Manor Park Medical Practice

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm. At our last assessment, we did not look at all quality statements but rated this key question as good. At this assessment, the rating remains the same.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice had a proactive and positive culture of safety, based on openness and honesty. Staff were encouraged to raise concerns when things went wrong. There was a process in place to report incidents, near misses and safety events. These were listened to and reported on to identify learning. The practice investigated complaints in line with their complaints policy. Incidents and complaints were discussed during monthly ‘all team’ meetings. Complaints were reviewed on a quarterly basis to identify themes. Lessons were learnt to continually identify and embed good practice. Learning from incidents and complaints resulted in changes that improved care for others. The practice had developed a ‘you said, we did’ log to evidence learning.

The practice worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. There were systems in place for managing incoming correspondence for patient’s medical records, including processing information relating to new patients. There were arrangements to ensure a safe and timely review of test results.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

The practice worked with people to understand and manage risks. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. 81%of respondents to the National GP Patient Survey felt they were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment.

Staff could recognise a deteriorating patient and were confident in the steps required to respond appropriately as they had practiced scenarios to become familiar with their roles in an emergency. The online triage model was designed to identify red flag symptoms in which alerted staff to act appropriately. Staff were able to contact the ‘on-call GP’ for support if they had any queries about a patient’s condition. Emergency equipment was available and maintained.

During the onsite visit, the premises were tidy. However, leaders told us that contracts with the landlord prevented them making the changes to the premises that they would like to do as the building was outdated. Leaders had a meeting scheduled with the landlord to address this.

The service detected and controlled potential risks in the care environment. They made sure equipment and technology supported the delivery of safe care. Health and safety risk assessments were completed and the risks identified had been addressed. Portable appliance testing and calibrations were completed. Systems were in place to check safety equipment including fire alarms and emergency lighting. Fire evacuation drills had been completed. There was a business continuity plan in place which was monitored and reviewed.

We reviewed staff personnel files and found that most essential recruitment documents were accessible. However, DBS checks were not risk assessed when necessary. Following our feedback, the provider provided us with the risk assessment to assure us the appropriate precautions had been considered. The practice provided us with a copy of their induction process and new starter checklist to ensure there were qualified, skilled and experienced staff. We also reviewed a newly employed staff member's personnel file and found that the necessary recruitment files were available.

There were a range of clinical and non-clinical roles within the practice to support safe delivery of care. Staff were working within their agreed areas of competence. We saw evidence of annual appraisals alongside effective support, supervision and development. Staff were given opportunities to learn and develop if this was of interest to them and were supported to do so. Staff feedback reflected they were happy within their roles and felt supported by their managers.

The practice assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The practice had a designated infection, prevention and control (IPC) lead and staff had completed IPC training relevant to their role. Staff knew their roles and responsibilities around IPC. IPC policies and cleaning schedules were in place and followed to ensure the premises and equipment were kept clean. IPC audits were completed, including hand hygiene audits; and actions were taken to mitigate risks. Clinical waste was stored in a locked area outside. Clinical rooms had adequate provision of personal protective equipment (PPE) and handwashing facilities.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.