Manor Field Surgery

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. There were enough staff with the right skills, qualifications and experience, however, there was limited monitoring of non-medical prescribers working within their competencies. Managers made sure staff received training. This assessment found that some members of staff were overdue appraisals, an action plan was submitted following the assessment to provide assurances and show how the provider planned to complete these. Staff managed medicines well and involved people in planning any changes.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. For example, the provider identified that potentially undiagnosed diabetic patients were not being recalled for a second blood test to measure their HbA1c level. Without this test, patients could not be diagnosed as diabetic. The provider implemented a team that continually monitored potential diabetic diagnosis to ensure patients were recalled for appropriate tests. Through clinical searches we ran on the practice’s clinical system we saw that all patients that had a potential missed diagnosis of diabetes had received appropriate reviews and monitoring.

Staff we spoke with, told us they were confident in raising significant events and could describe the process for doing this. Staff felt there was an open culture, however some staff told us that communication could be improved.

The provider had a process for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way.

Staff understood their roles and had systems in place to manage tasks and test results. The provider had recently outsourced their document management work to an external company; they had regular meetings and audited their work to ensure safe and effective practice was maintained. Through searches on the practice’s clinical system, we saw that referrals and test results were managed in a timely way.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. There was a safeguarding lead and deputy for concerns relating to adults and children.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed.

The service made sure there were enough qualified, skilled and experienced staff, however, the assessment identified that further supervision was required for some staff. A review of records on the practice’s clinical system showed that non-medical prescribers were working safely within their competencies. However, there was not a robust structure in place for auditing and reviewing the competencies of these members of staff. Following the assessment the provider put an action plan in place to address this. This included non-medical prescribers reviewing their prescribing practice alongside a GP. A prescribing audit looking at a random selection of prescriptions would be included in future appraisals also.

There was a partnership made up of 3 GPs (female) and a consultant geriatrician (male), who were responsible for running the practice. The practice also employed salaried GPs. There was a diverse mix of clinical roles which included advanced nurse practitioners, practice nurses and health care assistants. There was also a range of non-clinical roles at the practice.

Although the practice provided assurances that mandatory training was up to date, it was difficult to maintain oversight as to when individual staff members were due further training. This resulted in staff having to take responsibility to update the management team when they had completed training. Following the assessment, the provider submitted additional information for how this would be managed in the future, this included procuring a new software which would provide managers with the oversight they required.

Safe recruitment practices were followed. As part of this assessment, we looked at recruitment files of 4 members of staff. All files had appropriate checks carried out. A review of staff files showed that some members of the administration team were overdue appraisals. Following the assessment the practice provided an action plan for how these appraisals would be completed and a plan so that appraisals would be aligned and done roughly at the same time each year.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks. As part of our visit, we reviewed treatment rooms, consultation rooms and stockrooms.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms.

Staff received regular training, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely.

Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Searches we ran on the practice’s clinical system identified 32 patients on disease-modifying anti-rheumatic drugs (DMARDs) that had potentially not received the required monitoring within the last 6 months. We looked in detail at 5 patients and found that all 5 patients had been reviewed appropriate monitoring, however, they required the day they were taking the medicine to be added to their notes, as per the latest guidance.

Searches identified that 776 medicine reviews had been completed within the last 3 months. A review of 5 records showed that all patients had been reviewed appropriately and holistically. Searches also identified that 11 patients out of 135 on gabapentinoids, (medicine usually used for nerve pain, epilepsy and fibromyalgia) had potentially not received the required monitoring. A review of 5 patient records showed that 4 had been reviewed appropriately and 1 patient required a review.

The provider had effective systems to manage and respond to safety alerts and medicine recalls. Appropriate action had been taken in respect of combination medicine alert. However, a review of clinical records identified that an alert for women of childbearing age on teratogenic drugs (a substance or agent, which can interfere with the normal development of an embryo or foetus, potentially leading to birth defects or other abnormalities) required reviewing. We looked in detail at 5 patients clinical records, 4 out of 5 patients had not received the appropriate documented discussions around the side effects of this medicine and pregnancy prevention plans. Following the assessment, the provider provided an action plan for these patients, which included being recalled for discussions. There was also a plan going forward that these patients would be identified for future reviews.

Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines which were stored on site.