All inspections: Culcheth Medical Centre

Date of Assessment: 02 June 2026. Culcheth Medical Centre is a GP practice and delivers services to approximately 12,654 people under a contract held with NHS England. According to the latest available data, the ethnic make-up of the service area is approximately 95.8% White, 1.5% Asian, 0.7% Black, 1.7% Mixed ethnicity and 0.3% Other. Information published by the Office for Health Improvement and Disparities shows deprivation within the service population group is in the 9h decile (9 of 10). The lower the decile, the more deprived the service population is relative to others.

This was a focused assessment which was undertaken due to the length of time since our last assessment. We assessed 10 quality statements from across all 5 key questions. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.

The provider ensured the premises were kept clean and managed the risk of infection. The premises were appropriately maintained overall. However, some improvements were needed to how fire risks were assessed.

Staffing levels and staff skill mix were monitored to ensure they met the needs of the service. Staff told us they received effective support, supervision and training and they worked together well to care for patients. Overall, staff had the training required for their roles. The provider was making improvements to how the completion of mandatory training updates was monitored.

Staff supported people to live healthier lives, monitoring their care and treatment to ensure they received positive outcomes.

The service was good at treating people with kindness, empathy and compassion and in how they respected people’s privacy and dignity.

People could access care, treatment and support when they needed it. Leaders and staff were alert to discrimination and inequality that could disadvantage groups of people who used the service and sought ways to address any barriers.

The service had a clear vision and strategy, which considered the needs of the people who used their service and the wider community. Staff understood their individual roles and responsibilities.

We carried out an announced inspection at Culcheth Medical Centre on 20 May 2021. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection on 29 May 2019, the practice was rated Requires Improvement overall and the key questions safe and well-led. Effective, caring and responsive key questions were rated Good.

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

Why we carried out this inspection

This was a focused inspection to:

Inspect the key questions of safe, effective and well-led.
Follow up on breaches of regulation 12, 13, 16 and 17 and areas where the provider should improve as identified in our previous inspection.

The key questions caring and responsive were not inspected and so the ratings of good have been carried forward from the previous inspection.

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 and telephone
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 and reviewing 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 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. The systems for ensuring staff were appropriately authorised to administer medicines to patients and for monitoring uncollected prescriptions had been improved. The practice had appropriately notified CQC of significant events that met the criteria. Systems for identifying and reviewing children and vulnerable adults subject to safeguarding concerns had been improved.
Monitoring of safety alerts, consultations, referrals and prescribing of clinicians had improved since the last inspection and were formally documented.
Warning signs had been placed on plugs of fridges storing vaccines and window blind cords had all been secured.
Patients received effective care and treatment that met their needs.
Improvements had been made to the management of complaints, there was a clinical lead in place and they were discussed in various meetings with outcomes and actions disseminated appropriately.
The way the practice was led and managed promoted the delivery of high-quality, person-centre care. There had been improvements with communications, systems and processes had been strengthened and embedded and there was better oversight of all areas.

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

Continue with plans to strengthen the monitoring arrangements for patients prescribed specific medicines that require regular monitoring.
Complete annual reviews of significant events to identify themes, trends and assess the outcome of action taken.
Produce a formal audit plan based on local, national and service priorities.
Continue to review and monitor the clinical performance data that falls below national targets.
Record all outcomes for complaints and review these to identify themes, trends and actions completed.

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

We carried out an announced comprehensive inspection at Culcheth Medical Centre on 29 May 2019 as part of our inspection programme.

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.

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

The systems for ensuring staff were appropriately authorised to administer medicines to patients and for monitoring uncollected prescriptions was not robust.
The systems for identifying and reviewing children subject to safeguarding concerns and vulnerable adults was not robust.

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

The systems for managing complaints and significant events did not ensure the learning and actions were fully documented so that they could be shared effectively with staff.
The provider had not notified CQC of a patient death that may have been related to the regulated activity or how it was provided.

We rated the practice as good for providing caring, effective and responsive services because:

The practice reviewed the effectiveness and appropriateness of the care it provided.
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.

We rated the population groups as good.

The area where the provider must make improvements are:

Ensure that care and treatment is provided in a safe way.
Ensure patients are protected from abuse and improper treatment
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care
Ensure specified information is referred to CQC in accordance with the (Registration) Regulations 2009.

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

The areas where the provider should make improvements are:

Introduce a system to monitor two-week rule referrals to ensure patients receive the clinical care they are referred for.
Formalise the system for reviewing the practise of clinical staff to ensure consultations, referrals and prescribing are appropriate.
Review the system to monitor safety alerts to ensure it is effective.
Put a warning on the plug of the vaccine fridge so that the electricity supply is not interrupted and secure the cords of window blinds so that they do not present a hazard.
An annual review of significant events should be undertaken in addition to the quarterly reviews.
A designated clinical lead for complaints to be put in place.

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

Culcheth Medical Centre

All Inspections

During an assessment under our new approach

20 May 2021

During an inspection looking at part of the service

29/05/2019

During a routine inspection