The Care Quality Commission
  • Doctor
  • GP practice

The Uplands Medical Practice

Overall: Requires improvement read more about inspection ratings

Bury New Road, Manchester, Greater Manchester, M45 8GH (0161) 766 8221

Provided and run by:
The Uplands Medical Practice

All Inspections

13/10/2022

During a routine inspection

We carried out an announced comprehensive inspection at The Uplands Medical Practice on 13 October 2022. Overall, the practice is rated as requires improvement. We found that since our last inspection improvements had been made in some areas, but further improvement was required in others.

Safe - good

Effective - requires improvement

Caring - requires improvement

Responsive - requires improvement

Well-led - requires improvement

Following our previous inspection full comprehensive inspection on 1 September 2021 the practice was rated requires improvement overall. The safe, effective, caring and responsive domains were rated as requires improvement. The well led domain was rated as inadequate.

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

Why we carried out this inspection

We carried out this full comprehensive inspection in response to risk as the last inspection rated the practice as overall requires improvement. This inspection was a comprehensive inspection of all five key questions.

How we carried out the inspection

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 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

We have rated this practice as good for providing safe services because:

  • Safeguarding systems were well managed.
  • Health and safety and infection control had improved and were manged to keep patients safe.
  • The safe use of medicines was promoted. Systems of medicines management had improved.
  • Significant events and safety alerts were now well managed and shared with staff for learning.

We have rated this practice as requires improvement for providing effective, caring, responsive and well-led services because:

  • Childhood immunisations and cervical screening data was below local and national average and required further improvement.
  • Staff were now supported in their role with training and supervision.
  • Clinical audits were carried out to ensure the ongoing improvement of the service.
  • Patients raised concerns about trying to access the service and their overall experience of using the practice services.
  • Carers were well supported.
  • Patients had raised concerns with the CQC about the standard of the service provided.
  • Complaint systems and process had improved and were now well managed.
  • There was still a turnover of staff at the practice. A new practice manager had been employed and GPs had left resulting in the practice now using locum GPs.
  • The practice governance arrangements had improved but further improvements were required regarding patient experience.

We found one breach of regulations. 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 Hospitals and Interim Chief Inspector of Primary Medical Services

07 December 2021

During an inspection looking at part of the service

We carried out a full comprehensive announced inspection at The Uplands Medical Practice on 1 September 2021. This inspection included a site visit. The practice was given an overall rating of requires improvement with the following key question ratings:

Safe - requires improvement

Effective - requires improvement

Caring - requires improvement

Responsive - requires improvement

Well-led - inadequate

After the inspection on 1 September 2021 a requirement notice was issued for breaches of regulations 12 (safe care and treatment). A warning notice was also issued for a breach of regulation 17 (1) of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 (good governance).

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

This inspection, carried out on 7 December 2021, was to check the progress made with the warning notice.

We found that improvements had been made in most areas covered in the warning notice:

  • Staff were trained in infection control to ensure patient safety.
  • Patients’ records held more information about their medical conditions and specific care needs, including decisions on Do Not Attempt Cardiopulmonary Resuscitation, so their care needs were met.
  • Non-medical prescribing staff were provided with formal clinical supervision for support in their role.
  • There were plans to improve patient access to the service.
  • The management of prescriptions had improved to ensure patients received their medicines on time.
  • Complaints were managed promptly to ensure patients’ needs were met.

At this focused inspection no ratings can be changed. A full comprehensive inspection will take place during 2022 and the ratings will be reviewed at that point.

Details of our findings and the evidence supporting our judgements are set out in the evidence table.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

01 September 2021

During a routine inspection

We carried out an announced comprehensive inspection on 1 September 2021 at The Uplands Medical Practice on 1 September 2021. Overall, the practice is rated Requires Improvement.

Safe - requires improvement.

Effective - requires improvement.

Caring - requires improvement.

Responsive – requires improvement.

Well-led - inadequate.

Following our previous inspection on 23 September 2020 the practice was rated Requires Improvement overall and for all key questions and population groups. The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Uplands Medical Practice on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection and occurred because the practice had previously been rated Requires Improvement.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, considering 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 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 Requires Improvement for all population groups.

This inspection was an announced comprehensive inspection. We carried out this inspection to follow up on the issues raised at the last inspection.

We found that some of the concerns from our previous inspection has been addressed however others had not and additionally we identified new concerns.

We have rated this practice as Requires Improvement overall. The concerns that we found related to all population groups and so we rated the population groups as Requires Improvement overall.

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

  • Some patients’ medicines were not well managed.
  • Information gathered during follow-up consultations lacked consistent detail about patient's specific care needs.
  • Actions from an infection control audit required completing.
  • Improvements had been made to safeguarding processes and to the way significant events were managed.

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

  • Childhood immunisations were below the recommended target in two of the five areas.
  • Cervical screening rates were below the England target of 80%.
  • The need to improve immunisations and screening had been identified by the practice and work was ongoing to improve uptake.
  • Clinical audits required improvement and there was no plan of clinical audit to test the effectiveness of the service.

The practice was rated requires improvement for providing caring services because:

  • Feedback from patients about the service remained below local and national averages.
  • Although some steps had been taken to address the issues, significant elements of patient feedback was still negative.

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

  • Complaints were again not well managed.
  • Feedback from patients about access to the service and the standard of the service they received remained well below local and national averages.
  • The practice had taken some action to improve access for patients, however there was no evidence yet that this was impacting on patient experience and survey data.

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

  • The practice was still going through a period of change in the staff team. New relationships were emerging, which need to be established fairly and firmly to take the practice forward. These changes were re-establishing the practice team for the future development of the service.
  • The practice did not have a strategy for staff retention. The high turnover of practice managers in the last five years had a detrimental impact on the service. Staff commented this had impacted on the stability of the practice and the smooth running of the service.
  • The practice still did not always have clear and effective processes for managing risks and performance. There was no plan of clinical audits used to test the effectiveness of the service and to monitor quality and to make improvements.
  • The practice did not always act on appropriate and accurate information to improve the service.
  • The process of identifying and making improvements had started but there was little evidence of impact.
  • Some of the concerns identified at the previous inspection had not been effectively addressed.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a safe way for patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements as they are in breach of regulations are:

  • A record should be made of when GPs had offered or used a chaperone.
  • Establish a more efficient system for storing information about referrals.
  • Establish regular clinical meetings for the purpose of providing more time for discussing more complex issues.

The Care Quality Commission will refer to and follow its enforcement process in taking action that reflects these circumstances.


Details of our findings and the evidence supporting our ratings are set out in the evidence table.
Dr Rosie Benneyworth BM BS BMedSci MRCGP

23/09/2020

During a routine inspection

This inspection was an announced comprehensive inspection. The Uplands Medical Practice was registered in 2019 and has not yet been rated. This is the first inspection. We carried out the inspection due to concerns received about the standard of the service provided.  

In the light of the COVID-19 pandemic, we undertook some of the inspection processes remotely and spent more focussed time on site. We conducted remote staff interviews on 21 and 23 September 2020 and carried out a site visit on 23 September 2020.

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 this practice as requires improvement overall. The concerns that we found related to all population groups and so we rated the population groups as requires improvement overall. 

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

  • Some safeguarding records were not kept up to date.
  • The staff induction training did not include a system of competency assessments.
  • Some patients’ medicines were not well managed.
  • Some significant events were not fully processed to ensure identified actions were dealt with in a timely way.
  • Staff had access to information to deliver safe care and treatment.

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

  • Childhood immunisations were below the recommended target in three of the four areas.
  • Cervical screening rates were below the England target of 80%.
  • The need to improve immunisations and screening had been identified by the practice and work was ongoing to improve uptake.
  • Clinical audits were carried out to test the effectiveness of the service.

The practice was rated requires improvement for providing caring services because:

  • Feedback from patients was mixed about the way staff treated people.
  • Patients commented both positively and negatively on their overall experience of the practice.
  • Carers were identified and supported by the practice.

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

  • Some complaints were not responded to fully.
  • Some patients commented that they could not access the service easily.
  • The practice had taken some action to improve access for patients.

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

  • The practice was going through a period of change in the staff team. New relationships were emerging, which need to be established fairly and firmly to take the practice forward. These changes were re-establishing the practice team for the future development of the service.

  • The high turnover of practice managers in the last three years had a detrimental impact on the service. Staff commented this had impacted on the stability of the practice and the smooth running of the service.
  • The practice did not always have clear and effective processes for managing risks and performance.
  • The practice did not always act on appropriate and accurate information to improve the service.
  • The process of identifying and making improvements had started.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure safe care and treatment is provided.
  • Ensure safeguarding systems and processes are fully established.
  • 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 table.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care