• Doctor
  • GP practice

Oldham Medical Services

Overall: Good read more about inspection ratings

Langham House, 368 Ashton Road, Oldham, Lancashire, OL8 3HF (0161) 624 4716

Provided and run by:
Oldham Medical Services

All Inspections

25 January 2024

During an inspection looking at part of the service

We carried out a targeted assessment of Oldham Medical Services in relation to the responsive key question. This assessment was carried out on 25 January 2024 without a site visit. Overall, the practice is rated as Good. We rated the key question of responsive as Requires improvement.

Safe - Good

Effective – Good

Caring - Good

Responsive – Requires improvement

Well-led – Good

The full reports for previous inspections can be found by selecting the ‘all reports’ link for the

Oldham Medical Services on our website at www.cqc.org.uk

Why we carried out this review.

We carried out this assessment as part of our work to understand how practices are working to try to meet demand for access and to better understand the experiences of people who use services and providers.

We recognise the work that GP practices have been engaged in to continue to provide safe, quality care to the people they serve. We know colleagues are doing this while demand for general practice remains exceptionally high, with more appointments being provided than ever. In this challenging context, access to general practice remains a concern for people. Our strategy makes a commitment to deliver regulation driven by people’s needs and experiences of care. These assessments of the responsive key question include looking at what practices are doing innovatively to improve patient access to primary care and sharing this information to drive improvement.

How we carried out the assessment

This assessment was carried remotely.

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:

  • During the assessment process, the provider highlighted the efforts they are making or are planning to make to improve the responsiveness of the service for their patient population.
  • The effect of these efforts are not yet reflected in patient feedback. Patient feedback was that they could not always access care and treatment in a timely way. Some patients were dissatisfied with the arrangements for getting through to the practice by phone and their experience of obtaining an appointment.

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

  • Continue with their plan of responding to patient concerns/feedback about access and their experience of making an appointment with an aim to improve patient experience.

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

21 June 2022

During a routine inspection

We carried out an announced inspection at Oldham Medical Services on 21 June 2022. Overall, the practice is rated as Good.

The ratings for each key question are:

Safe - Good

Effective - Good

Caring – Good (rating awarded at last inspection May 2021)

Responsive – Good (rating awarded at last inspection May 2021)

Well-led - Good

The provider was last inspected May 2021 and was rated Good overall and in all of the key questions.

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

Why we carried out this inspection

We undertook this inspection as part of a random selection of services rated good and outstanding to test the reliability of our new monitoring approach. This included focusing on the key questions safe, effective and well led. Caring and responsive were not inspected.

How we carried out the inspection/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 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 and reviewing staff questionnaires
  • 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 Good overall

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 practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

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

  • Continue to encourage and improve uptake rates for childhood immunisations and cervical cancer screening.

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

28 May 2021

During an inspection looking at part of the service

We carried out a focused desktop review for the practice of Oldham Medical Services on 28 May 2021. The practice remains rated good overall and is now rated good for providing an effective service.

Safe - Good

Effective - Good

Caring - Good

Responsive – Good

Well-led - Good

On our previous comprehensive inspection on 18 December 2019 the practice was rated good overall. However, the key question effective was rated requires improvement. The population groups families, children and young people and working age people (including those recently retired and students) were also rated requires improvement for the key question effective. We also found that there was no formal audit plan in place.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Oldham Medical Services 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 28 May 2021 to review improvements made in the key question effective and for the population groups families, children and young people and working age people (including those recently retired and students) following our previous inspection on 18 December 2019.

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 included

  • Analysing data about the services provided and
  • 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 all population groups.

We found that:

  • The practice had improved the levels of childhood immunisations and cervical screening. Data showed improved outcomes for patients.
  • The practice had put a formal audit plan in place.

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

18 December 2019

During a routine inspection

We carried out an announced comprehensive inspection at Oldham Medical Services on 18 December 2019 as part of our inspection programme. The practice was last inspected on 9 November 2018. It had been rated good overall and good for all the key questions except safe, which was rated requires improvement due to recruitment procedures. At this inspection we saw these procedures had been updated and all required checks took place.

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. The key questions of safe, caring, responsive and well-led are rated good, and the key question effective is rated requires improvement due to data relating to childhood immunisations and cervical screening. The population groups families, children and young people and working age people (including those recently retired and students) are rated requires improvement for these reasons, and all other population groups are rated good.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients usually received effective care and treatment that met their needs. However, the practice had not met targets relating to childhood immunisations or cervical screening.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

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

  • Put a formal audit plan in place.
  • Improve the levels of childhood immunisations and cervical screening.

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

9 November 2018

During a routine inspection

This practice is rated as Good overall. (Previous rating February 2018 - Inadequate)

At the February 2018 inspection the key questions were rated as:

Are services safe? – Inadequate

Are services effective? – Requires improvement

Are services caring? – Requires improvement

Are services responsive? – Requires improvement

Are services well-led? – Inadequate

Requirement notices were issued in relation to regulation 16 (receiving and acting on complaints) and 19 (fit and proper persons employed). Warning notices were issued in April 2018 in relation to regulations 12 (safe care and treatment), 17 (good governance) and 18 (staffing). The practice was placed into special measures.

At this November 2018 inspection the key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at Oldham Medical Services on 9 November 2018. This was a full follow up inspection carried out six months after the report placing the practice into special measures was published. There had been a focussed follow-up inspection carried out on 27 July 2018 to check the progress of warning notices issued. The July 2018 inspection showed that the practice had started to work on the improvements required but further improvement was necessary.

At this inspection we found:

  • Recruitment procedures had improved but there was still some information not available for recently employed staff.
  • The complaints process had improved and the policy had been updated.
  • Safety processes had been improved and all relevant safety checks were carried out.
  • Significant events were recorded and investigated and discussed in meetings, so learning could be disseminated.
  • Staff training was now monitored for clinical and non-clinical staff. Evidence of training for all staff was held and we saw it was up to date.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.
  • The practice team met regularly to review and monitor improvements required.

The areas where the provider must make improvements are:

  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed. The provider must ensure specified information is available regarding each person employed.

The areas where the provider should make improvements are:

  • Improve child vaccination rates.
  • Make electronic information relating to complaints accessible to the partners and other managers.

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

27 July 2018

During an inspection looking at part of the service

On 16 February 2018 we carried out a full comprehensive inspection of Oldham Medical Services. This resulted in the practice being placed in special measures and Warning Notices being issued against the provider on 3 April 2018. The Notices advised the provider that the practice was failing to meet the required standards relating to Regulation 12 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014, Safe care and treatment, Regulation 17 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014, Good governance and Regulation 18 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014, Staffing.

On 27 July 2018 we undertook a focused inspection to check that the practice had met the requirements of the Warning Notices. We found that although some improvement had been made and some systems had been introduced further improvements were still required to ensure that safety was maintained. In particular we found that:

  • The practice introduced a new system for recording significant events. However, we found that there were still further improvements to be made to this system.
  • The practice introduced a nationally recognised Sepsis tool into the clinical system and clinical staff had been trained on its use.
  • The cold chain was now being appropriately managed and vaccinations were in date.
  • Infection control audits had been completed the most recent in 2018 which was conducted by the Local Authority infection control team and scored the practice as 96% compliant, with minor actions recommended which the practice was actioning.
  • Fire safety checks were being carried out and included a fire evacuation and testing of emergency lights.
  • Emergency medication was stored securely and checks were carried out by the nursing staff.
  • We saw monthly checks and records were now being kept for the defibrillator, however we did note that checks had already been recorded for August 2018. Speaking with the practice manager they told us this was an error.
  • We saw records were kept for regular locums and now included training. A training record was also maintained for the salaried GP.
  • A new locum had been employed to carry our minor surgery within the practice and we saw records of training and qualifications had been obtained.
  • A new system was in place for safety alerts including Medicines and Healthcare products Regulatory Agency (MHRA). However, we found that there were still further improvements to be made to this system.
  • A Legionella inspection had been carried out in April 2018.
  • A newly appointed reception manager had conducted appraisals with reception and administration staff.
  • Clinical audits had been initiated by GPs, including a warfarin audit. However, these had not yet been completed.
  • We reviewed four complaints received since our previous inspection and found that these had been investigated and responded to in line with policy and procedure.
  • The new reception manager had arranged a meeting with the patient participation group (PPG) in May 2018 in which two members attended. The meeting was minuted and noted ideas and suggestions from the PPG members. There was no record as to when or if the group would meet again in the future.
  • A meeting schedule has been introduced including monthly partner, clinical and practice meetings. We reviewed the minutes of meetings and saw a record of discussion and actions.
  • CQC records showed that an application for a new registered manager had not been received, however an application to add a partner had been received, but rejected in June 2018. Speaking with the practice manager they told us they would resubmit application for new partner once the Disclosure and Barring Service (DBS) had been completed. They believed an application for registered manager had been completed and they would review progress with the partners.The rating awarded to the practice following our full comprehensive inspection on 16 February 2018 of ‘inadequate’ remains unchanged. The practice will be re-inspected in relation to their rating in the future.

The rating awarded to the practice following our full comprehensive inspection on 16 February 2018 of ‘inadequate’ remains unchanged. The practice will be re-inspected in relation to their rating in the future.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

16/02/2018

During a routine inspection

This practice is rated as Inadequate overall. (Previous inspection March 2015 – Good)

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Requires improvement

Are services caring? – Requires improvement

Are services responsive? – Requires improvement

Are services well-led? – Inadequate

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Inadequate

People with long-term conditions – Inadequate

Families, children and young people – Inadequate

Working age people (including those recently retired and students – Inadequate

People whose circumstances may make them vulnerable – Inadequate

People experiencing poor mental health (including people with dementia) - Inadequate

We inspected Oldham Medical Services on 5 March 2015. The practice was rated as good in all domains and overall good. There were some areas where we suggested improvements should be made, but not all these had been carried out. During 2017 an assistant practice manager had joined the practice. They left in October 2017 and the practice manager left in November 2017. The practice had had no manager in place until the current practice manager started work six weeks prior to the inspection.

We carried out an announced comprehensive inspection at Oldham Medical Services on 16 February 2018. This was part of our inspection programme. We found that the overall rating had reduced to inadequate.

At this inspection we found:

  • The practice did not have systems in place to manage risk so that safety incidents were less likely to happen. For example the fire risk assessment was not adequate and fire checks were not up to date.

  • The infection control audit was not adequate and it had not been identified that some items were not stored hygienically.

  • Minor surgery took place approximately every month but the last recorded audit for minor surgery was in June 2013.

  • Medicines were not securely stored.

  • The cold chain was not effectively monitored.

  • When incidents did happen, there was no evidence of learning from them.

  • The practice had identified that 300 children had outstanding immunisations but the partners had not been informed of this by nursing or administrative staff..

  • There was no evidence new safety guidelines or medicine alerts were disseminated to appropriate staff.

  • There was no focus on continuous learning and improvement at any levels of the organisation.

  • Staff were not well supported and there was little evidence of appraisal.

  • Only 0.2% of patients had been identified as carers and no additional support was offered to carers.

  • Not all complaints were investigated and responses to complaints did not contain all the required information.

  • The governance in the practice did not support good practice.

  • The practice was not correctly registered by the Care Quality Commission (CQC); the registered manager had left and CQC had received no application to register a new one.

The areas where the provider must make improvements are:

  • The provider must ensure care and treatment is provided in a safe way to patients.

  • The provider must ensure that any complaint received is investigated and any proportionate action is taken in response to any failure identified by the complaint or investigation. The provider must 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.

  • The provider must establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

  • The provider must ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

  • The provider must ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed. The provider must ensure specified information is available regarding each person employed.

In addition the provider should:

  • The provider should take steps to correctly identify patients who are carers so appropriate support can be offered.

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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

5 March 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Oldham Medical Services on 5 March 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing safe, effective, caring, responsive 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, although some aspects of the recruitment process relating to Disclosure and Barring Service (DBS) needed strengthening.
  • 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 felt listened to by GPs and other staff.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an emergency appointment, although routine appointments were more difficult to access.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.

There were areas of practice where the provider needs to make improvements.

Importantly they should:

  • All staff should have an appraisal meeting with their line manager.
  • A Legionella risk assessment should be carried out and regular testing should take place if appropriate.
  • All staff should have training in the prevention and control of infection.
  • Record keeping should be improved, including minutes being taken at staff meetings and health and safety walkarounds of the practice being formalised and recorded.
  • A Disclosure and Barring Service (DBS) check should be carried out for appropriate staff, including those carrying out chaperone duties.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice