Letter from the Chief Inspector of General Practice

We undertook an announced focused inspection of The Manor Practice on 15 September 2016. We found the practice to be good for providing safe services and for being well-led. The practice is rated as good overall.

We had previously conducted an announced comprehensive inspection of the practice on 26 November 2015. As a result of our findings during that visit, the practice was rated as good for being effective, caring, and responsive, and requires improvement for being safe and well-led. This resulted in a rating of requires improvement overall. We found that the provider had breached three regulations of the Health and Social Care Act 2008: Regulation 12(2)(h) Safe care and treatment, Regulation 19(3)(a) Fit and proper persons employed, and Regulation 17(2) Good governance. You can read the report from our last comprehensive inspection at http://www.cqc.org.uk/location/1-572958578. The practice wrote to us to tell us what they would do to make improvements and meet the legal requirements.

We undertook this focused inspection on 15 September 2016 to check that the practice had followed their plan, and to confirm that they had met the legal requirements. This report only covers our findings in relation to those areas where requirements had not been met previously.

Our key findings on 15 September 2016 were as follows:

• An infection control audit had been completed and staff were receiving infection control training.

• Personnel files contained the required information about employees.

• Fire and legionella risk assessments and a business continuity plan were in place.

• Governance arrangements were in place to support the delivery of good quality care.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We undertook an announced focused inspection of The Manor Practice on 15 September 2016. We found the practice to be good for providing safe services and for being well-led. The practice is rated as good overall.

We had previously conducted an announced comprehensive inspection of the practice on 26 November 2015. As a result of our findings during that visit, the practice was rated as good for being effective, caring, and responsive, and requires improvement for being safe and well-led. This resulted in a rating of requires improvement overall. We found that the provider had breached three regulations of the Health and Social Care Act 2008: Regulation 12(2)(h) Safe care and treatment, Regulation 19(3)(a) Fit and proper persons employed, and Regulation 17(2) Good governance. You can read the report from our last comprehensive inspection at http://www.cqc.org.uk/location/1-572958578. The practice wrote to us to tell us what they would do to make improvements and meet the legal requirements.

We undertook this focused inspection on 15 September 2016 to check that the practice had followed their plan, and to confirm that they had met the legal requirements. This report only covers our findings in relation to those areas where requirements had not been met previously.

Our key findings on 15 September 2016 were as follows:

• An infection control audit had been completed and staff were receiving infection control training.

• Personnel files contained the required information about employees.

• Fire and legionella risk assessments and a business continuity plan were in place.

• Governance arrangements were in place to support the delivery of good quality care.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

At our previous inspection on 18 February 2014, we were concerned about the state of the premises. Concerns included dirty vinyl flooring and carpets, absence of electrical safety testing and woodchip wall paper in consulting rooms. On this visit on 9 September 2014, we found that no refurbishment had been started. There was evidence that the carpets and vinyl had been cleaned and the blinds had been replaced.

At our previous inspection on 18 February 2014, we found shortfalls with the infection control system in place. These included cleaning completed twice a week, lack of elbow taps and flooring and curtains that could not be cleaned. On this visit on 9 September 2014, we found that the cleaning schedule had been increased to twice a week and he floors had been deep cleaned. However there were still shortfalls. The elbow taps had not yet been installed. We also found shortfalls in the quality of cleaning provided in the consulting rooms.

Most people who use the service were satisfied with the extent to which they were shown respect and consideration by staff. One person said “yes, they are nice” and another person said “they’re ok, I do feel they respect me, yes”. People’s needs were assessed and their care and treatment was planned and monitored where appropriate, as part of a wider multi-professional team.

People who use the service were protected from the risk of abuse, because the provider had ensured that staff were appropriately trained and they were aware of the steps to take, to identify and prevent abuse from happening.

People were not protected from the risk of infection because the fabric of the building did not allow for effective cleaning of floors, walls and furniture. Inadequate maintenance of the building, including the buildings worn flooring and wall covering, unsuitable blinds and fabric furniture meant that people who use the service, staff and visitors were not protected against the risks of unsuitable premises.

Systems and processes ensured that people’s complaints were handled and responded to appropriately.

Managers were in the process of planning for the future refurbishment and development of the service and some minor building works were underway.