The Care Quality Commission
  • Doctor
  • GP practice

Holbrooks Health Team

Overall: Requires improvement read more about inspection ratings

71-77 Wheelwright Lane, Holbrooks, Coventry, West Midlands, CV6 4HN (024) 7636 6775

Provided and run by:
Holbrooks Health Team

All Inspections

18 August 2022

During a routine inspection

We carried out an announced comprehensive inspection at Holbrooks Health Team on 16 and 18 August 2022. Overall, the practice is rated requires improvement.

Safe - Good

Effective - Good

Caring - Good

Responsive – Requires Improvement

Well-led – Requires Improvement

Following our previous comprehensive inspection on 18 August 2021, the practice was rated requires improvement overall. Specifically, the practice was rated as requires improvement for providing safe and effective care, and inadequate for providing well-led services.

The full report for this inspection can be found by selecting the ‘all reports’ link for Holbrooks Health Team on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up on breaches of regulations from the previous comprehensive inspection. In addition, as part of this inspection we revisited areas of concern identified at a recent unannounced focussed inspection which took place on 2 August 2022. Therefore, as part of this comprehensive inspection we inspected all five key questions: safe, effective, caring, responsive and well-led.

How we carried out the inspection/review

This was a two-day inspection which included:

  • 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.
  • A full site visit.
  • Reviewing evidence from the provider.
  • Speaking with staff whilst on site.

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 demonstrated progress in providing safe and effective care.
  • We noted improvements in the practice’s management of patients with long term conditions.
  • There was a process for monitoring patients’ health in relation to the use of high risk medicines.
  • The practice had strengthened their system for recording and acting on safety alerts.
  • At this inspection, leaders demonstrated that they had the skills to deliver high quality care. There were clear responsibilities, roles and systems of accountability in place.
  • There was some evidence which demonstrated efforts to engage patients in programmes for childhood immunisations and cervical screening. However, data remained below local and national uptake rates.
  • During our inspection we observed that staff dealt with patients with professionalism, dedication and a caring nature.

Although we found that the provider had addressed key areas identified on the inspection in August 2021 and there was evidence of compliance with the specific regulatory breaches previously issued, we identified other areas that required further improvement:

  • Some of the practices processes for managing risks, issues and performance contained gaps and were not always effective.
  • Although there was evidence of an open culture at the practice, staff we spoke with were not aware of who their Freedom to Speak up Guardian was.
  • Engagement with the public and staff had not always been effective, this impacted on the practices efforts to sustain high quality and sustainable care.
  • We noted a theme in patient feedback indicating that they were not always able to access services in a timely way. The practice was making continued efforts to address and improve this, but they were unable to demonstrate impact at the time of our inspection.

We found a breach of regulations. The provider must:

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

In addition, the provider should:

  • Continue with efforts to engage patients’ patients in programmes for childhood immunisations and cervical screening.
  • Explore further ways of identifying and capturing patients who are carers so that they are supported where needed.
  • Continue to engage in practice support and improvement projects.
  • Expand on the formal clinical supervision in place for the wider clinical team.

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

18 August 2021

During an inspection looking at part of the service

We carried out an announced inspection at Holbrooks Health Team on 18 August 2021.

The key questions are rated as:

Safe - Requires Improvement

Effective – Requires Improvement

Well-led - Inadequate

Following our previous inspection on 5 January 2016, 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 Holbrooks Health Team on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focused inspection to follow up on the information of concern we had received into the Commission.

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
  • 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 Good for the population groups Older People, People whose circumstances make them vulnerable and People experiencing poor mental health. The population groups People with Long-term Conditions, Families, children and young people and Working age people have been rated as Requires Improvement.

We found that:

  • One medicine safety alert had not been acted upon which put patients at risk.
  • The premises was not being adequately monitored and maintained.
  • There were ineffective governance arrangements in place which resulted in risks within the practice not being identified and managed.
  • Improvement was needed in relation to staff support and communication with staff within the practice.
  • Patients with diabetes and Chronic obstructive pulmonary disease (COPD) had not always had their reviews in an effective way.
  • Good infection prevention and control processes were in place and these were adequately overseen to ensure patient safety.
  • The practice had improved the management structure and staff felt supported in their roles.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
  • Since the new partner joined the service in April 2021, there were newly embedded systems in place to ensure that significant events and incidents were recorded, and that learning was shared as a result of these.
  • There were good systems in place to safeguard vulnerable patients.

We found two breaches of regulations. The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Review COPD and diabetes patients in order that they have appropriate and timely reviews of their care and treatment at the practice.

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

To Be Confirmed

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Holbrooks Health Team on 5 January 2016. Overall the practice is rated as good for providing safe, effective, caring, responsive and well led services.

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. Events were fully investigated by the practice and learning points identified and implemented.
  • The practice was a founder member of a local GP federation. This enabled learning and best practice to be shared more widely within GP practices within the local area.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned. Training needs were also identified and actioned as a result of patient feedback.
  • Information about services and how to complain was available and easy to understand. All complaints were fully investigated by the practice and learning points identified. These were also shared when appropriate within the local GP federation of which the practice was part, to enable learning to be more widely applied.

  • The practice had good facilities and was well equipped to treat patients and meet their needs. A range of health care related commercial services was also available on site, for example a pharmacy and hearing centre.

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • 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 areas where the provider should make improvement are:

  • Ensure appropriate steps are taken to improve access to the service by telephone and for patients making appointments.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

7 January 2014

During a routine inspection

On the day of our inspection we spoke with six patients, one doctor and five members of staff. Two of the patients were members of the patient participation group (PPG).

All patients we spoke with were dissatisfied with the appointment system and said you could only get an appointment for the same day in an emergency. Two patients said: 'I had difficulty getting an appointment before Christmas.' Patients were satisfied with all other aspects of the practice. Three patients told us: 'They are very good.'

We saw that patients' views and experiences were taken into account in the way the service was provided and that they were treated with dignity and respect. When patients received care or treatment they were asked for their consent and their wishes were listened to.

The practice is located in a modern building with two floors. It is fully accessible for patients with disabilities and has a lift. There were disabled parking bays close to the entrance in the car park. The surgery is also fitted with a hearing aid loop.

We found the practice to be clean and well organised. Processes were in place to minimise the risk of infection. There were also processes in place for monitoring the quality of service provision. There was an established system for regularly obtaining opinions from patients about the standard of the service they received.