Archived: Failsworth Group Practice

Updated 14 January 2022

Failsworth Group Practice is located at:

Failsworth District Centre

Ashton Road West

Failsworth

Manchester

M35 0AD

We visited this address as part of the inspection activity.

The provider is registered with the CQC to deliver the regulated activities of diagnostic and screening procedures, family planning, maternity and midwifery services, surgical procedures and treatment of disease, disorder or injury.

The practice is a member of NHS Oldham Clinical Commissioning Group (CCG). It delivers commissioned services under a Primary Medical Services (PMS) contract. This is a contract between general practices and NHS England for delivering services to the local community. At the time of our inspection there were 12,166 patients registered with the practice.

The provider is registered as a partnership. There are two female GP partners. There are also two salaried GPs (one female and one male), and two healthcare assistants. Locum GPs and practice nurses also work at the practice. There is a practice manager and an administration manager, and they are supported by a team of reception and administrative staff.

Due to the enhanced infection prevention and control measures put in place since the pandemic, and in line with the national guidance, most GP appointments are telephone consultations. If the GP needs to see a patient face-to-face an appointment is made.

The National General Practice Profile states that 94% of the practice population are of white ethnicity, and 3% are Asian.

Information published by Public Health England rates the level of deprivation within the practice population group as level four on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest.

Male life expectancy is 78 years compared to the national average of 79 years. Female life expectancy is 81 years compared to the national average of 83 years.

Extended access is provided locally by a separate provider who provides late evening and weekend appointments are available.

Updated 14 January 2022

We carried out an announced inspection of Failsworth Group Practice on 7 December 2021. Overall, the practice is rated as Inadequate.

The ratings for each key question are:

Safe - Inadequate

Effective - Inadequate

Caring – Requires improvement

Responsive - Inadequate

Well-led - Inadequate

Following our previous inspection on 7 May 2021, the practice was rated Requires Improvement overall and for all key questions except well-led, which was rated Inadequate. We issued requirement notices in respect of breaches of Regulation 12 (safe care and treatment), Regulation 16 (receiving and acting on complaints) and 19 (fit and proper persons employed). We issued a warning notice in respect of a breach of Regulation 17 (good governance).

We carried out a further inspection on 1 September 2021 to check the progress made with the warning notice. We found that although some improvements had been made the warning notice had not been met.

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

Why we carried out this inspection

This inspection was a comprehensive inspection of all five key questions. We also followed up on the breaches of regulations we found in our 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
• 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 site visit

Our findings

We base 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.

We rated the provider as Inadequate for providing safe services. Concerns included:

• Systems were not in place to ensure all relevant pre-employment checks were carried out.
• Evidence of mandatory vaccinations for staff was not held.
• Actions required following fire and health and safety risk assessments had not been completed and routine safety checks were not carried out.
• Systems and processes were not in place to ensure the adequate monitoring of patients.
• Significant events were not monitored and not used for learning purposes.

We rated the provider as Inadequate for providing effective services. Concerns included:

• Required monitoring of patients taking high risk medicines did not always take place.
• A high number of patients had a potential missed diagnosis of chronic kidney Disease (CKD).
• There was no programme of targeted quality improvement.
• Appraisals were not used to support or develop staff.
• No formal clinical supervision was in place.
• When performance monitoring was in place for staff this had not been updated for several months.
• Do not attempt cardio pulmonary resuscitation (DNACPR) orders were not adequately recorded.

We rated the provider as Requires improvement for providing caring services. Concerns included:

• Data from the national GP patient survey was below average.
• There was limited privacy at the reception desk.
• Information about support groups was not available on the practice website.

We rated the provider as Inadequate for providing responsive services. Concerns included:

• The practice was short-staffed and there was a high staff turnover.
• There was poor telephone access.
• Data from the national GP patient survey was below average.
• The complaints policy and procedure were not followed, verbal complaints were not recorded, complaints were not responded to in a timely way and not all aspects of complaints were investigated.

We rated the practice as Inadequate for providing well-led services. Concerns included:

• Action had not been taken to address the issues found during the inspection of 7 May 2021 or to fully comply with the warning notice issued 19 May 2021.
• Staff reported they were unable to raise concerns.
• There was little emphasis on the well-being or safety of staff.
• Information in policies was conflicting, incorrect or not followed.
• Incorrect information was on the website
• Processes were not in place to manage performance.

We found four breaches of regulations. The provider must:

• 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 there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity.
• Ensure staff 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.

Due to the breaches of regulation identified we will be carrying out further enforcement action against the provider.

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.

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