• Doctor
  • GP practice

Stable Fold Surgery

Overall: Good read more about inspection ratings

119 Church Street, Westhoughton, Bolton, Lancashire, BL5 3SF (01942) 813678

Provided and run by:
Stable Fold 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 Stable Fold 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 Stable Fold Surgery, you can give feedback on this service.

21 April 2023

During an inspection looking at part of the service

We carried out an announced focused inspection at Stable Fold Surgery on 21 April 2023. Overall, the practice is rated good.

Safe - not inspected, rating of good carried forward from previous inspection

Effective - not inspected, rating of good carried forward from previous inspection

Caring - not inspected, rating of good carried forward from previous inspection

Responsive - requires improvement

Well-led - not inspected, rating of good carried forward from previous inspection

The overall rating for this practice is Good. At our previous inspection on 31 January 2020 the practice was rated requires improvement for providing a responsive service. This was in the main due to significantly lower than average national GP survey results in relation to ‘how easy it was to get through to someone at their GP practice on the phone’. The practice was also rated as requires improvement in effective for people with long term conditions due to the lower than average outcomes for people with long term conditions.

We completed a desktop review focused on responseive and effective on 19 May 2021. The desktop review confirmed some improvements had been made in relation to people with long term conditions, which was rated as good, however improvements still needed to be made to how people are able to contact the practice by telephone.

At this inspection on 21 April 2023, we found that the national GP survey results, in relation to ‘how easy it was to get through to someone at their GP practice on the phone’ were still significantly lower than average. Since this data was collected the practice has installed a new phone system to improve access for patients.

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

Why we carried out this inspection

We carried out this inspection to follow up concerns from a previous inspection. The review focused on the responsive key question.

How we carried out the inspection

This inspection was carried out as a desktop review, we did not visit the location.

This included:

  • Conducting staff interviews using video conferencing.
  • Requesting evidence from the provider.

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 found that:

  • Patients could not always access care and treatment in a timely way.

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

  • Apply to deliver the Regulated Activity of maternity and midwifery services without delay
  • Take action to evaluate the impact of the new phone system on patient experience.
  • Follow the complaints policy for all complaints.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Healthcare

19 May 2021

During an inspection looking at part of the service

We carried out a focused desktop review at the practice of Stable Fold Surgery on 19 May 2021. The practice is rated ‘good’ overall, and now rated 'good' in effective for people with long term conditions, however the practice remains ‘requires improvement' for providing ‘responsive’ services including all population groups.

Safe - Good

Effective - Good

Caring - Good

Responsive – Requires improvement

Well-led - Good

Following our previous comprehensive inspection on 31 January 2020 where the practice was rated good overall. The key question responsive was rated ‘requires improvement’ and the population group, people with long term conditions was also rated 'requires improvement' in the effective domain.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Stable Fold Surgery 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 19 May 2021 to review improvements made in the key question 'responsive' and for 'people with long term conditions, following our previous inspection on 31 January 2020.

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

  • Analysing data about the services provided
  • 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, and good for people with long term conditions in the effective domain, however the key question responsive remains ‘requires improvement’.

We found that:

  • Improvements to how patients were able to contact the practice and make an appointment had been made, however the planned improvements to the telephone system had yet to be completed.
  • Data showed improved outcomes for patients with long term conditions.
  • The practice has appointed a new salaried GP, increasing clinical capacity.
  • The practice now offers an online appointment booking system, whereby patients can book appointments with GPs and nurses without having to telephone the surgery.

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

  • The percentage of respondents to the GP patient survey who responded positively to how easy it was to get through to someone at their GP practice on the telephone continued to be significantly below average.

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

  • Continue with the planned improvements to the telephone system and continue to promote the online booking system.

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

31 January 2020

During a routine inspection

We carried out an announced comprehensive inspection at Stable Fold Surgery on 31 January 2020 as part of our inspection programme. The practice had previously been inspected on 17 December 2018 and had been rated as requies improvement with the following key question ratings:

Safe – requires improvement

Effective – requires improvement

Caring – good

Responsive – good

Well-led – requires improvement.

In December 2018 we found breaches in Regulation 12 HSCA (RA) Regulations 2014, safe care and treatment and Regulation 17 HSCA (RA) Regulations 2014, good governance.

This was an announced full comprehensive inspection to ensure the required improvements had been made.

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, with the following key question ratings:

Safe – good

Effective – good

Caring – good

Responsive – requires improvement

Well-led – good

We rated all the population groups requires improvement.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • 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 way the practice was led and managed promoted the delivery of high-quality, person-centre care.

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

  • The percentage of respondents to the GP patient survey who responded positively to how easy it was to get through to someone at their GP practice on the telephone was significantly below average and had decreased in the previous year.

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

  • Increase the number of clinical GP and nursing appointments available to patients.
  • Continue to review GP patient survey results.

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

17 December 2018

During a routine inspection

We carried out an announced comprehensive inspection at Stable Fold Surgery on 17 December 2018 as part of our inspection programme. At the last inspection in December 2014 we rated the practice as good in all domains.

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:

  • Some staff were not clear on the procedure for chaperoning patients. We were told that on occasions the GP requested that the chaperone stood outside the curtain.
  • There was no process to check previous employment dates or the reasons for leaving for appropriate staff.
  • Fire training for staff was out of date and there had been no formal fire drill.
  • There was no evidence that the infection control lead had appropriate training. Infection control procedures, such as for hand washing, were not followed.
  • Significant events were not well-managed. Significant event forms were not updated to include any investigation, discussion, learning or review. Information was instead recorded in various meeting minutes.

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

  • Training was not up to date, so the practice was unable to show that staff had the skills, knowledge and experience to carry out their roles.
  • Although the practice participated in some local and national schemes they were unable to show evidence of improvement following clinical audits.
  • Although there was evidence that the practice manager was well-supported, they had never had a formal appraisal.

We rated the practice as good for providing caring services because:

  • The practice was knowledgeable about registering patients living in vulnerable circumstances, including those without an address.
  • The practice knew how to respond to changes in patients’ preferred gender, name or title.
  • The practice had completed Pride in Practice gold level.

We rated the practice as good for providing responsive services because:

  • The practice opened until 8.30pm one evening a week and further late and weekend appointments were available at a nearby hub.
  • Patients told us appointments were easy to access and they could receive on the day advice in an emergency.
  • Although complaints were investigated and appropriately responded to there was no system to track their progress and use them to drive improvement.

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

  • There was some evidence of risk assessment but there were gaps in fire safety, infection control and emergency medicines. The policies were not always followed.
  • There was little evidence of systems and processes for learning and continuous improvement.
  • Clinical audits did not demonstrate an effective approach to quality improvement.
  • There was no evidence of formal support and assessment of staff.

These areas where improvements were required affected all population groups so we rated all population groups as requires improvement.

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).

The areas where the provider should make improvements are:

  • Have a failsafe system to check all cervical screening results are received by the practice.
  • Review patient group directions (PGDs) to check they are dated.
  • Make sure staff are aware of procedures such as chaperoning and how to deal with uncollected prescriptions.

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

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

9 December 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

Stable Fold Surgery was inspected on the 9 December 2014. This was a comprehensive inspection. We rated the practice overall as good. We rated Stable Fold Surgery as good in relation to being safe, effective, caring, responsive and well-led.

Our key findings 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, with the exception of those relating to recruitment checks.
  • People’s 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 with their GP 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.

We saw areas of outstanding practice for example:

  • Use of “Chat Clinics” to encourage patients reluctant to undertake some screening test.

There were areas of practice where the provider needs to make improvements and the provider should:

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

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice