Manston Surgery

Updated 27 February 2025

Manston Surgery is situated on the 1st floor in Cross Gates Medical Centre on Station Road, Leeds, LS15 8BZ. The medical centre houses another GP Practice on the top floor, and a pharmacist and private physiotherapy service on the ground floor. The practice also has a branch site at 96 Main Street, Scholes, Leeds, LS15 4DR. The branch site is a dispensing practice. We visited both sites as part of our inspection.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, treatment of disease, disorder or injury, surgical procedures and family planning.

The practice offers services from both the main practice and a branch surgery. Patients can access services at either surgery.

Manston Surgery is a partnership providing services to a patient list of 8,220 patients. The practice holds a Primary Medical Services (PMS) contract.

The practice is situated within the NHS West Yorkshire Integrated Care Board (ICB) and is part of a wider network of GP practices, known as a Primary Care Network (PCN). The practice sits within the Crossgates PCN.

Information published by Public Health England shows that deprivation within the practice population group is ranked 5th (1-10, where 10 is less deprived). According to the latest available data, the ethnic make-up of the practice area is 90% White, 4% Asian, 3% Mixed, 2% Black and 1% other.

The practice team consists of 2 GP Partners, 3 salaried GPs, and a regular locum GP. There are 3 practice nurses, 2 healthcare assistants (HCAs), 2 dispensers, a practice manager, an assistant practice manager, a reception manager and a team of reception and administrative staff. Support is provided by the PCN in the form of a Physician Associate, 2 advanced nurse practitioners (ANPs), a dementia nurse, a physiotherapist, a mental health practitioner and a pharmacy team.

The practice is open between 8am to 6pm Monday to Friday. Enhanced access is provided by the practice in collaboration with the PCN on Saturdays between 8am and 2pm for GP, nurse and HCA appointments, and between 5pm and 7pm for pharmacy support. Local Care Direct provide telephone cover Monday to Friday 6pm to 6.30pm and Leeds GP Confederation provide additional late evening and weekend appointments.

Appointment times at the practice are between 8.10am and 5.50pm. Patients can book appointments via telephone or online, and these can be booked on the day or in advance. The practice offers both face-to-face and telephone appointments.

Updated 27 February 2025

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

Updated 14 September 2016

The practice is rated as good for the care of people with long-term conditions.

• All these patients had a structured review to check that their health and medicines needs were being met. This review was undertaken on an annual basis or more often when required.
• The practice nurses had lead roles in the management of long term conditions.
• The practice worked closely with other services in the management of housebound patients who had complex long term conditions, to ensure they received the care and support they needed. For example; the community matron, heart failure and respiratory nurses.

• The practice was participating in the ‘Year of Care’ programme. This approach encouraged patients to understand their condition and have a more active part in determining their own care and support needs in partnership with clinicians.
• The practice offered spirometry screening for all smokers with the aim of early diagnosis of Chronic Obstructive Pulmonary Disease (COPD).
• The practice were involved in the winter pressures scheme and reviewed all patients with a long term condition within three days, following non elective discharge from hospital.
• 95% of patients with diabetes, on the register, had a record of a foot examination and risk classification; which was higher than the CCG average 88% and England average 88%.
• 100% of patient with diabetes, on the register, had received an influenza immunisation in the preceding seven months; which was higher than the CCG average 96% and England average 94%.
• 87% of patients diagnosed with asthma had received an asthma review in the last 12 months; which was higher than the CCG and England averages of 75%.