The Care Quality Commission
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  • GP practice

Chadderton Medical Practice

Overall: Good read more about inspection ratings

Chadderton Town Health Centre, Middleton Road, Chadderton, Oldham, Lancashire, OL9 0LH (0161) 357 2290

Provided and run by:
Chadderton Medical Practice

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Chadderton Medical Practice on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Chadderton Medical Practice, you can give feedback on this service.

10/11/2020

During a routine inspection

We carried out an announced comprehensive inspection at Chadderton Medical Practice on 10 November 2020. The practice is now rated Good overall.

The methodology used for this most recent inspection was adapted to minimise the risks of exposure to the coronavirus for patients, staff and the CQC inspectors. We undertook some of the inspection processes remotely and spent less time on site. We conducted staff interviews remotely during the week of 2 November 2020 and undertook a shorter site visit on 10 November 2020.

Previously we carried out an announced comprehensive inspection at Chadderton Medical Practice on 21 March 2020. The overall rating for the practice was inadequate. It was placed into special measures and warning notices were issued for breaches in Regulations 12 (safe care and treatment), 17 (good governance) and 18 (staffing). The full comprehensive report for the inspection in March 2020 can be found by selecting the ‘all reports’ link for Chadderton Medical Practice on our website at www.cqc.org.uk.

As a result of the restrictions imposed by the Covid-19 pandemic, site visit inspections scheduled to check compliance with warning notices were suspended. In the interim we sought and received assurance from the practice that the required improvements were being made. On 11 June 2020 the practice submitted evidence to show that sufficient changes had been implemented to comply with the breaches outlined in the warning notices.

Our judgement of the quality of care at this service is based on a combination of what we found when we inspected, information from our ongoing monitoring of data about services and information from the provider, and other organisations.

We rated the practice good overall. The key questions are rated as follows:

Safe Good

Effective Good

Caring Good

Responsive Good

Well Led Good

We rated the practice good for providing safe services because:

  • The process for managing significant events was now effective and learning from significant events could be demonstrated.
  • Staff were appropriately trained in safeguarding and people who used the service were protected from avoidable harm and abuse.
  • Medicine and safety alerts were appropriately managed and there was oversight to ensure these had been actioned. Records we reviewed confirmed action had been taken in response to recent alerts.
  • Medicines that required additional monitoring were appropriately managed and we saw patients had received blood tests within the recommended time frames. Staff at the practice, including the clinical pharmacist undertook regular searches of the clinical systems and ensured relevant patients were identified and invited for appointments.
  • There was oversight of pathology results and clinical practice throughout.
  • The practice had implemented clinical oversight for clinical and locum staff. Any identified needs were discussed and fed into the appraisal and review process.
  • All infection control requirements had been put in place and patients were sufficiently protected from any risks pertaining to the Covid-19 pandemic. However, the role of infection control lead required further clarity.

We rated the practice as good for providing effective services because:

  • Since the last inspection all staff had received appropriate training and appraisal to ensure they were able to meet the needs of patients. Staff were supported through supervision meetings to access training and increase their skills where they wished to.
  • The practice submitted evidence of a clinical audit improvement plan and two-cycle audits had been completed. The practice had a system of audits that were shared with staff and used to drive practice improvements. However, external peer review and sharing with other surgeries was not in place at present.
  • Patients with long-term conditions were reviewed appropriately. Records we looked at showed that patients were treated in line with national guidance.
  • Patients with a diagnosis of diabetes, or a possible diagnosis of diabetes, were reviewed following abnormal blood results.
  • Staff referred patients to secondary care and local resources as appropriate.
  • There was evidence of appropriate shared care management.

The practice was previously rated good for providing caring services and there was no change to this rating because:

  • GP survey results had improved since the previous inspection.
  • Staff we spoke with showed a strong commitment to patient care.
  • Evidence of patient support and social prescribing was demonstrated.
  • The practice had identified and supported carers.

The practice was previously rated good for providing responsive services and there was no change to this rating because:

  • Appropriate changes had been put in place to support patients throughout the Covid-19 pandemic.
  • Patients were able to access the practice remotely and face to face.

Complaints were managed in a timely way and were discussed and learned from. The practice had introduced better ways to increase and monitor patient feedback with a view to identifying and acting on any trends. This would be demonstrated, if effective, in the future.

We rated the practice as Good for providing well-led services because we saw many areas of good governance newly implemented since the inspection in February 2020.

  • The practice had sought support from the Royal College of General Practitioners (RCGP), the Primary Care Network (PCN) and the Clinical Commissioning Group (CCG) following the inadequate report in February 2020. Each area of concern had been reviewed and addressed and the conditions of the warning notices had been met.
  • The practice demonstrated that improvements in June 2020 had been maintained.
  • Patient feedback was positive.
  • The governance and culture of the practice promoted high quality person-centred care.
  • Leaders were approachable and supportive, and staff felt better informed about practice issues.

The areas where the provider should make improvements are as follows:

  • There was no dedicated infection control lead who was appropriately trained and responsible for all infection control processes at the practice. Those responsibilities should include identification of risk, regular infection control audit, staff training and implementation and response to all concerns.
  • The clinical audit programme did not include peer and network discussion and learning.
  • The process to obtain and monitor patient satisfaction did not include verbal feedback.
  • The system to record and monitor diabetes patients was not failsafe.
  • Although medicine reviews were occurring, they were not always consistently detailed.

I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.

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

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

21 March 2020

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Chadderton Medical Practice on 21 February 2020 as part of our inspection programme.

The practice had previously been inspected on 12 March 2015. It had been rated good overall and good for each key question except safe, which was rated requires improvement. On 8 March 2017 we carried out a desk top review and received evidence of improvement. We then rated the key question safe good.

This inspection initially focused on the key questions safe, effective and well-led. During the inspection we opened up the caring and responsive key question due to concerns we had found.

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 inadequate overall with the following key question ratings:

Safe – inadequate

Effective – inadequate

Caring – good

Responsive – good

Well-led – inadequate.

We rated the practice as inadequate for providing safe services because:

  • Safeguarding, fire and infection control training was not up to date.
  • Actions required following a fire risk assessment had not been monitored or completed.
  • Patient Specific Directions were not in place to allow the healthcare assistant to administer vaccinations.
  • A clinician was not always at the practice and there was no formal arrangement to manage this.
  • There was no protocol for managing repeat prescription requests for high risk medicines and appropriate blood tests were not always carried out prior to a prescription being issued.
  • Sepsis training had not been carried out for all staff.
  • The process for managing significant events was not effective and learning from significant events could not be demonstrated.

We rated the practice as inadequate for providing effective services because:

  • The practice was below the local and national average for several of their performance indicators. There was little evidence of improvement and no formal plan to improve.
  • There was no evidence of any two-cycle audits and where it had been identified that a second audit was required these had not been completed.
  • Training was not well-managed; there were gaps in staff training and it was difficult to ascertain what training had been carried out as some evidence was kept in individual personnel files and not recorded elsewhere.
  • There was no formal clinical supervision of employed clinical staff and the partners had no involvement in the appraisals of their clinicians or of the practice manager..

We rated the practice as good for providing caring services.

We rated the practice as good for providing responsive services.

We rated the practice as inadequate for providing well-led services because:

  • The partners did not understand the challenges to the practice and had not identified any of the areas of concern we found.
  • The partners had not considered the clinical effectiveness of their employed clinicians.
  • Gaps in governance systems had not been identified. Some policies had not been reviewed for several years and not all policies were followed.
  • The website contained outdated information.
  • There was no formal process to manage risks.
  • There was no focus on learning and improvement.

The areas where the provider must make improvements 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.
  • Ensure persons employed by the service provider receive appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform.

In addition, the provider should:

  • Work to accurately identify carers so appropriate support could be offered.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration. Special measures will give people who use the service the reassurance that the care they get should improve.

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

8th March 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

This is a focused inspection of Chadderton Medical Practice for one area within the key question safe.

We found the practice now to be good in providing safe services. Overall, the practice is rated as good.

The practice was previously inspected on 12 March 2015. The inspection was a comprehensive inspection under the Health and Social Care Act 2008. At that inspection, the practice was rated good overall. However, within the key question safe, one area was identified as requiring improvement, as the practice was not meeting the legislation at that time:

Regulation 19 HSCA (RA) Regulations 2014 Fit and proper persons employed. We found that the registered person had not protected people against risk related to staff employed at the

registered location. This was in breach of regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulation 19 (1)(3)(a) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

During the inspection on 8 March 2017 we were provided with evidence which demonstrated Chadderton Medical Practice are now meeting the requirements of Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

12 March 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

Chadderton Medical Practice was inspected on 12 March 2015. This was a comprehensive inspection. This means we reviewed the provider in relation to the five key questions leading to a rating on each on a four point rating scale. We rated the practice as good in respect of being effective, caring, responsive and well-led and requiring improvement in relation to being safe.

Our key findings were as follows:

The practice has systems in place for reporting, recording and monitoring significant events. Significant incidents and events are used as an opportunity for learning and improving the safety of patients, staff and other visitors to the practice.

The practice has systems in place to ensure best practice is followed. This is to ensure that people’s care, treatment and support achieves good outcomes and is based on the best available evidence.

Information we received from patients reflected that practice staff interacted with them in a positive and empathetic way. They told us that they were treated with respect, always in a polite manner and as an individual.

Patients spoke positively in respect of accessing services at the practice. A system is in place for patients who require urgent appointments to be seen the same day.

However, there were also areas of practice where the provider needs to make improvements.

Importantly, the provider must:

Improve the system of staff recruitment to ensure that patients are protected by operating effective recruitment and selection procedures that includes obtaining the required information and conducting relevant checks being carried out (and evidenced) when staff are employed or are engaged in a role where such checks are required.

In addition the provider should:

Whilst we acknowledge that the practice team is relatively small and staff had a clear understanding of how to keep children and vulnerable adults safe it was not clear who the clinical lead was in respect of safeguarding at the practice. To ensure staff are completely clear on where they can access support regarding safeguarding matters, the practice should identify a clinical safeguarding lead and communicate who this person is to all staff.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice