The Care Quality Commission
  • Doctor
  • GP practice

Hollyhurst Medical Centre

Overall: Requires improvement read more about inspection ratings

8 Front Street, Blaydon On Tyne, Tyne And Wear, NE21 4RD (0191) 499 0966

Provided and run by:
Dr Inder Singh

All Inspections

During an assessment under our new approach

Hollyhurst Medical Centre an NHS GP practice which provides primary care services to patients in the Blaydon area of Gateshead. There is also a branch practice called Elvaston Road Surgery which provides primary care services to patients in the Ryton area of Gateshead. We visited the main registered location and the branch practice as part of this assessment. The sole provider is registered with CQC to deliver the Regulated Activities: the treatment of disease, disorder or injury; diagnostic and screening procedures; family planning, maternity and midwifery services and surgical procedures.

The practice is situated within the North East and North Cumbria Integrated Care Board (ICB) area and delivers Personal Medical Services (PMS) to a patient population of about 4,500. This is part of a contract held with NHS England.

The last comprehensive inspection of this service took place in September 2022, when it was rated as good overall and for all of the key questions except for effective where it was rated requires improvement. We carried out this assessment on 20 June 2024. The reason for the assessment was in response to the previous inspection which rated the effective domain as requires improvement.

The service has been rated as requires improvement overall and for the key questions safe and well-led. We found 2 breaches of the legal regulations in relation to governance and staffing. This is because some systems and processes were ineffective to provide clear oversight of governance arrangements to ensure risks were considered, managed and where possible mitigated for patients, staff and visitors to the practice. These included the lack of clinical supervision, an effective audit process, oversight of staff workloads on the clinical operating system and infection prevention and control and fire risk assessments.

Effective, caring and responsive were rated as good.

21 and 26 October 2022

During an inspection looking at part of the service

We carried out an announced focused inspection) at Hollyhurst Medical Centre on 21 and 26 October 2022. Overall, the practice is rated as good.

Safe - good

Effective - requires improvement

Caring - not inspected, rating of good carried forward from previous inspection

Responsive - not inspected, rating of good carried forward from previous inspection

Well-led - good

Following our previous inspection on 28 September 2021, the practice was rated requires improvement overall and for the key questions, was the practice safe, effective and well led. The key questions, was the practice responsive and caring, were both rated as good.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Hollyhurst Medical Centre 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 focus of the inspection was the key questions:

  • Safe
  • Effective
  • Well led
  • Also, the breaches of Regulation 17 HSCA (Regulated Activities) Regulations 2014 – Good Governance and Regulation 12 HSCA (Regulated Activities) Regulations 2014 Safe care and treatment.
  • We also followed up on the areas where we said they should make improvements in the previous inspection.

How we carried out the inspection/review

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.
  • A short site visit.
  • Sending questionnaires to staff working in the practice.

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:

  • The practice had made and sustained improvements in several areas following the CQC inspection in September 2021.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Most patients received effective care and treatment that met their needs.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

We rated the practice as requires improvement for providing effective service because

  • Whilst they had made some improvements, the practice should improve the way they supported those with poor control of their asthma symptoms.

Whilst we found no breaches of regulations, the provider should:

  • Improve following up patients with poor control of their asthma symptoms.
  • Continue with the progress made to improve the sustainability of staffing levels to improve continuity of care.
  • Continue with plans to implement a strategy in response to when patients fail to attend for health checks and reviews.
  • Improve the significant events process to ensure systematic learning from trends and themes and review any improvements implemented have been successful.
  • Maintain a full record of staff vaccination status and ensure the safety and security of paper prescription stationery in line with current UK Health Security Agency guidance.
  • Review and update the health and safety risk assessment to capture and mitigate any new or emerging risks on a regular basis.
  • Ensure flooring in clinical areas is in line with national guidance on infection control in the built environment.
  • Improve coverage of childhood immunisations and cervical screening.

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

28 September 2021

During an inspection looking at part of the service

We carried out an announced inspection at Hollyhurst Medical Centre on 28 September 2021. Overall, the practice is rated as requires improvement.

The key question ratings were as follows:

Safe – Requires improvement

Effective – Requires improvement

Caring - Good

Responsive - Good

Well-led – Requires Improvement

We carried out a comprehensive inspection at Hollyhurst Medical Centre 21 August 2018 as part of our inspection programme. The practice was rated as good overall and for all domains and population groups.

Following information of concern we received, we carried out a remote regulatory assessment on 18 and 22 December 2020. This was carried out without entering the premises due to the Covid-19 pandemic. Following this assessment, we identified areas where the practice should make improvements:

  • Carry out medication reviews where appropriate in line with current guidance.
  • Monitor patients in line with current guidance who are prescribed direct oral anticoagulants (DOACs)
  • Review the process for patient safety alerts so it is clear what action has been taken.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Hollyhurst Medical Centre our website at www.cqc.org.uk.

Why we carried out this inspection

This inspection was a follow-up inspection, to check what progress the provider had made to improve on those areas where we said they should at the last regulatory assessment.

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 a minimum amount of 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
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short site visit

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 and for all population groups.

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

  • Although some improvements had been made there remained further work to be carried out on the monitoring of patients’ medication.
  • The practice did not have a sustainable and stable clinical team and there was low morale amongst staff.
  • Some recruitment records we not up to date.
  • Arrangements for infection control were partially met.

We rated the practice as requires improvement for being effective because:

  • We saw that patients ongoing needs were not always fully assessed.
  • Records relating to minor surgery were not correctly documented.
  • The monitoring of the usage of a certain type of inhaler for asthma was poor.
  • We were concerned the practice were not undertaking timely follow up of patients whose test results indicated they may be pre-diabetic or diabetic.

We rated the practice as requires improvement for being well-led because:

  • The practice struggled to build a sustainable and stable clinical team.
  • Staff told us they felt the staffing issues put pressure on them.

We also found that:

  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
  • Patients could access care and treatment in a timely way.

The areas where the provider must make improvements as they are in breach of regulations are:

  • 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.

See the requirement notice section at the end of this report for further details

The areas where the provider should make improvements are:

  • Continue with and deliver plans to reinstate the three-monthly meetings with the health visitor.

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

18 and 22 December 2020

During an inspection looking at part of the service

In light of the current Covid-19 pandemic, CQC has looked at ways to fulfil our regulatory obligations, respond to risk and reduce the burden placed on practices by minimising the time inspection teams spend on site.

In order to seek assurances around potential risks to patients, we are currently piloting a process of remote working as far as practicable. This practice consented to take part in this pilot and the evidence in the report was gathered without entering the practice premises, information was gathered from the practice electronically.

The assessment did not include an on-site inspection and therefore ratings from our previous inspection have not been reviewed.

Background

  • We carried out a comprehensive inspection at Hollyhurst Medical Centre 21 August 2018 as part of our inspection programme. The practice was rated as good overall and for all domains and population groups.
  • We have carried out this assessment to gain assurances due to information of concern raised to us regarding the practice. We undertook a remote regulatory assessment on 18 and 22 December 2020. During the assessment we reviewed Hollyhurst Medical Centre’s clinical records system which included the practice’s task management system and a sample of patient’s electronic records.

We found that:

  • Significant events and complaints had been managed appropriately.
  • Blood monitoring tests were being appropriately carried out for patients who were prescribed high risk medicines.
  • Care plans for vulnerable patients were compiled to a good standard.
  • Medication reviews of patients who were prescribed several medications, or affected by drug or patient safety alerts, were found to be overdue in a number of patients. Opportunities had been missed to carry out these medication reviews when contact had been made with these patients for other appointments.
  • Some patients who were prescribed direct oral anticoagulants (DOACs) were not appropriately monitored.
  • It was unclear what action was taken in response to medication and safety alerts.

The areas where the practice should make improvements are:

  • Carry out medication reviews where appropriate in line with current guidance.
  • Monitor patients in line with current guidance who are prescribed direct oral anticoagulants (DOACs).
  • Review the process for patient safety alerts so it is clear what action has been taken.

Another regulatory review will be carried out in another six months to monitor the progress the practice have made against the improvements we have said they should make.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

21 Aug to 21 Aug 2018

During a routine inspection

This practice is rated as Good overall. (Previous rating December 2016 – Good)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Hollyhurst Medical Centre on 21 August 2018 as part of our current inspection programme.

At this inspection we found:

  • The practice had systems in place to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes. However, the fire risk assessment for the branch surgery at Elvaston Road was basic and lacked the necessary details.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • There was a focus on continuous learning and improvement at all levels of the organisation.

There were areas where the provider should make improvements:

  • Improve and strengthen the current fire risk assessment in respect of the branch surgery.
  • Familiarise all staff with the practice business continuity plan.
  • Continue to recruit patient participation group members and seek their views in relation to the running, development and performance of the practice.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

14 December 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced inspection of this practice on 3 December 2015. Breaches of legal requirements were found. After the comprehensive inspection the practice wrote to us to say what they would do to meet the following legal requirements set out in the Health and Social Care Act (HSCA) 2008:

  • Regulation 17 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 Good governance.
  • Regulation 18 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 Staffing.

We undertook this comprehensive inspection on 14 December 2016 to check that they had followed their plan and to confirm that they now met legal requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Hollyhurst Medical Centre on our website at www.cqc.org.uk . The practice was rated as good overall following this inspection.

Our key findings at this inspection on the 14 December 2016 were as follows:

  • The practice had addressed the issues identified during the previous inspection.
  • Staff understood and fulfilled their responsibilities to raise concerns, and report incidents and near misses.
  • Risks to patients were assessed and well managed.
  • Outcomes for patients who use services were good.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • Staff were consistent and proactive in supporting patients to live healthier lives through a targeted approach to health promotion. Information was provided to patients to help them understand the care and treatment available.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • The practice had a system in place for handling complaints and concerns and responded quickly to any complaints.
  • Patients we spoke with raised no concerns regarding making an appointment.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a leadership structure in place and staff felt supported by management. The practice sought feedback from staff and patients, which they acted on.
  • The practice was aware of and complied with the requirements of the Duty of Candour regulation.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

3 December 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Hollyhurst Medical Centre on 3 December 2015. Overall the practice is rated as requires improvement.

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

  • Non-clinical risks to patients, such as health and safety, were assessed and well managed.
  • Significant events were recorded, investigated, however we had concerns about how learning from them was shared with staff.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles.
  • The practice could not demonstrate they had an effective system for clinical audit or that they used audits successfully to improve quality.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they were able to get an appointment with a GP when they needed one, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice sought feedback from patients, which they acted on.
  • Staff said managers were approachable; however there were no formal staff meetings, other than monthly clinical meetings.
  • The lead GP in the practice had the experience, but not the capacity to run the practice effectively. The salaried GPs did not receive an appraisal or clinical supervision from the provider.

The areas where the provider must make improvements are:

  • Ensure that there is an effective system for clinical audit and that audits are used successfully to improve quality.

  • Ensure there is appropriate support and appraisal for salaried GPs.

The areas where the provider should make improvements are:

  • Consider sharing the learning from significant events and complaints formally with staff and carry out an annual review of significant events and complaints to ensure there are no patterns or trends.

  • Record the numbers of the pre-printed prescription stock which has been distributed in the practice in accordance with national guidance.

  • Implement a checking regime for the emergency equipment to ensure items included in it are in date and fit for use.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice