The Care Quality Commission
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Archived: Failsworth Group Practice

Overall: Inadequate read more about inspection ratings

Failsworth District Centre, Ashton Road West, Failsworth, Manchester, Greater Manchester, M35 0AD (0161) 357 1620

Provided and run by:
Failsworth Group Practice

All Inspections

7 December 2021

During a routine inspection

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

1 September 2021

During an inspection looking at part of the service

We inspected Failsworth Group Practice, Ashton Road West, Failsworth, Manchester, M35 0AD on 7 May 2021. This was a full comprehensive inspection following a CQC assessment where potential risks had been identified. The practice was given an overall rating of requires improvement with the following key question ratings:

Safe – Requires improvement

Effective – Requires improvement

Caring – Requires improvement

Responsive – Requires improvement

Well-led – Inadequate.

After the inspection on 7 May 2021 requirement notices were issued for breaches of regulations 12 (safe care and treatment), 16 (receiving and acting on complaints) and 19 (fit and proper persons employed) of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014. A warning notice was issued for a breach of regulation 17 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 (good governance).

This inspection, carried out on 1 September 2021, was to check the progress made with the warning notices.

We found that although some improvements had been made the warning notice had not been met.

In particular we found:

  • Staff did not have the appropriate authorisations to administer medicines.
  • Recruitment systems did not ensure all the required information was held for new staff.
  • Complaints were not routinely used to improve the quality of care.
  • Improvements were required in systems and processes for learning, continuous improvement and innovation.
  • The system for acting on and monitoring poor performance needed to be improved.
  • There had been an improvement in information contained in meeting minutes.
  • Training had been brought up to date and staff training was monitored.
  • Significant events were recorded, acted on and discussed.
  • The system for taking action when test results were received had been improved.
  • The practice had a Freedom to Speak Up Guardian in place.

The rating of requires improvement awarded to the practice following our full comprehensive inspection on 7 May 2021 remains unchanged. A further full inspection of the service will take place within six months of the original report being published and their rating revised if appropriate.

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

7 May 2021

During a routine inspection

We carried out an announced inspection at Failsworth Group Practice on 7 May 2021. Overall, the practice is rated as requires improvement, with the following key question ratings:

Safe – requires improvement

Effective – requires improvement

Caring – requires improvement

Responsive – requires improvement

Well-led – inadequate.

The practice was rated good overall following our most recent full comprehensive inspection on 9 October 2016.

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 full comprehensive inspection of all key questions following a Transitional Monitoring Approach (TMA) assessment where potential risks had been identified.

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 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 requires improvement for all population groups.

We rated the provider requires improvement for providing safe services. Clinical staff were not correctly authorised to administer certain medicines. Not all staff had been trained in safeguarding, infection control or sepsis awareness. Not all pre-recruitment checks were carried out. Significant events were not being managed effectively.

We rated the provider requires improvement for providing effective services. Training had not been a priority for staff and was not monitored. We found patients with potentially missed diagnoses. Required actions highlighted in staff appraisals were not monitored or followed up.

We rated the provider requires improvement for providing caring services. The provider had not effectively actioned concerns about a staff member. There was no information about support groups on the practice website.

We rated the provider requires improvement for providing responsive services. The system for managing and responding to complaints was not effective. Patient satisfaction with telephone access was below average.

We rated the provider inadequate for providing well-led services. Not all leaders were visible in the practice. Behaviour inconsistent with the practice’s vision and values had not been addressed. Staff were unaware of the Freedom to Speak up Guardian. Training was not monitored and several staff had not completed mandatory training. Policies were not being routinely followed and did not always contain the required information. Meeting minutes did not give enough detail for staff to determine what had been discussed. The process for managing test results required improvement.

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 persons employed by the service provider are of good character, have the qualifications, competence, skills and experience which are necessary for the work to be performed by them and have all the information required under Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service will be inspected again within six months of the publication of this report. If the service is rated as inadequate for any key question or any population group at the second inspection, it will be placed in special measures. Special measures 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

20/03/2018

During an inspection looking at part of the service

We first carried out an announced comprehensive inspection at Failsworth Group Practice on 8 December 2015. Following this inspection the practice was rated inadequate and placed in special measures.

We carried out a further full comprehensive inspection on 9 August 2016 to check the required improvements had taken place. Overall the practice was rated as good following the August 2016 inspection. The domain of safe was rated as requires improvement as improvement was required regarding recruitment procedures. The previous inspection reports can be found by accessing the ‘all reports’ link for Failsworth Group Practice on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 20 March 2018. This inspection was to check the areas where the provider must or should make improvements had been actioned. At this inspection we found:

  • All the required checks were carried out prior to new staff being employed.

  • Clinical audits were discussed with all appropriate staff in meetings. A summary of audits including actions that were required was also kept.

  • The process for recording significant events had been reviewed and all staff had attended a workshop to discuss the process.

The practice is now rated good in the safe domain.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

09/08/2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Failsworth Group Practice on 9 August 2016. Overall the practice is rated as good.

The practice had been previously inspected on 8 December 2015. Following this inspection the practice was rated inadequate with the following domain ratings:

Safe – Inadequate

Effective – Requires improvement

Caring – Requires improvement

Responsive – Inadequate

Well-led – Inadequate

The practice was placed in special measures.

Following this re-inspection on 9 August 2016 our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed, with the exception of some recruitment procedures.
  • 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 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 and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they usually found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • 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.
  • The provider was aware of and complied with the requirements of the duty of candour.

The area where the provider must make improvement are:

  • The provider must ensure all relevant pre-employment procedures are carried out for staff, including locum clinicians.

The areas where the provider should make improvements are:

  • The provider should share the findings of audits with all appropriate staff in the practice to ensure relevant learning is carried out.

  • The provider should check that all clinicians are aware of how significant events should be recorded.

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

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

8 December 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Failsworth Group Practice on 8 December 2015. Overall the practice is rated as inadequate.

Our key findings across all the areas we inspected were as follows:

  • Patients were at risk of harm because systems and processes were not in place to keep them safe. For example appropriate recruitment checks on staff had not been undertaken prior to their employment.

  • Staff were not clear about reporting incidents, near misses and concerns and there was no guidance available for them to follow.

  • Clinically, patient outcomes were identified and there was reference made in audits to quality.

  • Patients were unclear how to complain and information was not easily available. The complaints’ policy did not contain all the required information.

  • Patients were positive about their interactions with staff and said they were treated with compassion and dignity.

  • Appointment systems were not working well so patients did not receive timely care when they needed it.

  • There was insufficient leadership capacity and limited formal governance arrangements.

The areas where the provider must make improvements are:

  • Ensure the safeguarding policy contains up to date information to guide staff. Ensure all staff are aware of who the practice leads are for safeguarding. Ensure all staff have received appropriate safeguarding training.

  • Ensure the complaints’ policy includes the required information and patients are able to easily find out how to make a complaint. To also ensure complaints’ responses are in line with current legislation.

  • Ensure there are policies and procedures in place to guide staff and ensure effective governance systems. To use the views of patients to improve aspects of the service. To put systems in place so when quality and safety is compromised this is recognised. To ensure appointment availability is monitored appropriately so access issues are identified.

  • Ensure all staff receive appropriate training on induction, and effective training at the required intervals. To ensure the practice manager is supervised.

  • Ensure recruitment arrangements include all necessary employment checks for all staff.

The areas where the provider should make improvement are:

  • Give guidance to staff so they understand what a significant event is so all appropriate events are correctly recorded and actioned.
  • Improve the infection control policy so more guidance is available.
  • Bring the mission statement to the attention of all staff.
  • Put in place a remit for the patient participation group and liaise with them in order for them to feel the practice is receptive to their ideas.

I am placing this practice in special measures. Practices 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 practice 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 vary the provider’s registration to remove this location or cancel the provider’s registration. Special measures will give people who use the practice the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice