The Care Quality Commission
  • Doctor
  • GP practice

Archived: Dr Winifred Helen McManus Also known as Albert Road Surgey

Overall: Good read more about inspection ratings

118 Albert Road, Jarrow, Tyne and Wear, NE32 5AG (0191) 300 9659

Provided and run by:
Dr Winifred Helen McManus

Important: The provider of this service changed. See new profile

All Inspections

11 Dec 2019

During a routine inspection

We carried out an announced comprehensive inspection at Dr Winifred Helen McManus on 11 December 2019 as part of our inspection programme, and to follow up on breaches of regulations identified at a previous inspection on 15 May 2019. Previous ratings:

  • June 2015 – comprehensive inspection, rated as good overall but requires improvement for providing safe services;
  • December 2017 - focused inspection, remained rated as requires improvement for safe;
  • September 2018 – comprehensive inspection, rated as requires improvement for providing safe and well led services and overall;
  • May 2019 – comprehensive inspection, rated as inadequate overall and for providing safe and well led services, and as requires improvement for providing effective services. The practice was placed into special measures following this inspection.

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.

At this inspection, we found that the provider had satisfactorily addressed these areas and we have now rated this practice as good overall. The practice will therefore be removed from special measures.

We found that:

  • The practice had taken action to comply with the warning notices issued at the last inspection. They had addressed all of the concerns we raised previously and had put systems and plans in place to reduce the likelihood of them reoccurring in future.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • 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.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

The areas where the provider should make improvements are:

  • Continue to monitor data from QoF and Public Health England to ensure screening and review rates improve;
  • Continue work to improve antibacterial prescribing.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

15 May 2019

During a routine inspection

We carried out an announced comprehensive inspection at Albert Road Surgery (Dr Winifred Helen McManus) on 15 May 2019 as part of our inspection programme, and to follow up on breaches of regulations identified at a previous inspection on 27 September 2018. Previous ratings:

  • June 2015 – comprehensive inspection, rated as good overall but requires improvement for providing safe services
  • December 2017 - focused inspection, remained rated as requires improvement for safe
  • September 2018 – comprehensive inspection, rated as requires improvement for providing safe and well led services and overall.

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 have rated this practice as inadequate overall. We have rated all population groups as requires improvement.

We rated the practice as inadequate for providing safe services because:

  • While the practice had made some improvements since our inspection on 27 September 2018, it had not appropriately addressed the Requirement Notice in relation to ensuring that staff had received the immunisations appropriate to their role. At this inspection we also identified additional concerns that put patients at risk. For example:
  • Appropriate standards of cleanliness and hygiene were not met.
  • There were gaps in systems to assess, monitor and manage risks to patient safety.
  • The practice did not have appropriate systems in place for the safe management of medicines.

We rated the practice as inadequate for providing well-led services because:

  • While the practice had made some improvements since our inspection on 27 September 2018, they had not appropriately addressed the Requirement Notice in relation to the implementation of systems to assess, monitor and mitigate risks to service users.
  • There was still no detailed strategy or vision for how the practice was going to address staffing concerns.
  • Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
  • The practice did not have a clear vision, supported by a credible strategy.
  • The overall governance arrangements were ineffective.
  • The practice did not have clear and effective processes for managing risks, issues and performance.
  • We saw little evidence of systems and processes for learning, continuous improvement and innovation.

We rated the practice as requires improvement for providing effective services because:

  • The practice did not have a systematic programme of quality improvement.
  • There was a lack of guidance available for the locum GPs in relation to clinical guidelines and prescribing protocols.
  • Staff appraisals did not assess the learning and development needs of staff.
  • There were no records to demonstrate the training undertaken by the lead GP.

We rated the practice as good for providing caring and responsive services because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Ensure all premises and equipment used by the service provider is fit for use.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Provide appropriate training for non-clinical staff on sepsis awareness.
  • Maintain records of all staff’s training.
  • Take steps to review patient safety alerts issued during the practice manager’s absence and take action as appropriate.
  • Implement a system to keep all clinicians up to date with current evidence based practice.
  • Review the contents of the locum pack to ensure all necessary guidelines and up to date information is available.
  • Take action to ensure that patients who need support to access the premises can summon assistance.

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

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

27/09/2018

During a routine inspection

This practice is rated as Requires Improvement overall. (Previous rating 06 2015 – Good)

The key questions at this inspection are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Requires improvement

We carried out an announced comprehensive inspection at Dr Winifred Helen McManus (also known as Albert Rd Surgery) on 27 September 2018, as part of our inspection programme, and to follow up on breaches of regulations.

At a previous follow up inspection in December 2017 we found regulatory breaches around the areas of infection control and staff appraisals, and the practice was rated as requires improvement for providing safe services, with an overall rating of good.

At this inspection we found:

  • The practice had some systems in place to manage risk so that safety incidents were less likely to happen, however not all risks had been identified and risk assessments were not kept sufficiently under review.
  • Staff knew how to report incidents and safety concerns and felt confident doing so, however there was insufficient documented learning and action points to show improved processes to prevent the same incident happening again.
  • The practice carried out some monitoring around the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Due to staffing difficulties, the practice had become heavily reliant on locum cover. Whilst this was managed effectively, we did identify some areas with a need for increased oversight, such as receipt of test results.
  • Staff were proactive in supporting people to live healthier lives.
  • Staff involved and treated patients with compassion, kindness, dignity and respect. The majority of patient feedback was very complimentary.
  • Patients found the appointment system easy to use and on the whole reported that they were able to access care when they needed it.
  • The arrangements for governance and performance management did not always operate effectively. Risks were not always dealt with appropriately or in a timely fashion. Ongoing staffing difficulties meant that service delivery was reactive and focused on short-term issues. There was no clear strategic plan.
  • Staff and other stakeholders told us that where they had raised concerns or feedback, this was dealt with in an open and transparent fashion, and changes made where possible.

We saw one area of outstanding practice:

  • The practice had a longstanding system for weekly open-access baby clinics, which catered for both well and sick babies. Parents could choose to have their baby seen by the nurse, GP or both without the need for an appointment. Services offered at the clinics included well baby checks, immunisations, children under 5 who were unwell, and postnatal checks. Childhood immunisation uptake rates were above the target percentage of 90%.

The areas where the provider must make improvements are:

  • The provider must ensure that staff receive the immunisations that are appropriate to their role, and be able to demonstrate that staff have received occupational health assessment or pre-employment assessment which includes review of their immunisation needs.
  • The provider must develop assurance and auditing systems and processes, to effectively assess, monitor and mitigate risks. This includes demonstrating learning and action points from safety incidents or risk assessments, and ensuring practice policies and procedures are comprehensive and regularly reviewed.

The areas where the provider should make improvements are:

  • Instigate process to ensure urgent results are actioned and checked before the end of the day.
  • The provider should ensure the secure storage of medicines.
  • Continue to develop a programme of two cycle clinical audit which is clearly linked to driving improvement in patient outcomes.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

15 December 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Winifred Helen McManus on 23 June 2015. The overall rating for the practice was good, although the practice was rated as requires improvement for providing safe services. The full comprehensive report for the June 2016 inspection can be found by selecting the ‘all reports’ link for Dr Winifred Helen McManus on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 15 December 2017 to review in detail the actions taken by the practice to improve the quality of care. This report covers our findings in relation to those requirements and additional improvements made since our last inspection.

The practice is rated as requires improvement for providing safe services, and overall the practice is rated as good.

Our key findings at this inspection were as follows:

  • At our previous inspection on 23 June 2015, we told the provider that they should make improvements in some areas. These included the arrangements for a legionella risk assessment of the practice, infection control, appraisals and recruitment checks. We saw at this inspection that some improvements had been made.
  • A legionella risk assessment had been completed.
  • Overall the practice appeared clean and hygienic, however, the practice had not completed an infection control audit.
  • The practice manager had been provided with an appraisal. However, no other staff had been appraised since the practice manger was appointed in October 2015.
  • Appropriate recruitment checks had been completed for the two most recently employed members of staff at the practice.

There were areas of practice where the provider needs to make improvements as they are in breach of regulations.

Importantly, the provider must:

  • Ensure care and treatment is provided in a safe way to patients (See Requirement Notice Section at the end of this report for further detail).
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties (See Requirement Notice Section at the end of this report for further detail).

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

23/06/2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out a comprehensive announced inspection at Dr Winifred Helen McManus on 23 June 2015. Overall, the practice is rated as good. Specifically, we found the practice to be good for providing effective, caring, responsive and well led services. We found the practice to be requires improvement for safe. The practice was good at providing services for the six key population groups we looked at during the inspection. Our key findings across all the areas we inspected were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Information about safety was recorded, monitored, reviewed and addressed;
  • Risks to patients were assessed and well managed;
  • Overall, the practice was clean and hygienic, and there were good infection control arrangements, although infection control audits had not been carried out;
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance;
  • Data from the National GP Patient Survey showed patient satisfaction levels were either above or broadly in line with national and local Clinical Commissioning Group (CCG) comparators;
  • Information about the services provided by the practice was readily available and easy to understand, as was information about how to raise a complaint;
  • The practice had satisfactory facilities and was suitably equipped to treat patients and meet their needs;
  • Governance arrangements had been put in place and there was a clear leadership structure.

However, there were areas of practice where the provider needs to make improvements. Importantly the provider should:

  •   Carry out a Legionella risk assessment;
  •   Carry out regular infection control audits;
  • Provide the practice manager with an appraisal;
  • Complete retrospective recruitment checks for recently appointed staff. 

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice