Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Manor Road Surgery on 27 April 2016. As a result of our findings during that visit the provider was rated as good overall and requires improvement for providing safe services. The full comprehensive inspection report from that visit was published on 19 August 2016 and can be read by selecting the ‘all reports’ link for Manor Road Surgery on our website at www.cqc.org.uk.

The provider submitted an action plan to tell us what they would do to make improvements and meet the legal requirements. We undertook an announced comprehensive follow-up inspection on 15 November 2017 to check that the provider had followed their plan, and to confirm that they had met the legal requirements. As a result of our findings the provider is now rated as requires improvement for providing safe, effective, responsive and well-led services. Overall the practice is now rated as requires improvement.

Our key findings were as follows:

• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• Results from the national GP patient survey were above average in all areas they showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.
• The practice did not have clearly defined and embedded systems to minimise risks to patient safety.

• Some staff had not completed role specific training, and there was no system in place to monitor staff training. Staff were having basic life support training every two years, instead of annually as recommended by Resuscitation Council (UK) guidance.

• The practice was not conducting fire drills.

• Although some audits had been carried out, we saw no evidence that audits were driving improvements to patient outcomes.

• The practice had not conducted any practice meetings since March 2017.

• All clinical staff had up to date appraisals, however non clinical staff had not had an appraisals carried out since March 2016.

• There were no cleaning schedules.

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

Importantly, the provider must:

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

• Ensure care and treatment is provided in a safe way to patients:

In addition the provider should:

• Consider conducting a risk assessment for not providing interpreting services.

• The provider should consider proactive strategies to set up a patient participation group (PPG).

• The provider should continue to review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is made available to them.

• Review role specific training for staff training and monitoring processes.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Manor Road Surgery on 27 April 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

• Staff appeared to understand their responsibilities to raise concerns and to report incidents and near misses. However, we were unable to review the practice’s approach to the reporting and investigation of incidents as no serious event analysis (SEA) reports were available to review and a recent incident within the practice had not been reported and investigated in line with the practice procedure.
• Risks to patients were generally assessed and well managed. However, some staff were not adhering to the requirements of the practice Chaperone Policy and had been undertaking chaperone duties despite not having undergone a DBS check or receiving training.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with 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. Complaints were reviewed and appropriate action taken.
• Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on. However there was no active patient participation group (PPG).

There are areas where the provider must make improvements:

• The provider must ensure that all staff are aware of and adhere to the requirements of the practice Chaperone Policy.

• The provider must ensure that all staff are aware of and adhere to the practice procedure for incident reporting and that learning from incidents is shared with all relevant staff.

• The provider must ensure that the Infection Control lead for the practice undertakes appropriate infection control training and carries out an annual infection control audit.

There are areas where the provider should make improvements:

• The provider should ensure that all staff are aware of the identity and responsibilities of the infection control lead within the practice.

• The provider should record batch numbers of blank electronic prescriptions placed in individual printers.

• The provider should consider carrying out regular fire evacuation drills.

• The provider should consider proactive strategies to encourage patients to join the patient participation group (PPG).

• The provider should review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is made available to them.

• The provider should consider undertaking an annual appraisal with the Practice Nurse to ensure they are operating in line with practice objectives.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

On this occasion, we did not speak with people using the service as part of our inspection.

We found that the provider had made significant improvements and that there were policies and procedures in place to ensure that only suitable staff were recruited.

People we spoke with were generally happy with the treatment they received from the surgery. One person told us "I’ve been a patient for a long time and I am very happy with my GP” and another described the care they received as "very good and the GP’s are very supportive". We found that most people felt listened to by the GPs and found reception staff at the practice very helpful. People felt that personal issues were handled sympathetically and confidentiality was maintained; they told us that the receptionists were all very discreet and never asked personal questions.

We found that the majority of people were consulted with and involved in their care and provided with an explanation about their condition or illness. People's needs were assessed and care was planned in a way that met their needs. There were policies in place and most staff had been trained in both child and adult safeguarding procedures. The practice had systems in place to ensure that the safety of the premises and the quality of the service was monitored. However, the practice had not taken adequate steps to ensure that only suitable people were employed at the surgery.

We carried out an announced comprehensive inspection at Manor Road Surgery on 19 December 2018 as part of our inspection programme.

At the last inspection in November 2017 we rated the practice as requires improvement for providing safe, effective, responsive and well-led services because:

• No fire drills were being conducted.
• There were no cleaning schedules or records.
• Prescriptions were left in the printers overnight and not locked away.
• A health and safety risk assessment and fire risk assessment had not been conducted since 2012.
• A legionella risk assessment had not been conducted since 2012.
• There was no evidence that audits were driving improvements to patient outcomes.
• The practice was not conducting meetings, consequently records were not kept.
• The patient information leaflet contained out of date information.

• Appraisals for non clinical staff had not taken place since April 2016.

• The Infection Control lead had not had any infection control training.

At this inspection, we found that the provider had satisfactorily addressed these areas.

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 and good for all population groups.

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 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:

• Continue to review medication optimisation for patients prescribed antibiotics, and patients with hypertension.
• Review information that is provided to patients that experience bereavement.
• Review accessibility of information leaflets in other languages and in easy read format.
• Consider undertaking a premises/security risk assessment.
• Review the practice mission statement and staff understanding of it.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP  

Chief Inspector of General Practice