The Care Quality Commission
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  • GP practice

Hoyland Medical Practice

Overall: Good read more about inspection ratings

High Croft, Hoyland, Barnsley, South Yorkshire, S74 9AF (01226) 355800

Provided and run by:
Hoyland Medical Practice

All Inspections

30 November 2023

During an inspection looking at part of the service

We carried out an announced assessment of Hoyland Medical Practice on 30 November 2023. The assessment focused on the responsive key question.

Following our previous inspection in July 2023 the practice was rated good overall and for all key questions. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Hoyland Medical Practice on our website at www.cqc.org.uk.

The practice continues to be rated as good overall and for providing safe, effective, caring and well led services as this was the rating given at the last comprehensive inspection. However, as a result of the findings of this focused assessment we have now rated the responsive key question as requires improvement.

Safe - Good

Effective - Good

Caring - Good

Responsive – Requires improvement.

Well-led - Good

Why we carried out this assessment.

We carried out this assessment as part of our work to understand how practices are working to try to meet demand for access and to better understand the experiences of people who use services and providers. We recognise the work that GP practices have been engaged in to continue to provide safe, quality care to the people they serve. We know colleagues are doing this while demand for general practice remains exceptionally high, with more appointments being provided than ever. In this challenging context, access to general practice remains a concern for people. Our strategy makes a commitment to deliver regulation driven by people’s needs and experiences of care. These assessments of the responsive key question include looking at what practices are doing innovatively to improve patient access to primary care and sharing this information to drive improvement.

How we carried out the assessment

This assessment was carried out remotely and did not include a site visit.

This included:

  • Conducting provider and staff interviews using video conferencing.
  • Reviewing patient feedback form a variety of sources.
  • Requesting evidence from the provider.
  • Reviewing data we hold about the practice.
  • Seeking information form relevant stakeholders.

Our findings

We based our judgement of the responsive key question on a combination of:

  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We found that:

  • During the assessment process, the provider highlighted the efforts they are making or are planning to make to improve the responsiveness of the service for their patient population. The effect of these efforts are not yet reflected in patient feedback. Patient feedback was that they could not always access care and treatment in a timely way. Patients were dissatisfied with the arrangement for getting through to the practice by phone, appointment times offered and their experience of making an appointment. However, they were satisfied with the appointments offered to them.

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

  • Produce a plan as to how they intend to respond to patient concerns/feedback about access and their experience of making an appointment with an aim to improve patient experience.

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 Health Care

18 and 25 July 2022

During a routine inspection

We carried out an announced comprehensive inspection at Hoyland Medical Practice on 18 and 19 July 2022. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection on 16 March 2016, the practice was rated Good overall and for all key questions. We also previously undertook a remote regulatory assessment in May 2021 following receipt of information of concern. We focused our assessment on the well-led key lines of enquiry. This was an unrated assessment but we found the practice was in breach of Regulation 17: Good governance.

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

Why we carried out this inspection

  • A breach of regulations and recommendations identified in the previous inspection.
  • The service had not been inspected for six years.

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 at both locations

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 Good overall

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs. Clinical searches and medical records we reviewed showed effective management and monitoring of patients with long-term conditions although there were some areas that required review.
  • 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 way the practice was led and managed promoted the delivery of high-quality, person-centre care.

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

  • Obtain four DBS checks for non-clinical staff.
  • Continue with plans to recruit additional clinical and non-clinical staff.
  • Standardise the medication review protocol to ensure all staff are following the same process.
  • Develop a plan to follow up patients to check response to the treatment within a week of an acute exacerbation of asthma.
  • Continue to improve uptake of cervical cytology screening.
  • Improve engagement with the patient participation group.

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

6 May 2021

During an inspection looking at part of the service

This report was created as part of a pilot which looked at new and innovative ways of fulfilling Care Quality Commission’s (CQC) regulatory obligations and responding to risk in light of the Covid-19 pandemic and reducing the burden placed on practices by minimising the time inspection teams spend on site.

This was conducted with the consent of the provider. Unless the report says otherwise, we obtained the information in it without visiting the Provider.

The practice was last inspected in February 2016 when it was rated as good overall and for all domains and population groups.

Background

We undertook a remote regulatory assessment on 6 May 2021 following receipt of information of concern. We focused our assessment on the well-led key lines of enquiry.

During the assessment we spoke with one GP, two practice managers and the administration manager and reviewed information that we had asked the provider to send to us. We also had 15 responses to a questionnaire sent to all staff.

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we carried out the assessment
  • 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 adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Staff described how they had worked as a team to provide good care and treatment to patients.
  • The practice culture required review to effectively support high quality sustainable care. Specifically, the practices speaking up policies were not in line with national guidance as they did not contain contact details for an independent and impartial source of advice to staff.
  • Staff told us they did not always feel listened to when raising concerns relating to the practice telephone system as the issues had existed for a number of years.

We found one breach of regulations. The provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care and improve telephone access to the practice.

The provider should:

  • Ensure all staff complete equality and diversity training.
  • Review the practices speak up policies.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

22 February 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Hoyland Medical Practice on 22 February 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 the skills, knowledge and experience to deliver effective care and treatment.
  • Patients told us that they were treated with compassion, dignity and respect; they were involved in all aspects of their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP, had access to urgent appointments on the same day and there was continuity of care.
  • 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 sought feedback from staff and patients, which it acted on.
  • The registered provider was aware of and complied with the requirements of the Duty of Candour.

We saw two areas of outstanding practice.

The nurse team had developed their own fail safe call and recall system for cytology screening. This was used to actively encourage all female patients requiring screening to attend and to ensure that every cytology result was followed up and recalled when necessary. Patients who had not attended for recent screening or had failed to attend follow up of abnormal results were flagged on the system. All staff knew to alert the nurses who would speak with them and offer screening straight away or an appointment if that is what the patient wanted. This call and recall system was checked on a monthly basis and there was no upper limit to the attempts made verbally or by letter to encourage cytology screening. This system was also used as an extra safety net to ensure all abnormal results had been actioned accordingly and patients had attended colposcopy where required. Annual audits were carried out and all abnormal results had been followed up accordingly.

The practice employed their own podiatrist to care for patients who required assessment, advice or treatment but did not meet requirements for NHS care.

However, there was one area of practice where the provider should make improvements:

A poster advising patients how to complain was displayed in the waiting room but it was not easy to see and did not contain details of any outside agencies, such as the ombudsman.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

5 November 2013

During a routine inspection

We found patients were fully involved in decisions relating to their treatment and care. We found patients privacy and dignity was maintained whilst attending the practice. Patient's overall experience when attending the practice had been positive. For example patients told us staff were 'Nice and friendly' and '[Staff are] smashing 'all of them are really helpful'.

We found processes were in place to safeguard patients from the risks of abuse.

We conducted a tour of the premises and found it was clean and tidy. There were systems in place to reduce the risk and spread of infection.

We found staff were adequately supported because they received regular training sessions and an annual appraisal.

We found there were effective systems to regularly assess and monitor the quality of service that patients receive.