in a safe way to patients (refer to the requirement notice at the end of the report for more detail).

In addition, the provider should:

• Improve cervical screening rates.
• Improve immunisation rates for children aged 5 for measles, mumps and rubella (2 doses).
• Complete the planned refurbishment of both sites to tackle deficiencies noted in the latest infection prevention and control audits.
• Embed actions and processes to improve patient satisfaction in respect to access.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services