The Care Quality Commission
  • Doctor
  • GP practice

Parbold Surgery

Overall: Good read more about inspection ratings

The Surgery, The Green, Parbold, Wigan, Lancashire, WN8 7DN (01257) 514000

Provided and run by:
Parbold Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Parbold Surgery 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 Parbold Surgery, you can give feedback on this service.

30 July 2021

During an inspection looking at part of the service

We carried out an announced inspection at Parbold Surgery on 28, 29 and 30 July 2021. Overall, the practice is rated as Good.

The key question ratings are as follows:

Safe - Good

Effective - Good

Caring – not inspected (Good rating carried forward from previous inspection)

Responsive – not inspected (Good rating carried forward from previous inspection)

Well-led - Good

Following our previous inspection on 10 September 2019, the practice was rated requires improvement overall and requires improvement for safe services, inadequate for Well led services and good for the remaining key questions. We issued the practice with a warning notice as enforcement for breaches of regulations. We carried out an inspection to follow up on the warning notice on 20 February 2020, we were assured during the visit that those breaches of regulation had been addressed.

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

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on breaches of regulations identified at the previous inspections and areas identified that the provider should focus on.

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 on 30 July 2021.
  • Speaking with a member of the PPG (patient participation group) over the telephone to consult on the service provided.

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 and good for all population groups.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm. We noted some prescribing was not in line with best practice. The provider sent us evidence the following day to demonstrate that they had taken steps to resolve these issues. Letters had been sent to the small number of patients effected to arrange medication reviews. There was no evidence of any harm having come to patients.
  • We noted that safety alerts were not always well recorded, and some historic alerts had not been acted on. We were sent evidence the day after the inspection assuring us that work was underway to consolidate protocols for recording and dealing with alerts, any historic alerts were being reviewed and acted upon.
  • Patients received effective care and treatment that met their needs, however there was some inconsistency in the documenting of patient notes and medication reviews.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Staff spoke highly of the management team and described an excellent working environment.
  • 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.
  • Access to the practice was assessed as excellent by patients.

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

  • Develop a single comprehensive record for safety alerts and review any that may not have been appropriately dealt with.
  • Continue to embed new higher risk medicines protocols.
  • Develop a more consistent approach to documenting care plans and medication reviews.

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

25 Feb 2020

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Parbold Surgery on 10 September 2019 as a follow up to the previous inspection (22 January 2019) which had led to the practice being rated as requires improvement overall.

The inspection looked at the following key questions: Safe, Effective, Caring, Responsive and Well-led. We rated the practice as good for providing effective, caring and responsive services, however, we rated them as requires improvement for providing safe services and inadequate for providing well-led services.


The inspection report can be found by selecting the ‘all reports’ link for Parbold Surgery on our website at https://www.cqc.org.uk/location/1-583471641.


We issued a warning notice for breaches of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Good Governance). This inspection was an announced focused inspection undertaken on 25 February 2020 to confirm the practice had carried out their plan to meet the legal requirements in relation to the breaches identified within the warning notice.

At this inspection we found:

  • Managerial oversight of significant events and complaints had been much improved and processes to record, review and learn from these were in place.
  • A new acting practice manager was in post and policies relating to significant events and complaints had been reviewed updated and cascaded to staff.
  • Infection control audits had been conducted on a monthly basis and were now being followed up with action plans and appropriate measures.
  • Safeguarding processes had been improved and coding of vulnerable patients and their family members was now in place.
  • Both clinical and non-clinical audit had been improved, providing management oversight of safety and performance.


Details of our findings and the evidence supporting them are set out in the evidence tables. A further full comprehensive inspection will be carried out in the near future in line with our inspection methodology in order to update the practice’s ratings

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

10 September 2019

During a routine inspection

We carried out an announced comprehensive inspection at Parbold Surgery on 10 September 2019. We had previously inspected the practice in January 2019 and May 2018; where the practice overall rating was requires improvement on both occasions. This inspection identified some improvements in the quality of the service, however gaps remained in some areas and this inspection resulted in an overall rating of requires improvement. We issued the practice with a requirement notice for a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Good Governance) following the previous inspection. The full comprehensive reports following the inspections in January 2019 and May 2018 can be found on our website here:

We carried out our most recent inspection in order to ensure the practice had implemented appropriate improvements.

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 all population groups.

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

  • There were gaps in the practice systems to safeguard patients; patient records were not updated following review at safeguarding meetings.
  • Systems to manage and identify learning following incidents and near misses did not follow best practice guidelines.
  • Risks to health and safety were not always comprehensively mitigated, in particular in relation to infection prevention and control and lone working.

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

  • Systems to ensure comprehensive oversight of the service being delivered were ineffective.
  • Patient complaint records were not always comprehensive and lacked sufficient information to enable staff learning. Essential documents were sometimes missing from complaints and learning opportunities missed.
  • Despite improvements in the governance arrangements, there were still gaps in safeguarding and significant event processes and in some areas of risk management.
  • Risk management systems required improvement for example; there were no action plans developed following infection prevention and control audits and identified risks remained the same from one audit to the next. Risks associated with home visits had been identified but not addressed.
  • Opportunities to learn and develop from incidents and complaints were not recognised.

We rated the practice as good for Effective, Caring and Responsive services and all the populations groups.

  • The practice had addressed concerns raised at our January 2019 inspection relating to the coding of patients on the safeguarding register and the management and response to patient safety alerts.
  • The practice had introduced an online information system to support governance and management oversight of the service.
  • Patient feedback was strongly and consistently positive about the standard of care and treatment received.
  • 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.
  • Patients could access care and treatment in a timely way.

The areas where the provider must make improvements are:

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

(Please see the specific details on action required at the end of this report).

In addition, the provider should:

  • Establish a system to regularly monitor the prescribing practice of those working in advanced roles including non-medical prescribers.
  • Monitor and improve prescribing of antibacterial medicines.
  • Take action to improve achievements for cervical screening.

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

22 January to 22 January 2019

During a routine inspection

We carried out an announced comprehensive inspection at Parbold Surgery on 22 January 2019. We had previously inspected the practice in May 2018; this inspection had resulted in an overall rating of requires improvement. We issued the practice with a requirement notice for a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Good Governance). The full comprehensive report following the inspection in May 2018 can be found on our website here: https://www.cqc.org.uk/location/1-583471641.

We carried out our most recent inspection in order to ensure the practice had implemented appropriate improvements.

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 all population groups.

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

  • Although systems to manage and identify learning following incidents and near misses had improved, oversight was insufficient to ensure they were operating effectively. Incidents and associated learning were not logged in a timely manner and documentation was not always comprehensive enough to provide a clear description of what had happened.
  • Risks were not always comprehensively mitigated, in particular in relation to recruitment processes.
  • Actions following receipt of safety alerts were not always appropriate to fully mitigate risks to patients.

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

  • We identified further gaps in the practice’s governance arrangements, despite improvements being implemented to address specific concerns identified at our May 2018 inspection.
  • Oversight of practice policies was lacking, for example the significant event policy was not being followed in practice, and the safeguarding policies contained outdated information.

However, we also found that:

  • The practice had appropriately addressed concerns raised at our May 2018 inspection relating to the management of incoming correspondence and uncollected prescriptions.
  • Patient feedback was strongly and consistently positive anout the standard of care and treatment received.
  • 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 organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

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.

(Please see the specific details on action required at the end of this report).

In addition, the provider should:

  • Improve the identification of carers to enable this group of patients to access the care and support they need.
  • An action plan should be generated following completion of the infection prevention and control (IPC) audit and health and safety risk assessments to ensure appropriate oversight of any required improvements.

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

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

10 May to 10 May 2018

During a routine inspection

This practice is rated as requires improvement. (Previous rating 30 March 2016 – Good)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

We carried out an announced comprehensive inspection at Parbold Surgery on 10 May 2018 as part of our inspection programme.

At this inspection we found:

  • Patients were satisfied with the care and treatment they received. They told us they felt listened to and that staff were friendly. The practice prioritised the delivery of patient-centred care.
  • Patients were extremely positive about the access at the practice and felt they could get appointments when they needed them. We were told the appointment system was easy to use.
  • The practice lacked clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice did not always document it had investigated in a timely way and communication channels to disseminate any learning identified were not always effective.
  • There were gaps in governance systems which resulted in risks. We saw that staff were not undertaking tasks in line with the documented policy guidance in place.
  • 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.
  • There was a focus on continuous learning and improvement at all levels of the organisation. Staff were encouraged in developing their careers and the practice supported trainee clinicians and offered work experience placements.

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

  • 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:

  • The provider should implement a formal process of monitoring clinical decisions made by staff working in advanced roles is implemented in order to be assured staff are working within their competencies.
  • Actions completed on receipt of patient safety alerts should be logged in order to provide a clear audit trail of what has been done.
  • Patients should be signposted to appropriate organisations with whom they can escalate their complaint should they be unhappy with the practice’s response to issues raised.

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

30/03/2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Parbold Surgery on 30th March 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 a system in place for reporting and recording significant events.
  • Risks to patients were assessed although actions to mitigate these risks were not always implemented in a timely manner.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients were extremely positive about the care they received and 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 for patients.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.

  • Fifteen minute appointment slots were routinely offered to ensure patients had enough time with the clinician.

  • 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 proactively sought feedback from staff and patients, which it acted on.

We saw two areas of outstanding practice:

  • A dietician attended the practice on a monthly basis specifically to run a clinic for diabetic patients.

  • The practice had designed a pre-health check preparation sheet for patients attending learning disability health check reviews which contained symbols and pictures to supplement the written information and make it easier to understand. This ensured the patients were able to get the most from their appointment.

The areas where the provider should make improvement are:

  • Ensure that changes implemented following the inspection around infection control practices and the management of complaints are fully embedded into practice.

  • Ensure only the treatment rooms, with hard flooring are used for minor surgical procedures, rather than the carpeted consultation rooms.

  • Ensure action plans resulting from completed risk assessments are implemented fully and in a more timely manner in order to mitigate any identified risk.

  • Ensure meeting minutes are comprehensive and contain sufficient detail around who attended in order to ensure a robust audit trail of the dissemination of information is maintained. Meeting agendas should include feedback from significant events and complaints in order to formalise and maximise learning outcomes from these.

  • Ensure policy documents used to govern activity are kept up to date and reflect practice processes.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice