The Care Quality Commission
  • Doctor
  • GP practice

Peel Hall Medical Practice

Overall: Good read more about inspection ratings

Forum Health, Simonsway, Wythenshawe, Manchester, Greater Manchester, M22 5RX (0161) 375 1000

Provided and run by:
Dr Ashraf Bakhat

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Peel Hall Medical 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 Peel Hall Medical Practice, you can give feedback on this service.

9 August 2022

During a routine inspection

We carried out an announced comprehensive inspection at Peel Hall Medical Practice on 5 & 9 August 2022. Overall, the practice is rated as good.

Safe - good

Effective - good

Caring - good

Responsive - good

Well-led - good

Following our previous inspection on 29 July 2021, the practice was rated requires improvement overall and for the effective and responsive key questions but was rated good for providing safe, caring and well-led services.

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

Why we carried out this inspection

We carried out this fully comprehensive inspection in line with our inspection priorities to ensure that continuing improvements were made.

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.
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting 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 found that:

  • The practice continued to provide a safe service with systems and processes in place to keep patients and staff safe. They took immediate actions when things went wrong and were working on reducing their higher than average prescribing in some areas.
  • The practice had made improvements to both their childhood immunisation and cervical screening uptake performance from the previous inspection. This was an ongoing project in conjunction with engaging patients as stakeholders in their own care.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care. Patient feedback in relation to how patients felt they were treated was generally positive.
  • The practice had systems and processes in place to ensure that patients could access care and treatment in a timely way. Patient feedback was not always positive about access to care and treatment, although the practice showed that improvements were beginning to take place. They had further interventions booked in to ensure that these continued in full consultation with patients, to provide the service they wanted, within the limits of primary care.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care. Governance arrangements were well-established and had led to a culture of openness, honesty and convivial professionalism.

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

  • Enact plans and actions to continue to address lower than average cervical screening and childhood immunisations.
  • Reduce historic high prescribing to within best practice guidance limits, working with patients and other stakeholders.
  • Execute plans to further address low patient satisfaction around access to the service and continue to educate and engage patients as far as possible.

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 Hospitals and Interim Chief Inspector of Primary Medical Services

29 July 2021

During a routine inspection

We carried out an announced inspection at Peel Hall Medical Practice on 27 and 29 July 2021. Overall, the practice is rated as Requires Improvement.

Safe - Good

Effective – Requires Improvement

Caring - Good

Responsive – Requires Improvement

Well-led - Good

Following our previous inspection on 9 November 2020, the practice was rated requires improvement overall and in the safe and well-led key questions; the practice was rated inadequate in the effective key question and good in the caring and responsive key questions.

The full reports for previous inspections can be found by selecting the “all reports” link for Peel Hall Medical Practice on our website at www.cqc.org.uk

Why we carried out this inspection;

The practice had been previously placed in special measures on 6 November 2019, the practice was subsequently inspected on 6 February 2020 to ensure that warning notices issued at the previous inspection had been complied with. In November 2020 we re-inspected the service and found that although improvements were made the practice remained inadequate in the effective key question and in special measures as insufficient improvements had been made. We were provided with action plans detailing how they were going to make the required improvements throughout this process. This inspection was to check the improvements made to date.

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 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 requires improvement overall and in the effective and responsive key questions and in all the population groups overall. We have rated the practice good in the safe, caring and well-led key questions.

We found that:

  • The practice was rated good for providing safe services because we found that the practice had embedded new systems put in place to address concerns identified at the previous inspection such as the implementation of the new significant event process and oversight of risk.
  • The practice was rated requires improvement for providing effective services because they were able to demonstrate progress had been made from the previous inspections. They had developed plans and had taken action to begin to address their lower than average performance and provided evidence that this had led to improvements beginning to be made.
  • The practice was rated good for providing caring services because we found that patient satisfaction was generally high and that in areas where this was not as high, the practice had further surveyed their patients, analysed the results and formed action plans to address it.
  • The practice was rated requires improvement for providing responsive services because although they had been proactive in trying to understand why patient satisfaction was lower and had surveyed patients independently it remained low. Unverified data supplied by the practice and publicly published data agreed that although satisfaction was improving many patients felt that it did not meet their needs.
  • The practice was rated good for providing well-led service because we found that the practice had continued to build on improvements in all areas and had established systems and processes that were still being embedded but were working as intended.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.

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

  • Reduce prescribing and review processes in areas of antibiotics, hypnotics, pain relief and psychotropic medicines.
  • Develop formal supervision processes for the clinical pharmacist staff members.
  • Implement plans to review clinical systems to ensure that historic safety alerts are considered during prescribing decisions and further embed systems to ensure blood results are actioned in a timely manner.
  • Improve uptake of childhood immunisations and cervical screening in line with national targets.
  • Further develop the current process for the documentation and recording of patients DNACPR.
  • Review and collate data to demonstrate continued improvements with regards to patient satisfaction and effectiveness of actions taken.

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

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

09 November 2020

During a routine inspection

We carried out an announced comprehensive inspection at Peel Hall Medical Practice on 9 November 2020 as part of our inspection programme.

At this inspection we followed up on breaches of regulations identified at a previous inspection on 3 September 2019 where the practice was rated inadequate overall due to significant concerns in relation to safety, quality and governance within the practice. The practice was placed into special measures and issued with warning notice for regulation 17 and requirement notices for regulations 19 and 16.

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:

  • We found that some improvements had been made, most notably in areas such as recruitment and safety systems to identify and mitigate risk associated with the premises. We found that the practice was unable to demonstrate fully effective systems regarding identification and mitigation of clinical risk in relation to emergency medicines, monitoring patients taking medicines with a high risk, and the lack of evidence of the maintaining supervision of non-medical prescribers and oversight of medicine safety alerts. Following the inspection, the practice provided evidence that supervision of non-medical prescribers had been maintained but this was not always in line with the practice policy of quarterly.

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

  • We saw that some improvements had been made throughout the practice, most notably in relation to risk associated with the premises and in some areas of governance. Practice staff and the new management team had clearly worked hard to achieve these improvements; however, we saw that further improvements were required. Areas of concern were identified in relation to systems and process to enable the practice to maintain safe care and treatment and achieve high levels of quality of care.

We rated the practice as Inadequate for providing effective services because:

  • We saw some improvement in some areas of quality data, but most remained below local and national averages and the practice was unable to demonstrate a plan to address these issues. We saw improvements in relation to training although some training had been delayed due to Covid-19.

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

  • The work the practice had completed in the community ensured the vulnerable received the care and treatment they required.
  • Patient feedback was positive about the way the practice treated them.
  • Improvements had been made to the management of complaints.
  • The practice had considered ways to make appointments more accessible to patients including the addition of telephone consultations. Although patient satisfaction remained low in relation to access, the practice had taken action to address this, such as ordering a new telephone system.

We saw an area of outstanding practice by the practice;

  • In response to the needs of their population, the practice provided over 200 hot meals for the local population, which were hand delivered by the practice staff to support their community during the difficult financial times brought about by the pandemic. They also supported 150 families with free school meals and another 50 of these meals were provided to food banks locally. The practice told us that they intended to repeat this regularly.

The areas where the provider must make improvements are:

  • 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:

  • Improve the capture of complaints and significant events with overall trend analysis, to aid future learning. Develop the complaints system to have clear actions associated with them and that they are closed when no longer active.
  • Continue to address high hypnotic prescribing so that the practice can demonstrate a sustained reduction in the area of prescribing.

This service was placed in special measures in September 2019.

Insufficient improvements have been made such that there remains a rating of inadequate for providing effective services overall and both the “people with long term conditions” and “people experiencing poor mental health” population groups. Special measures give people who use the service the reassurance that the care they get should improve. The service will still be kept under review and if needed could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within 6 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.

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

06/02/2020

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Peel Hall Medical Practice on 03 September 2019 following our annual review of the information available to us.

The inspection looked at the following key questions: Safe, Effective, Responsive and Well-led. We did not specifically inspect the Caring key question and the rating therefore remained unchanged based on the findings from the last inspection in August 2017.

The inspection report can be found by selecting the ‘all reports’ link for Peel Hall Medical Practice on our website at https://www.cqc.org.uk/location/1-526710208/reports

We issued a warning notice for breaches of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Good Governance). This inspection was an announced focused inspection undertaken on 06 February 2020 to confirm the practice had carried out their plan to meet the legal requirements in relation to the breaches identified within the warning notice.

At this inspection we found:

  • A range of policies, procedures and/or protocols had been developed to provide guidance to practice leaders, clinicians and staff.
  • Systems and processes for the safe management of prescriptions, significant events, safety alerts and complaints had been reviewed and improved.
  • Action had been taken in response to premises safety issues and associated risk assessments.
  • The competency of non-medical prescribers had been assessed and staff had received appraisals.
  • The management of workflow processes and patient test results had been strengthened. GP audit of the work flow process had not yet taken place but was scheduled.
  • Records relating to the recruitment of staff, professional registrations and staff vaccination had been reviewed and improved.
  • Staff had been supported to complete key training modules and systems had been established to monitor progress.
  • A range of meetings had been held for practice staff to attend and plans were in place to schedule ongoing meetings throughout the year.
  • Governance arrangements had improved and were being embedded into practice.

At our previous inspection on 03 September 2019, we rated the practice as inadequate and placed the service into special measures. As per our published inspection methodology, a further full comprehensive inspection visit will be carried out within six months of the publication date of the inspection report, to monitor the work the practice has started to produce the required improvements to the service.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

03/09/2019

During an inspection looking at part of the service

We last undertook an announced comprehensive inspection of this service in August 2017. It was then rated as good overall and for the four key questions of Safe, Effective, Caring and Responsive. The Well-led question was rated requires improvement and breaches were identified in relation to good governance. We undertook a focused inspection in July 2018. The focused inspection identified that improvements had been made in service delivery for the key question Well-led and the rating was changed from requires improvement to good.

We decided to undertake an inspection of this service on 3 September 2019 following our annual review of the information available to us. This inspection looked at the following key questions: Safe, Effective, Responsive and Well-led.

We did not specifically inspect the caring key question and the rating therefore remains unchanged based on the findings from the last inspection in August 2017.

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 Inadequate overall.

We rated the practice as Inadequate for providing safe services because:

  • The practice did not have clear systems and processes to keep people safe.
  • Recruitment records were missing key information required by legislation.
  • The practice did not have appropriate systems in place for the safe management of prescriptions.
  • Safety systems and records were not up-to-date.

We rated the practice as Inadequate for providing effective services because:

  • The practice was unable to show that staff had the skills, knowledge and experience and supervision to carry out their roles.
  • Performance data was significantly below local and national averages.
  • There was a lack of data analysis and action plans to improve performance.

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

  • Complaint records were not up-to-date and complaints were not always handled effectively.
  • Patient survey data and feedback indicated that some patients experienced difficulties making appointments and had experienced poor customer care.

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

  • Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
  • The overall governance arrangements were ineffective.
  • The practice did not have clear and effective processes for managing risks, issues and performance.
  • We saw little evidence of systems and processes for learning, continuous improvement and innovation.

These areas affected all population groups, so we rated all population groups as inadequate.

The areas where the provider must make improvements are:

  • 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 recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.
  • Establish effective systems and processes to ensure good governance 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:

  • Continue to explore ways to improve the appointment booking system in response to patient feedback.
  • Introduce systems to review patient feedback in order to learn and make improvements to the service.

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

11/07/2018

During an inspection looking at part of the service

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

14 August 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Peel Hall Medical Practice on 21 July 2015. The overall rating for the practice was requires improvement with the key questions of safe and well-led rated as requires improvement. The full comprehensive report on the July 2015 inspection can be found on our website at http://www.cqc.org.uk/location/1-526710208.

This inspection was an announced comprehensive inspection carried out on 14 August 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 21 July 2015. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good.

  • At our inspection in July 2015, we found that systems for recording significant events were lacking. At this inspection, we saw that a comprehensive incident reporting form had been introduced and a system for sharing and reviewing events was in place although this system was not always followed or sufficiently documented.
  • The practice had systems to reduce risks to patient safety. The system for securely storing and monitoring loose prescriptions in the practice had been improved since our last inspection and a new cleaning record for clinical equipment was in place. At our inspection in July 2015, we found that the system for managing patient safety alerts was insufficient; however, at this inspection we found that this had improved.
  • The practice was able to demonstrate safe staff recruitment although there was a lack of some suitable checks for a recent locum GP working in the practice.
  • The practice was clean and tidy and an infection prevention and control (IPC) audit had been carried out. However, the practice lacked some policies and procedures for infection prevention and control and there was no record of IPC training for some staff.
  • The practice had copies of risk assessments for the premises and all building safety checks were in place although there was evidence of insufficient risk assessment for staff working. Recruitment processes and procedures did not allow for non-clinical staff to be risk-assessed for the role and there was no confidential health questionnaire issued to staff on recruitment.
  • The practice had adequate arrangements to respond to emergencies and major incidents although there had been no review of those emergency medicines held by the practice. The practice business continuity plan was not complete.
  • At our previous inspection, we found that staff had not been trained to the appropriate level for safeguarding children and vulnerable adults. At this inspection, we saw evidence that clinical staff had trained to the appropriate safeguarding level although records of non-clinical staff training were sometimes lacking. We found that all staff we spoke to had a good knowledge of their responsibilities regarding safeguarding. Meetings with other health professionals for safeguarding discussions were often informal and not minuted.
  • Staff were aware of current evidence based guidance. Clinical staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment although records of non-clinical staff training were incomplete. There was no management overview of staff training.
  • The practice had introduced a programme of staff appraisal since our inspection in July 2015 and all staff had received an appraisal; however, records of discussion at nurse appraisals were lacking and lacked a personal development plan to guide future training.
  • Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns. We saw that the system for documenting patient complaints had improved since our last inspection.
  • Patients we spoke with told us they liked the practice morning walk-in surgeries with GPs. They understood that this meant that they did not always see the same GP and that they needed to wait sometimes. Patients could also book appointments with a named GP up to two weeks in advance.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a leadership structure and staff felt supported by management. There were policies and procedures in place to govern activity although these were insufficient for some areas of practice service delivery and some needed review. Not all staff we spoke to were able to access the policies when asked.
  • There was no overarching governance framework to support the delivery of the strategy and good quality care. Quality improvement was not embedded in the practice; there was no set agenda of quality improvement items for staff meetings.
  • The practice encouraged feedback from staff and patients, which it acted on.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The area where the provider must make improvement is:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the practice should make improvements are:

  • Review the practice process for identifying significant events and follow the significant event procedure to review actions taken as a result of events.
  • Consider what medicines are held by the practice for use in medical emergencies.
  • Improve the clinical staff appraisal process to document discussion at appraisal and produce staff development plans.
  • Improve the overview of training, particularly to demonstrate all staff have undertaken safeguarding training and training relevant to their role.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

21 July 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection of Dr Bakhat on the 21 July 2015. Overall the practice is rated as requires improvement. Specifically, we found the practice to require improvement for providing  safe and well led services. It was good for providing an effective caring and responsive service.

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

  • The practice had a system in place for reporting, recording and monitoring significant events, incidents and accidents. However, no record was kept of discussions that took place about the analysing of incidents.
  • Safeguarding policies and procedures were available for staff to refer to when necessary. Further safeguarding training was planned for a number of clinical and non- clinical staff.
  • Information about services and how to complain was available.
  • Potential risks to the service were anticipated and planned for in advance.
  • Staff were supported with their training and learning development.
  • The practice worked with other agencies and professionals to support continuity of care for patients
  • Patients said they were treated with dignity and respect and they were involved in their care and decisions about their treatment.
  • Most staff considered there to be an open culture within the practice, and they had the opportunity to raise issues during team meetings.

Importantly the provider must:

  • All staff should be provided with the appropriate level of safeguarding training for their role. A record should be kept of meetings held in relation to patient safeguarding concerns.
  • Ensure medicines are managed safely including improvements to the process for dealing with medicine alerts and the security of prescriptions.
  • Ensure governance systems bring about improvements to the running of the service.

In addition the provider should:

  • Improve the way significant events and incidents are recorded and keep a hard copy of this information to demonstrate and support staff learning and improvement of patient outcomes.
  • Improve the process for deciding which audits are completed and consider involving the whole clinical staff team in any decisions.
  • Improve the process for auditing alerts that come into the practice and consider appointing a member of staff to take responsibility for disseminating these alerts. An audit trail of all alerts received should be kept.
  • Provide staff with chaperone training as necessary.
  • Establish a cleaning schedule for the equipment used by clinical staff.
  • Provide staff with an annual appraisal of their work.
  • Improve systems for keeping clinical staff informed about patients’ care needs.
  • Provide staff with training on the Mental Capacity Act and patient consent to treatments.
  • Improve the documentation kept in relation to the management of complaints.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

19 September 2013

During a routine inspection

We spoke with seven people who used the service. They all told us that overall they were happy with the service they received. Comments included: 'I can't put them high enough up the scale. They're wonderful', 'They've always been great, sat back and listened. I've never felt rushed' and 'I can't thank them enough for their care and attention. All the doctors, the nurses and the reception staff; they've been wonderful.'

The practice had single consultation rooms and offered a chaperone service to promote people's privacy and dignity. People were given information about the services available and this information could be provided in different formats to meet people's need.

The practice met with other health and social care professionals to ensure people were receiving care and support from appropriate services in order to improve their overall health and wellbeing.

Staff received appropriate training in adult safeguarding and child protection. They were able to identify the possible signs that abuse may be occurring.

The practice undertook a range of audits and participated in the Quality and Outcomes Framework system in order to monitor and assess the quality of the service they provided.

Appropriate pre-employment checks were carried out for new staff.