Background to this inspection
Updated
12 October 2021
The Manor Street Surgery Centre is located at Manor Street, Berkhamsted, Hertfordshire HP4 2DL in a converted house for the provision of primary medical services.
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures.
The practice is part of NHS Herts Valleys Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of approximately 12,000. This is part of a contract held with NHS England.
The practice is also part of the Dacorum Healthcare Providers Federation and ALPHA Primary Care Network (PCN). A Primary Care Network is a group of GP practices working together to address local priorities in patient care.
Information published by Public Health England rates the level of deprivation within the practice population group as ten on a scale of one to ten. Level one represents the highest level of deprivation and level ten the lowest.
According to the latest available data, the ethnic make-up of the practice area is 96% White.
Clinical staffing consists of four GP partners and three salaried GPs (three male and four female) and two GP registrars, three practice nurses (all independent prescribers) and two healthcare assistants. Non-clinical staff include a practice manager and a team of 19 administrative, reception and secretarial staff.
Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered a choice of either the main GP location or the branch surgery.
The Manor Street Surgery is open 8am to 6.30pm Monday to Friday, with extended opening on a Monday between 7am and 8am and 6.30pm to 8pm and every second Saturday each month. Patients can also obtain appointments at other practices through their federation extended access hubs. When the practice is closed, out of hours services can be accessed via the NHS 111 services.
Updated
12 October 2021
We carried out an announced inspection at The Manor Street Surgery. Overall, the practice is rated as Good.
The ratings for each key question are as follows:
Safe - Good
Effective - Good
Caring - Good
Responsive - Good
Well-led – Good
Following our previous inspection on 10 December 2020, the practice was rated Inadequate overall and for the safe, effective and well-led key questions due to ineffective systems to manage medicines safely, low numbers of care plans for those in vulnerable groups and lack of oversight of non-medical prescribers.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Manor Street Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a comprehensive follow-up inspection to follow up on the breaches of regulation and the areas the practice should improve that were identified at the previous inspection.
How we carried out the inspection
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included:
- Conducting staff interviews using video conferencing
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider
- Reviewing patient records to identify issues and clarify actions taken by the provider
- Requesting evidence from the provider
- A site visit.
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 have rated this practice as good overall.
We found that:
- The practice had made significant improvements since our previous inspection, despite the challenges presented during the COVID-19 pandemic. The practice had addressed all the concerns raised in their recent warning notice.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm. In particular we found improvements in the management of high-risk medicines and medicines used in the treatment of asthma, systems for ensuring cleaning was completed and with the monitoring of referrals.
- We found improvements in the care and treatment provided, for example in relation to patients with learning disabilities. However, we found patients on the mental health register who were overdue their mental health reviews.
- We found improvements to the systems for maintaining oversight of the competence of non-medical prescribers through regular audit.
- Staff received regular opportunities for learning and development.
- Not all staff received regular appraisals, most notably non-clinical staff. We also found a lack of formal opportunities for non-clinical staff to be involved in discussions about the service and provide feedback.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice scored highly in the latest national GP patient survey in questions relating to patient experience and access and was rated as third in the county for patient satisfaction. Online feedback was equally as positive.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
- While we found the practice was largely well managed and promoted the delivery of high-quality, person-centred care, there were some areas that still needed improvement.
Whilst we found no breaches of regulations, the provider should:
- Complete portable appliance testing in line with recommendations or ensure appropriate risk assessments are in place.
- Provide sepsis awareness training or guidance for non-clinical staff.
- Undertake regular appraisals and provide formal opportunities for all staff to be involved in discussions about the service and to provide feedback to support improvement.
- Implement systems for monitoring external appraisals and revalidation for clinical staff with their professional bodies to ensure they are up to date.
- Improve the recall and monitoring of patients with poor mental health and uptake of cervical screening.
- Introduce systems for recording of verbal complaints and suggestions to help support service improvement.
I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.
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