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Inspection carried out on 29 January 2019

During a routine inspection

We carried out an announced follow up inspection at The Manor Clinic on 29 January 2019 as part of our inspection programme.

At the last inspection in July 2018 we rated the practice as requires improvement for providing safe and well-led services because:

  • The practice did not have a good track record on safety in all areas of the practice.
  • The practice did not have an effective system for making improvements when things went wrong.
  • The practice ensured that care and treatment was delivered according to evidence-based guidelines. However, not all clinical audits were repeated in a timely way.
  • There were no specific guidelines, training or red flags for reception staff in the management of patients with sepsis symptoms.

At this inspection, we found that the provider had satisfactorily addressed these areas.

We based our judgement of the quality of care at this service is 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 good overall.

We rated the practice as good for safe services because:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Services were tailored to meet the needs of individual patients. They were delivered in a flexible way that ensured choice and continuity of care.

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

  • The practice had identified areas where there were gaps in provision locally and had taken steps to address them.
  • The culture of the practice and the way it was led and managed drove the delivery and improvement of high-quality, person-centred care.

These good areas benefitted all population groups and so we rated all population groups as good.

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

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

Inspection carried out on 19/07/2018

During a routine inspection

Inspection carried out on 11 February 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Manor Clinic on 11 February 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing safe, responsive, caring, effective and well-led services. It was also good for providing services for the care to older people, people with long term conditions, families, children and young people and working age people (including those recently retired and students). It was outstanding for providing services for the care of people whose circumstances may make them vulnerable.

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. All opportunities for learning from internal and external incidents were maximised.
  • The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. For example, working in partnership with seven other GP practices and a local crisis centre for homeless people.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Information was provided to help patients understand the care available to them.
  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the Patient Participation Group (PPG).
  • The practice had good facilities and was well equipped to treat patients and meet their needs. Information about how to complain was available and easy to understand.
  • The practice had a clear vision which had quality and safety as its top priority. A business plan was in place, was monitored and regularly reviewed and discussed with all staff. High standards were promoted and owned by all practice staff with evidence of team working across all roles.

We saw one area of outstanding practice:

  • The practice had worked with the local crisis drop-in team to support those people in the local community who were homeless or asylum seekers in vulnerable circumstances. The practice had registered these people as patients at the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice