• Doctor
  • GP practice

Chorlton Family Practice

Overall: Requires improvement read more about inspection ratings

Chorlton Health Centre, 1 Nicolas Road, Chorlton-cum-Hardy, Manchester, Greater Manchester, M21 9NJ (0161) 881 4545

Provided and run by:
Chorlton Family Practice

Latest inspection summary

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Background to this inspection

Updated 5 March 2024

Chorlton Family Practice is located in City of Manchester at:

Chorlton Health Centre

1 Nicolas Road

Chorlton

Manchester

M21 9NJ

The practice has a branch surgery at:

9 Corkland Road

Chorlton-cum-Hardy

Manchester M21 8UP

The practice offers services from the main practice and the branch surgery. Patients can access nursing services from the branch site.

The provider is registered with CQC to deliver the Regulated Activities of diagnostic and screening procedures, maternity and midwifery services, family planning, treatment of disease, disorder or injury and surgical procedures. These are delivered from both sites.

Chorlton Family Surgery is located within the Greater Manchester Care Partnership and NHS Greater Manchester Integrated Care Board. They want people across all boroughs to stay well and bring together different organisations that support people’s health and social care.

They deliver General Medical Services (GMS) as part of a contract held with NHS England.

The practice is part of a wider network of GP practices in West Central Manchester primary care network (PCN) which has a total of 7 practices. Chorlton Family Surgery serves a patient population of 22,640.

Information published by the Office for Health Improvement and Disparities shows that deprivation within the population group is 5 (5 out of 10). The higher the decile the less deprived the practice population is relative to others. According to the latest available data, the ethnic make-up of the practice area is 68.6% white British, 17.7% Asian 4.9% Black, 5.3% mixed and 3.5% other.

The practice has struggled with GP recruitment and loss of staff following mergers over the last twelve months which has had a negative impact on safety and governance. They initiated their own internal and external investigations and were on a journey of recovery and improvement at the time of the inspection. There is currently no permanent practice manager but the practice have increased duties of other staff to cover practice management until March 2024.

There is a team of 8 GP partners and 8 salaried GPs who provide cover at both practices. The practice has a team of nurses that include 2 independent prescribing advanced practitioners, a minor illness nurse, an independent nurse practitioner prescriber, 4 practice nurses, 2 paramedics, 2 assistant practitioners and a health care assistant. The nursing team provide nurse led clinics for long-term conditions and other minor ailments at both the main and the branch locations. The GPs are supported at the practice by a team of reception/administration staff. The practice management was under review but there was a finance manager, a deputy practice manager and an informatics manager in place at the time of the inspection.

The practice is open between 8am to 8.30pm on Monday and 8am to 6.30pm Tuesday to Friday. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Extended access is provided locally by the primary care network in various settings where late evening and weekend appointments are available. Out of hours services are provided by 111.

Overall inspection

Requires improvement

Updated 5 March 2024

We carried out an announced full comprehensive inspection of Chorlton Family Practice 12 January 2024. All key questions were inspected. We have rated the practice requires improvement overall.

Safe – Requires Improvement

Effective – Good

Caring - Good

Responsive – Requires Improvement

Well-led – Requires Improvement

At the last inspection in 2017 the practice was rated good overall.

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

Why we carried out this inspection

We carried out this inspection because of an aged rating and to follow up information of concern reported to us.

We inspected the key questions of safe, effective, caring, responsive and well-led.

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 shorter 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
  • information from the provider, patients, the public and other organisations.

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

  • Recruitment checks and staff vaccinations had not been maintained consistently.
  • Health and safety assessments did not identify all potential risks.
  • There was mixed feedback from staff about how absence and staffing levels were managed.
  • The system to report and manage significant incidents was not effective.
  • The practice had undertaken their own inhouse investigation due to concerns that had been highlighted to them internally.
  • They were still in the process of embedding improvement and completing actions at the time of the inspection.

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

  • We recognise the pressure that practices are currently working under and the efforts staff are making to maintain levels of access for their patients. At the same time, our strategy makes a commitment to deliver regulation driven by people’s needs and experiences of care. Although we saw the practice was attempting to improve access, this was not yet reflected in the GP patient survey data or other sources of patient feedback.

We have rated the practice as requires improvement for providing well led services because:

  • Staff feedback was mixed regarding visibility and approachability by leaders.
  • There was a lack of oversight for non-clinical risk in the absence of a practice manager.
  • The arrangements for identifying, managing and mitigating risks were not reliable and although improvements had been identified and some actions had been taken they were not embedded.

In addition we found:

  • Patients received effective care and treatment that met their needs.
  • Staff mostly dealt with patients with kindness and respect and involved them in decisions about their care, although some feedback from patients disputed this.
  • The practice had internally identified areas for concern and an improvement plan was in place.

We found a breach of regulation. The provider must:

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

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

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