The Care Quality Commission
  • Doctor
  • GP practice

Manston Surgery

Overall: Inadequate read more about inspection ratings

Cross Gates Medical Centre, Crossgates, Leeds, West Yorkshire, LS15 8BZ (0113) 264 5455

Provided and run by:
Manston Surgery

Important: This service was previously registered at a different address - see old profile
Important: We are carrying out a review of quality at Manston Surgery. We will publish a report when our review is complete. Find out more about our inspection reports.

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Manston Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Manston Surgery, you can give feedback on this service.

23 January 2024

During a routine inspection

We carried out an announced comprehensive inspection at Manston Surgery on 19 and 23 January 2023. Overall, the practice is rated as inadequate.

Safe - inadequate

Effective - requires improvement

Caring - good

Responsive - requires improvement

Well-led - inadequate

Following our previous inspection in April 2016, the practice was rated good overall and for 4 of the 5 key questions. We rated the practice requires improvement for providing safe care. Following a focused follow-up inspection in March 2017, the practice was rated good for providing safe care.

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

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities and to follow up concerns reported to us.

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 shorter site visit.
  • Reviewing staff questionnaires.

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:

  • The practice did not have systems and processes that operated effectively to evidence compliance with requirements to demonstrate good governance.
  • Staff did not receive adequate training or support.
  • The culture of the practice did not enable staff to raise concerns.
  • 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.

We found 2 breaches of regulations. The provider must:

  • Ensure 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.

In addition, the provider should:

  • Take action to reduce the backlog of summarising of new patient notes.
  • Take steps to improve the number of NHS health checks offered to patients.
  • Implement a system for regular formal discussions with external stakeholders.
  • Implement a system of regular documented competency checks for dispensary staff.
  • Continue to take steps to improve patient experience with making appointments.

I am placing this service in special measures. Services placed in special measures will be inspected again within 6 months. If insufficient improvements have been made such that there remains a rating of inadequate for any 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 6 months if they do not improve.

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

9 March 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Manston Surgery on 27 April 2016. We also visited the branch site in Scholes as part of our inspection. The overall rating for the practice was good. However; we rated the practice as requires improvement for providing safe care The full comprehensive report on the inspection can be found by selecting the ‘all reports’ link for Manston Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 9 March 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the issues that we identified in our previous inspection on 27 April 2016. This report covers our findings in relation to those requirements.

The practice has now met the legal requirements in the key question of safe and is now rated as good.

Our key findings were as follows:

  • The practice had comprehensive Standard Operating Procedures in place to support the staff working within the dispensary at the Scholes branch site.
  • The practice had a Standard Operating Procedure to cover the management of controlled drugs.
  • There was a system in place to routinely check stock medicines were within expiry date and fit for use. This was supported by a Standard Operating Procedure to govern the activity.
  • The practice had implemented a system to record near misses (a record of errors that had been identified and corrected before medicines had left the dispensary).
  • The practice had a system in place to record and investigate incidents. We saw minutes of meetings where these had been discussed.
  • There was a system in place to manage medicines safety alerts.
  • The practice had a documented record of when checks were carried out on the oxygen and defibrillator.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

27 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

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

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. However; documented learning from incidents was limited.
  • There were issues identified in the dispensary at the branch site. For example; staff did not keep a ‘near-miss’ record (a record of errors that have been identified before medicines have left the dispensary), standard Operating Procedures only covered basic aspects of the dispensing process and were limited in scope and detail and staff did not routinely check stock medicines were within expiry dates.
  • The staff we spoke with told us that regular checks were carried out to ensure the oxygen and defibrillator had been carried out. However, saw there was no formal record documenting these checks.
  • 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • 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 and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

  • Ensure dispensing standard operating procedures are fit for purpose and cover all required processes.
  • Ensure there is a system in place for identifying and sharing learning from medicines management incidents.
  • Ensure that there are documented checks and records relating to medicines management to ensure the quality and safety of services

The area where the provider should make improvement are:

  • Manage controlled drugs in accordance with the relevant legislation

Keep a documented record of when checks are carried out on the oxygen and defibrillator.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice