We inspected Dr Pal & Partners, Royton Health Wellbeing Centre, Park Street, Royton, Oldham, OL2 6QW, on 14 June 2018 as part of our inspection programme. The practice was given an overall rating of requires improvement with the following domain ratings:

Safe – Inadequate

Effective – Requires improvement

Caring – Good

Responsive – Good

Well-led – Requires improvement.

Warning notices were issued in respect of breaches of Regulation 12 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 (safe care and treatment), Regulation 18 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 (staffing) and Regulation 19 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 (fit and proper persons employed). A requirement notice was issued in respect of Regulation 17 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 (good governance).

On 2 November 2018 we carried out a focused inspection to check that the practice had met the requirements of the warning notices. We found that although the improvements had been made in relation to Regulations 12 and 18, some improvements were still required in relation to Regulation 19.

On 2 April 2019 we carried out a further full comprehensive inspection of Dr Pal & Partners. We inspected the main surgery at Royton Health Wellbeing Centre and also inspected the branch surgery at 164 Trent Road, Shaw, Oldham, OL2 7QR

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 now rated this practice as inadequate overall.

The domain ratings are:

Safe – Inadequate

Effective – Requires improvement

Caring – Good

Responsive – Requires improvement

Well-led – Inadequate

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

• The practice did not have clear systems and processes to keep patients safe.
• Receptionists had not been given guidance on identifying deteriorating or acutely unwell patients.
• The practice did not have appropriate systems in place for the safe management of home visit requests.
• Staff did not have the appropriate authorisations to administer medicines under a Patient Specific Direction.

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

• Patients’ needs were not always assessed, and care and treatment was not always delivered in line with current legislation.
• The practice did not have arrangements for following up failed attendance of children’s appointments following an appointment at the federation’s extended hours hub.
• The practice was unable to show that it always obtained consent to care and treatment.

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

• Staff treated patients with kindness, respect and compassion. Feedback from patients was positive about the way staff treated people.
• Staff helped patients to be involved in decisions about care and treatment.
• The practice respected patients’ privacy and dignity.

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

• Patients with urgent needs did not have their care prioritised.
• The practice did not have a system to assess the urgency of the need for medical attention when patients requested a home visit.

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.
• While the practice had a clear vision, that vision was not supported by a credible strategy.
• The practice culture did not effectively support high quality sustainable care.
• The overall governance arrangements were had improved slightly since the last inspection.
• The practice did not have clear and effective processes for managing risks, issues and performance.
• The practice did not always act on appropriate and accurate information.
• Although we saw there had been improvements since our previous inspection, we saw little evidence of systems and processes for learning, continuous improvement and innovation going forward.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• 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:

• The practice should further develop the patient participation group.
• Sharps bins should be sealed and disposed of in line with the practices infection control policy.
• The practice should correctly identify carers so the appropriate help 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.

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

On 14 June 2018 we carried out a full comprehensive inspection of Dr Pal & Partners, Royton Health Wellbeing Centre, Park Street, Royton, Oldham, OL2 6QW. Oldham Medical Services. The practice was given an overall rating of requires improvement with the following domain ratings:

Safe – Inadequate

Effective – Requires improvement

Caring – Good

Responsive – Good

Well-led – Requires improvement.

A requirement notice was issued in respect of Regulation 17 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 (good governance). On 25 June 2018 warning notices were issued in respect of Regulation 12 of the Health & Social Care Act 2008

(Regulated Activities) Regulations 2014 (safe care and treatment), Regulation 18 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 (staffing) and Regulation 19 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 (fit and proper persons employed). The warning notices stated the provider must be compliant with the regulations by 30 September 2018.

On 2 November 2018 we carried out a focused inspection to check that the practice had met the requirements of the warning notices. We found that although the improvements had been made in relation to Regulations 12 and 18, some improvements were still required in relation to Regulation 19 (fit and proper persons employed).

In particular we found:

• Not all the required pre-employment checks had been completed for staff who had started their employment following the June 2018 inspection.
• Up to date fire risk assessments were in place for both surgeries and appropriate safety checks were carried out.
• Health and safety checks were carried out at both surgeries.
• A risk assessment had been carried out to determine what emergency medicines should be held at the surgeries.
• Training was monitored and staff had completed appropriate training.
• Staff appraisals had been carried out although some records included little input from the appraiser.
• A staff induction template was in use and all new staff had completed an induction to the practice.

The rating of requires improvement awarded to the practice following our full comprehensive inspection on 14 June 2018 remains unchanged. The practice will be re-inspected and their rating revised if appropriate in the future.

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.

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

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Requires improvement

We carried out an announced comprehensive inspection at Dr Pal & Partners on 14 June 2018. This was as part of our inspection programme.

There have been changes in the registration of this practice since the inspection in March 2015. That inspection report can be found by searching for Dr Pal & Partners in the archived services section in www.cqc.org.uk.

At this inspection we found:

• The practice reported on and discussed significant events but this was not consistent and their significant event policy was not followed.

• Training and supporting staff had not been a priority. Appraisals had not taken place and mandatory training was not up to date.

• There was insufficient emphasis placed on safety, with actions identified during fire risk assessments not being monitored.

• Although staff understood safeguarding, several staff had not received training.

• Evidence of medical indemnity insurance was not available for all appropriate staff.

• The practice was in the process of re-launching a patient participation group (PPG).

• Patients said they found the appointment system easy to use and reported that they were usually able to access care when they needed it.

• Staff involved and treated patients with compassion, kindness, dignity and respect.

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 to patients.

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

• 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.

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

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice