Background to this inspection
Updated
23 December 2019
Dr P J P Holden and Partners (also known as Matlock & Ashover Practices – Imperial Road) is registered as a location with the CQC, with the provider being a partnership consisting of five male GPs and one female GP.
The practice is situated in Matlock, a town in Derbyshire on the south-eastern edge of the Peak District. It provides primary care medical services commissioned by NHS North Derbyshire CCG and NHS England.
The practice has approximately 7,700 registered patients. Patients are predominantly of white British origin, with only 1.3% of people within the practice area being from black and minority ethnic (BME) groups. The age profile of registered patients shows a higher percentage of patients aged over 65 at 27.7%, compared to the CCG average of 20.5%, and the national average of 17.3%. The practice serves a population that is ranked in the third least deprived decile for deprivation, and has lower levels of unemployment compared to the national average.
In addition to the four GP partners (one female and three male GPs), there are six salaried GPs (one male and five females) working at the practice.
The nursing team consists of a community matron, two practice nurses, and two healthcare assistants.
The clinical team are supported by a business manager, an assistant practice manager, and an operations lead. The practice also employs a care coordinator, and a team of 10 staff who provide reception, administrative and secretarial support. A cleaner is also directly employed by the practice.
Dr P J P Holden & Partners is an established training practice. It accommodates GP registrars and medical students.
The practice opens from 8am until 6.30pm Monday to Friday, with extended hours opening on a Tuesday morning from 7.30am and Monday evening until 8pm. Patients can obtain late weekday appointments and weekend appointments through a recently introduced scheme for NHS extended access to GP services. These were available at one of four local practices participating in the scheme subject to the day of the week, and on a rotating rota each weekend.
The surgery closes between 1pm and 4pm on one afternoon on 10 months of the year for staff training. When the practice is closed, patients are directed to Derbyshire Health United (DHU) out of hours via the 111-service.
Updated
23 December 2019
Dr P J P Holden & Partners received a previous comprehensive inspection in December 2018 as part of the Care Quality Commission’s inspection programme. The overall rating for the practice was ‘good’, however, the practice was rated as ‘requires improvement’ for providing safe services 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 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 practice was rated as good for all population groups except for people experiencing poor mental health (including people with dementia) as some indicators relating to mental health had exception reporting rates above local and national averages.
The practice was asked to develop an action plan to address the areas of concern that were identified during our inspection.
The full comprehensive report from the inspection in December 2018 can be found by selecting the ‘all reports’ link for Dr P J P Holden & Partners on our website at
This inspection was an announced focused inspection carried out on 6 December 2019 to review the actions taken by the practice since our previous inspection. This report covers our findings in relation to actions taken by the practice since our last inspection in respect of the safe domain.
Overall the practice remains rated as ‘good’. The practice is now also rated ‘good’ for providing safe services, and ‘good’ for the population group of people experiencing poor mental health (including people with dementia).
Our key findings were as follows:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- Coding for safeguarding records had been reviewed and improved to ensure greater consistency and accurate information.
- The practice provided evidence of staff immunisation status. An improved system ensured any new staff had this reviewed as part of their induction.
- The practice had revised its processes to ensure events and near misses were used to promote learning, and had evidence that these were discussed and appropriately actioned.
- Exception reporting rates for mental health indicators had decreased and the practice was monitoring their QOF performance more comprehensively.
- In addition, the practice had improved patient satisfaction with access to appointments, and had strengthened their approach to quality improvement processes, including audit. We also observed that the exception reporting rates for some Quality and Framework (QOF) indicators relating to mental health had reduced in the latest published QOF data (2018-19).
Details of our findings and the evidence supporting our rating is set out in the evidence table.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care.