MA Surgeries Ltd

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We found this practice was not providing well-led care in accordance with the relevant regulations. We will be following up on our concerns to ensure they have been put right by the provider.

During our assessment of this key question, we found that the registered person had systems or processes that operated ineffectively in that they failed to enable them to assess, monitor and mitigate the risks relating to NHS prescription management, control of substances hazardous to health, disabled access and fire safety management.

These concerns were in breach of Regulation 17 Governance and Sustainability, Regulation 18 Staffing, and Regulation19 Fit and Proper Persons Employed of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can find more details of our concerns in the evidence category findings below.

Find out what we look at when we assess this area in our information about our new Single assessment framework.

The judgement for Shared direction and culture is based on the latest evidence we assessed for the Well-led key question.

The judgement for Capable, compassionate and inclusive leaders is based on the latest evidence we assessed for the Well-led key question.

The judgement for Freedom to speak up is based on the latest evidence we assessed for the Well-led key question.

The judgement for Workforce equality, diversity and inclusion is based on the latest evidence we assessed for the Well-led key question.

The provider’s oversight of regulatory requirements required improvement.

Systems and processes were not embedded among staff which highlighted a number of issues which included, recruitment, control of substances hazardous to health, disabled access, radiography, infection prevention and control, NHS prescription security and fire safety management.

Staff password protected patients’ electronic care records and complied with General Data Protection Regulations (GDPR).

Improvements should be made to ensure that computer screens automatically locked when left unattended.

The management of accident and complaint records complied with General Data Protection Regulation requirements.

The frequency of radiography and infection prevention audits did not follow current guidance and legislation.

The practice should also ensure that, where appropriate, audits have documented learning points, and the resulting improvements can be demonstrated.

There was no evidence available to confirm staff gathered feedback from patients, the public and external partners.

The practice could not confirm that any external laboratories used to provide dental appliances for patients were registered with the Medicines and Healthcare products Agency (MHRA).

The judgement for Partnerships and communities is based on the latest evidence we assessed for the Well-led key question.

The judgement for Learning, improvement and innovation is based on the latest evidence we assessed for the Well-led key question.