The Care Quality Commission
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  • GP practice

Chorlton Family Practice

Overall: Requires improvement read more about inspection ratings

Chorlton Health Centre, 1 Nicolas Road, Chorlton-cum-Hardy, Manchester, Greater Manchester, M21 9NJ (0161) 881 4545

Provided and run by:
Chorlton Family Practice

All Inspections

19 January 2024

During an inspection looking at part of the service

We carried out an announced full comprehensive inspection of Chorlton Family Practice 12 January 2024. All key questions were inspected. We have rated the practice requires improvement overall.

Safe – Requires Improvement

Effective – Good

Caring - Good

Responsive – Requires Improvement

Well-led – Requires Improvement

At the last inspection in 2017 the practice was rated good overall.

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

Why we carried out this inspection

We carried out this inspection because of an aged rating and to follow up information of concern reported to us.

We inspected the key questions of safe, effective, caring, responsive and well-led.

How we carried out the inspection/review

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A shorter 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
  • information from the provider, patients, the public and other organisations.

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

  • Recruitment checks and staff vaccinations had not been maintained consistently.
  • Health and safety assessments did not identify all potential risks.
  • There was mixed feedback from staff about how absence and staffing levels were managed.
  • The system to report and manage significant incidents was not effective.
  • The practice had undertaken their own inhouse investigation due to concerns that had been highlighted to them internally.
  • They were still in the process of embedding improvement and completing actions at the time of the inspection.

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

  • We recognise the pressure that practices are currently working under and the efforts staff are making to maintain levels of access for their patients. At the same time, our strategy makes a commitment to deliver regulation driven by people’s needs and experiences of care. Although we saw the practice was attempting to improve access, this was not yet reflected in the GP patient survey data or other sources of patient feedback.

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

  • Staff feedback was mixed regarding visibility and approachability by leaders.
  • There was a lack of oversight for non-clinical risk in the absence of a practice manager.
  • The arrangements for identifying, managing and mitigating risks were not reliable and although improvements had been identified and some actions had been taken they were not embedded.

In addition we found:

  • Patients received effective care and treatment that met their needs.
  • Staff mostly dealt with patients with kindness and respect and involved them in decisions about their care, although some feedback from patients disputed this.
  • The practice had internally identified areas for concern and an improvement plan was in place.

We found a breach of regulation. The provider must:

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

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 Health Care

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20 March 2017

During a routine inspection

Letter from the Chief Inspector of General Practice


We carried out an announced comprehensive inspection at the Chorlton Family Practice on 4 February 2016. The overall rating for the practice was requires improvement with the key questions of safe and effective rated as requires improvement. The full comprehensive report on the February 2016 inspection can be found on our website at http://www.cqc.org.uk/location/1-544250271

This inspection was an announced focused inspection carried out on 20 March 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 4 February 2016. 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.

Our key findings were as follows:

  • At our inspection in February 2016 we found that appropriate recruitment checks had not always been conducted prior to employment and that some GP and locum GP files were incomplete. We also saw that appropriate Disclosure and Barring Service (DBS) checks had not been carried out for staff acting as chaperones. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable). At this inspection, we saw evidence that all staff recruited since our last inspection had been checked appropriately prior to employment. We also saw that information held at the practice for GPs and locum GPs was complete and that all staff at the practice had had a DBS check.
  • During our previous inspection we found that some staff had not received appraisals in the preceding 12 months although these had been scheduled for dates following our visit. At this inspection visit we saw that all staff had received an appraisal within the last 12 months.
  • At our inspection in February 2016 we found that the system in place to monitor and audit the traceability of the prescription paper used in the practice was insufficient. At this inspection, the practice showed us evidence that all prescription paper in the practice was held and logged securely.
  • We saw in February 2016 that improvements indicated by audits conducted by the practice were not always implemented or monitored. We viewed audit work undertaken by the practice since the inspection in 2016 and saw that the audit process was comprehensive and supported practice quality improvement.
  • During our previous inspection we saw that lessons learned as a result of patient safety alerts and incident reports were not always shared to ensure that action was taken to improve safety in the practice. At this inspection we saw that the process for dealing with patient safety alerts and incident reports was sound and that patient safety was not compromised.
  • At our inspection in February 2016 we saw no evidence that there was a system to check the expiry dates of drugs in the practice. We saw at this inspection that there was a system in place and that expiry dates were checked regularly.
  • During our inspection in February 2016, we found that there were systems lacking in relation to staff making patient home visits. There was no policy for staff lone working and the blood samples that were collected were not always managed appropriately. During this inspection we saw that there were safe systems in place for the transport of patient blood samples and that staff were protected with a comprehensive lone worker policy.
  • At our inspection in February 2016 we observed that reception staff handled patient urine samples inappropriately, there was no policy in place and staff had not received appropriate training. At this inspection, we saw that staff had all received training in handling patient samples, there were gloves available if necessary and that there was a policy in place.
  • At our previous inspection, we saw that practice policies in relation to patient care were not always reviewed in order to ensure that they were consistent with current guidance. We also found that some staff were not always aware of practice policies. At this inspection, we saw that there was a process in place to update policies when necessary in line with current guidance and staff demonstrated that they were aware of practice policies and where to find them.
  • During our inspection in February 2016 we found that staff acting as chaperones had not received comprehensive training. We also found that staff training records were not always accurate. At this inspection, we saw that staff acting as chaperones had received some training and that staff knowledge of procedure was safe although staff told us that further training would be appreciated. We also saw that while staff training records had been improved they were not always up to date and lacked detail.
  • At our inspection in February 2016 we found that clinical staff meetings were infrequent and lacked structure. We saw at this inspection, that whole practice staff meetings happened every month and that there was an appropriate fixed agenda for these meetings. Clinical staff met at these meetings and also informally on an ad hoc basis.
  • We found in February 2016 that the practice had no formal strategy for development in place. However, at this inspection we were given a very comprehensive practice report for 2016 and strategic plan for 2017 to 2020.
  • Following our inspection in February 2016, we published a report that contained information that we had agreed was incorrect and had agreed to remove. We did see evidence that the practice had responded in a timely manner to feedback from sources including the national GP patient survey and information from the NHS Choices website.

The areas of practice where the provider should make improvements are:

  • Provide further training to staff acting as chaperones.
  • Update the records of staff training to include completed training dates for all training courses undertaken.


Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

4 February 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection on 4 February 2016 at Chorlton Family Practice. Overall the practice is rated as requires improvement. 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 not always assessed appropriately. For example, risks in relation to lone working, carrying blood samples and health and safety risks.
  • Clinical audits did not always demonstrate quality improvement.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Staff had 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.
  • The practice was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management.

Areas of outstanding practice:

  • The practice was working with other local practices and the community nursing team to actively support and manage people living in care and nursing homes to avoid unplanned admissions into hospital.

The areas where the provider must make improvements are:

  • Ensure recruitment arrangements include all necessary employment checks for all staff employed by the practice as well as locum staff. This includes the need for a Disclosure and Barring Service (DBS) check when appropriate.
  • Ensure all staff receive supervision and appraisal within appropriate timescales and all staff files are monitored regularly.
  • Ensure there is a system to monitor and audit the traceability of the prescription paper used in the practice.
  • Ensure audits and re-audits are implemented to improve patient outcomes.

The areas where the provider should make improvements are:

  • Undertake a thorough review of risks with appropriate mitigating actions. For example, risks in relation to lone working, carrying blood samples and health and safety risks.
  • Review and update policies to ensure the practice has access to all the required policies, such as handling samples in the reception area, and ensure all staff are aware of the relevant policies for their roles.
  • More routine staff meetings should be available and any learning should be shared with all staff groups.
  • Ensure the practice business strategy is up to date and fit for purpose.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice