The Care Quality Commission
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Unsworth Group Practice

Overall: Good read more about inspection ratings

Peter House Surgery, Captain Lees Road, Westhoughton, Bolton, Lancashire, BL5 3UB (01942) 812525

Provided and run by:
Unsworth Group 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 Unsworth Group 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 Unsworth Group Practice, you can give feedback on this service.

10 June 2021

During an inspection looking at part of the service

We carried out a focused desktop review of Unsworth Group Practice on 10 June 2021. Overall, the practice is now rated good for providing ’responsive’ services and remains rated ‘good’ overall.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection on 12 November 2020, the practice was rated Good overall and for key questions safe, effective, caring and well-led but rated Requires Improvement for providing responsive services:

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

Why we carried out this review

This inspection was a focused desk top review carried out on 10 June 2021 to confirm that the practice had carried out its plan to meet the requirements in relation to those identified in our previous inspection on 12 November 2020. This report covers our findings in relation to

those requirements and additional improvements made since our last inspection.

How we carried out the review

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 and reviews differently.

This review was carried out in a way which enabled us to analyse information without spending time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included

  • Requesting evidence from the provider

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • information from our ongoing monitoring of data about services and
  • information from the provider.

We have rated this practice as Good overall with the key question responsive now rated as Good.

We found that:

  • There is an accessible system for identifying, receiving, recording, handling and responding to complaints.
  • A new system is in place to ensure patients prescribed certain medicines are having regular, required checks carried out.

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

12 November 2020

During a routine inspection

We carried out a full comprehensive inspection to Unsworth Group Practice on 12 November 2020. We rated the practice good, with the following key question ratings:

Safe – good

Effective – good

Caring – good

Responsive – requires improvement

Well-led – good

All the population groups were rated requires improvement due to a breach of Regulation 16 in the key question responsive.

We had previously inspected Unsworth Group Practice on 11 December 2019. The inspection was following our annual regulatory review of the information available to us including information provided by the practice. Our review indicated that there may have been a significant change to the quality of care provided since the last inspection.

At the December 2019 inspection the service was rated inadequate overall and place into special measures. The following ratings were given:

Safe – inadequate

Effective – requires improvement

Caring – not inspected

Responsive – not inspected

Well-led – inadequate

We issued warning notices for Regulation 12 HSCA (RA) Regulations 2014 (safe care and treatment) and Regulation 17 HSCA (RA) Regulations 2014 (good governance), and a requirement noticed for Regulation 19 HSCA (RA) Regulations 2014 (requirements relating to workers).

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. In May 2020 the practice submitted evidence to show that sufficient changes had been implemented to comply with the breaches outlined in the warning notices.

This most recent inspection was a full comprehensive inspection. The inspection methodology used for this inspection was adapted to minimise the risks of exposure to the coronavirus for patients, staff and the CQC inspectors. We requested information from the practice which we collected, collated and analysed. A CQC national clinical advisor and a GP specialist advisor then remotely accessed the practice clinical computer systems to carry out targeted searches. We carried our remote interviews via Microsoft teams with GPs, nurses, members of the management team and administrative and reception staff. A site visit to the Westhoughton practice was then carried out by CQC inspectors on 12 November 2020.

At this inspection we found that improvements had been made under each of the key questions previously inspected and all the requirements of the warning notices and requirement notice had been achieved. However, there was a breach of Regulation 16 HSCA (RA) Regulations 2014 due to how the practice managed complaints.

We rated the practice good for providing safe services because:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm. Improvements had been as follows:
  • Safeguarding training was now up to date for all staff.
  • Pre-recruitment checks were completed and ongoing information was held.
  • Fire safety and other health and safety checks were carried out.
  • Appropriate standards of hygiene and infection control were met.
  • Patient Group Directions were well-managed.
  • Prescription security was well-managed.
  • Safety alerts were actioned in a timely manner.
  • The vaccination status of staff in relation to infectious diseases was monitored.

We rated the practice good for providing effective services because:

  • Patients received effective care and treatment that met their needs. Improvements had been as follows:
  • Staff induction was consistent.
  • Training was well-managed and up to date.
  • Appraisals had been completed.

We rated the practice good for providing caring services because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.

We rated the practice requires improvement for providing responsive services because:

  • Although the practice organised and delivered services to meet patients’ needs and patients could access care and treatment in a timely manner the process for handling complaints required improvement.

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

  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care. Improvements had been as follows:
  • All partners had an overview of the management of the practice.
  • A new governance system was in place that was being monitored.
  • Safety audits were in place and well-managed.
  • The partners managed performance appropriately.

The areas where the provider must make improvements are:

  • Ensure there is an accessible system for identifying, receiving, recording, handling and responding to complaints.

In addition, the areas where the provider should make improvements are:

  • Regularly check patients prescribed certain medicines are having the required checks carried out.

I am taking this service out of special measures. This recognises the significant improvements 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 BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

11 December 2019

During an inspection looking at part of the service

On 11 December 2019 we carried out an inspection of Unsworth Group Practice following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a significant change to the quality of care provided since the last inspection.

We inspected the main surgery at Peter House, Captain Lees Road, Westhoughton, Bolton, BL5 3UB. As part of the inspection we also visited the branch surgery at Blackrod Health Centre, Church Street, Blackrod, Bolton, BL6 5EN.

The practice had previously been inspected 17 November 2015. It had been rated good overall and good for each key question except safe, which was rated requires improvement. On 29 December 2016 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 effective and well-led. Because of the assurance received from our review of information we carried forward the ratings for the key questions caring and responsive. During the inspection we opened up the safe key question due to concerns we had found.

We rated the practice inadequate overall with the following key question ratings:

Safe – inadequate

Effective – requires improvement

Well-led – inadequate

The population groups were all rated requires improvement.

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 rated the practice inadequate for providing safe services because:

  • Safeguarding training was not up to date.
  • Clinical records were not always appropriately coded in relation to safeguarding children.
  • Not all the required pre-recruitment information or checks were held.
  • Fire safety and other health and safety checks were not carried out.
  • Appropriate standards of hygiene and infection control were not met.
  • Sepsis training had not been carried out for staff.
  • Patient Group Directions were not adequately managed.
  • Prescription pad security was not managed.
  • Safety alerts were not all actioned in an appropriate or timely manner.
  • The vaccination status of staff, in relation to infectious diseases, was not monitored.

We rated the practice requires improvement for providing effective services because:

  • Staff induction was not consistent.
  • Training was not well-managed; there were gaps in staff training and it was difficult to ascertain what training had been carried out or updated at the appropriate time.
  • Staff appraisals were not up to date.

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

  • There was no overview of the management of the practice.
  • Managers and partners had not identified the gaps in their governance systems.
  • Internal safety audits were either not taking place or not adequate.
  • Performance issues had not been identified.

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

In addition, the provider should:

  • Develop all-staff meetings to improve communications within the practice.

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

29 December 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

This is a focused desk top review of evidence supplied by Unsworth Group Practice for one area within the key question safe.

After reviewing evidence supplied to support this inspection process we found the practice to be good in providing safe services. Overall, the practice is rated as good.

The practice was previously inspected on 17 November 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, recruitment was identified as requires improvement, as the practice was not meeting the legislation at that time. The area where the practice was told they must make improvement was as follows :

Regulation 19 (1)(3)(a) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Regulation 19 HSCA (RA) Regulations 2014 Fit and proper persons employed :

  • Recruitment checks were carried out and the staff files we reviewed showed that appropriate recruitment checks had been undertaken prior to employment. For example, proof of identification, qualifications, registration with the appropriate professional body where appropriate. However no evidence was available to demonstrate some of the nurses and phlebotomy staff had received Disclosure and Barring Service (DBS) checks. Not all of the staff trained to be chaperones had received a DBS check. There was no evidence of a risk assessment being conducted in relation to the need to (or not to) conduct DBS checks on the remaining practice staff. Whilst we acknowledge the provider had initiated the process to conduct DBS checks on some staff the provider must assess the different responsibilities and activities of all staff to determine if they are eligible for a DBS check. Where the decision has been made not to carry out a DBS check on staff, the practice should be able to give a clear rationale as to why.

The practice has submitted to the CQC, a range of documents which demonstrates they are now meeting the requirements of Regulation 19 (1)(3)(a) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Regulation 19 HSCA (RA) Regulations 2014 Fit and proper persons employed.

In addition there were areas where the practice were told they should make improvements. These were as follows :

  • The provider should take action to review their arrangements for assessing the risk from legionella.

  • Clinical staff had received training in relation to consent and mental capacity. The provider should extend this training (at the appropriate level) to other members of the practice team to maximise the support provided to patients in relation to consent to care and treatment.

The practice has submitted to the CQC, a range of documents which demonstrates they have made these suggested improvements.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

17 November 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Unsworth Group Practice on 17 November 2015. Overall the practice is rated as good. Specifically, we found the practice to require improvement for providing safe services and good for providing effective, responsive, caring and well led services.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • 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.
  • Patients said they found it easy to make an appointment and that 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 area where the provider must make improvements is:

The provider must assess the different responsibilities and activities of all staff to determine if they are eligible for a DBS check. Where the decision has been made not to carry out a DBS check on staff, the practice should be able to give a clear rationale as to why.

In addition the provider should:

The provider should take action to review their arrangements for assessing the risk from legionella.

Clinical staff had received training in relation to consent and mental capacity. The provider should extend this training (at the appropriate level) to other members of the practice team to maximise the support provided to patients in relation to consent to care and treatment.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

2 September 2013

During a routine inspection

We found the practice based within a modern building which was well maintained throughout. All consulting areas were on the ground level. The practice also had a branch surgery based in Blackrod which we did not visit on this inspection.

The practice's reception area had adequate seating but as space was limited patients with prams were asked to leave them outside or collapse them if possible. Within the practice there was adequate room for patients with limited mobility or wheel chairs to move around freely and access consulting rooms.

The practice had electronic records in place to accurately describe the contact patients had with the service and the actions taken to provide appropriate care and treatment.

We found staff had access to contact details for both child protection and adult safeguarding teams. They were able to describe the appropriate actions they had taken with recent safeguarding concerns.

The practice had a range of policies and procedures in place for staff to access, which supported the safe running of the service.

The practice was bright clean and airy and had appropriate infection prevention and control systems in place.

The practice leaflet and website were informative and provided patents with a range of information including how to raise a concern. Patients we spoke with told us they would raise any concerns with the clinical or reception staff.

Patients told us; 'You don't wait long for appointments if you don't mind which doctor you see. If you want a specific one you may have to wait a number of days'. 'I feel the practice has improved as time has gone on I am pleased with the service I get'. 'I feel safe here, I am comfortable with the doctors and trust them'. 'My X works late and the practice is great as they offer evening appointments he can access. We have recently moved to this practice and it was their reputation that drew us here and up to now we have not been disappointed'.