The Care Quality Commission
  • Doctor
  • GP practice

Manchester Road East Medical Practice

Overall: Good read more about inspection ratings

4 Longshaw Drive, Worsley, Manchester, M28 0BB (0161) 799 3233

Provided and run by:
Dr Mohammad Khan

Important: This service was previously registered at a different address - see old profile

All Inspections

During an assessment under our new approach

Date of assessment 28 August 2024. Manchester Road East is a NHS GP practice located in Manchester in an area of low deprivation. There were approximately 2366 people registered with the service at the time of our assessment. We conducted this assessment because the practice had a previous inadequate rating and due to receiving information of concern. We assessed all quality statements across the safe, effective, responsive and well led key questions and have combined the scores for these areas with scores from the last inspection for the key question caring. At this assessment we found there was an improved focus on safety and governance. We saw improved systems to support effective outcomes for patients. Managers and staff involved people in decisions and supported them to seek feedback if their care or treatment fell short of expectations.

9 November 2023

During an inspection looking at part of the service

We inspected Manchester Road East Medical Practice on 18 July 2023. This was a full comprehensive inspection.

Following this inspection, the practice was given an overall rating of inadequate with the following key question ratings:

Safe – Inadequate

Effective – Requires improvement

Caring – Good

Responsive – Requires improvement

Well-led – Inadequate.

After the inspection on 18 July 2023, warning notices were issued for breaches of Regulations 12 (safe care and treatment), 17 (good governance) and 19 (requirements relating to workers).

This inspection, carried out on 9 November 2023, was to check the progress made with the warning notice.

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

This included:

  • Conducting an interview with the lead GP 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 short site visit.

We found that improvements had been made. In particular:

  • Our clinical searches found that patients had the required monitoring for their conditions, and medicines were regularly reviewed.
  • There was a system to manage and act on safety alerts.
  • Urgent referrals, test results and safety alerts were monitored with a documented process in place.
  • Emergency medicines were kept in a secure place. The practice had carried out risk assessments to determine which emergency medicines they held.
  • Actions required following an infection prevention and control audit had been carried out.
  • There was documented clinical supervision for the practice nurse.
  • The fire doors were kept closed.
  • The systems for managing complaints and significant events had been updated, and clear information was now recorded so these could be easily monitored.
  • The practice manager had updated policies and procedures where appropriate and was continuing to make amendments where it was found they could be improved on.
  • The locum pack had been updated so locum GPs had clear guidance to follow.
  • The system for managing staff training had been updated and clear records were kept for each staff member.
  • The practice had appointed a Freedom to Speak Up Guardian.
  • The practice had not recruited any new staff members since the inspection in July 2023, but they had updated their recruitment process for when they did employ new staff. However, we found that there had been no up to date check that the practice nurse was correctly registered with the appropriate professional body.

The rating of inadequate given to the practice following our full comprehensive inspection on 18 July 2023 remains unchanged. A further full inspection of the service will take place and their rating revised if appropriate.

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

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

18 July 2023

During a routine inspection

We carried out an announced inspection at Manchester Road East Medical Practice on 18 July 2023. Overall, the practice is rated inadequate.

The ratings for each key question are:

Safe - inadequate

Effective – requires improvement

Caring - good

Responsive – requires improvement

Well-led – inadequate

Why we carried out this inspection

We carried out this inspection due to a change in the provider’s registration. The practice had moved to new premises in 2022. This inspection was a comprehensive inspection of all five key questions.

How we carried out the inspection

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:

  • 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.
  • Conducting an interview with the provider using video conferencing.
  • Requesting evidence from the provider.
  • A short site visit.
  • Issuing questionnaires to staff.

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 inadequate overall.

We rated the provider inadequate for providing safe services:

  • Recruitment systems were not effective and relevant legislation was not adhered to.
  • The process for managing significant events was not effective.
  • Safety alerts were not appropriately actioned.
  • Patients prescribed high risk medicines were not always appropriately monitored.
  • Emergency medicines had not been considered, and were not safely stored.
  • Actions had not been taken following the infection prevention and control audit.
  • Information provided to locum GPs was not accurate.

We rated the provider requires improvement for providing effective services:

  • Up to date clinical guidance was not always being followed.
  • The system for keeping clinicians up to date with current guidance was not effective.
  • Evidence of training for the practice nurse was not held by the practice.
  • There was no documented clinical supervision for the newly qualified practice nurse.
  • Childhood immunisation and cervical screening data was below target.

We rated the provider good for providing caring services:

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

We rated the provider requires improvement for providing responsive services:

  • The process for identifying, investigating, responding to and learning from complaints was not effective.

We rated the provider inadequate for providing well-led services:

  • Leaders had not identified the risks we found during the inspection.
  • Policies were not always followed and did not always contain enough information to provide relevant guidance.
  • Systems for managing risks were not effective.
  • Information, such as from complaints and significant events, was not recorded and acted on.
  • We did not see examples of continuous learning and improvement.
  • There were no arrangements in place to access a Freedom to Speak Up Guardian.

We found 4 breaches of regulation. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.
  • Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints made by patients and other persons in relation to the carrying on of the regulated activity.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

In addition, the provider should:

  • Take steps to improve the uptake of childhood immunisations and cervical screening.
  • Monitor the vaccination status of non-clinical staff and take action where required.

I am placing this service in special measures. Services placed in special measures will be inspected again within 6 months. If insufficient improvements have been made such that there remains a rating of inadequate for any 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 6 months if they do not improve.

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