The Care Quality Commission
  • Doctor
  • GP practice

Hollyns Health and Wellbeing

Overall: Requires improvement read more about inspection ratings

4 Glenholme Park, Pasture Lane, Clayton, Bradford, West Yorkshire, BD14 6NF (01274) 880650

Provided and run by:
Hollyns Health and Wellbeing

All Inspections

25 April 2023

During a routine inspection

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

22 and 23 June 2022

During a routine inspection

We carried out an announced inspection at Hollyns Health and Wellbeing on 22 and 23 June 2022. Overall, the practice is rated as Requires Improvement.

Safe – Inadequate

Effective – Requires improvement

Caring - Good

Responsive - Requires improvement

Well-led - Requires improvement

Following an inspection on 17 May 2016 the provider was rated as good overall and good in all five key questions.

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 undertook this inspection as part of a random selection of services rated Good and Outstanding to test the reliability of our new monitoring approach.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend less time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Requesting evidence from the provider
  • A site visit
  • Requesting staff feedback via a questionnaire.

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 have rated this practice as requires improvement overall

We found that:

  • The provider did not consistently demonstrate the delivery of safe, responsive, effective and well-led care to all their patients.
  • The practice did not have effective systems for the appropriate and safe use of medicines, including medicines optimisation.
  • Care and treatment was not consistently delivered in line with current evidence-based guidance.
  • The practice did not consistently demonstrate clear systems, practices and processes which kept people safe.
  • During the pandemic the practice had completed a large amount of wellbeing calls to patients including the elderly and vulnerable, signposting them to food banks, supermarkets who were offering deliveries, dog walking, befriending and other services which were available to patients locally.
  • Feedback from patients regarding access was mixed.
  • Staff dealt with patients with kindness and respect.
  • We saw evidence of a cohesive and supportive staff team who were able to raise concerns. Staff told us they were confident concerns would be addressed.
  • The practice had adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.

We found three breaches of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure that all premises and equipment used by the service are clean, suitable for the purpose for which they are used and properly maintained.

In addition, the provider should:

  • Improve uptake rates for cancer screening programmes
  • Explore and develop ways to improve patient satisfaction at the practice.
  • Take action to ensure staff to keep up to date with training, including training relating to safeguarding and mental capacity.

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

Tuesday 17 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Mayfield Medical Centre

on 17 May 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • 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.
  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

  • While the practice had safety records, incident reports and patient safety alerts it was not clear how the lessons from such incidents were shared in order to improve the safety in the practice.

We saw areas of outstanding practice:

  • The practice had a ‘Virtual Surgery’ where patients can visit the electronic GPs and get advice on a range of the most common ailments.

  • The practice offered clinics who suffered chronic pain. A GP was involved in the British Pain Society paper on ‘Language specific and culturally adapted pain management programme’. This enabled a better understanding of a patients culture specific social relationships on how to advise GPs on how to communicate pain experiences. The paper was published in December 2015. This has helped patients move from dependence on pain medication and self-management.

  • The practice worked with Bradford District Care Trust to support women who had mental health problems. It was the only practice that offered support to women from outside of Bradford.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

1 October 2013

During a routine inspection

We spoke with 10 people that used the service. They were of varying ages from young adults to the elderly. The general opinion on the practice was that it was good or very good.

Patients told us they were treated with care and respect and we saw positive exchanges between patients and staff. One person said, 'I've been coming for 12 years'.

None of the patients had any significant concerns regarding safeguarding or fitness to practice.

Some of the patients had been registered for many years (as long as 40 years), and despite an alternative surgery in very close proximity they had no desire to move.

None of the patients had ever submitted a complaint or knew of any family or friends who had made a complaint.