Background to this inspection
Updated
3 September 2021
Manor and Park Group Practice is located in Sheffield at:
204 Harborough Avenue
Sheffield
S2 1QU
The practice has a branch surgery at:
190 Duke Street
Sheffield
S2 5QQ
Both sites received a short visit as part of this inspection activity.
The practice offers services from both a main practice and a branch surgery. Patients can access services at either site.
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, treatment of disease, disorder or injury and surgical procedures at both sites.
The practice is situated within the NHS Sheffield Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of about 8383. This is part of a contract held with NHS England. The practice is also part of a wider primary care network of GP practices.
Information published by Public Health England shows that deprivation within the practice population group is in the first lowest decile (one of 10). The lower the decile, the more deprived the practice population is relative to others.
According to the latest available data, the ethnic make-up of the practice area is 5% Asian, 85% White, 5% Black, 3% Mixed, and 2% Other.
The disease prevalence of the practice population closely mirrors the local and national averages though was above average for patients with diabetes mellitus, depression and chronic obstructive pulmonary disease (COPD).
There is a team of six GPs who provide cover at both sites. The practice has a team of five nurses, one health practitioner and four health care assistants who provide clinics at both the main and the branch locations. The GPs are supported at the practice by a business partner, two operational managers and a team of reception and administration 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 an appointment at either the main GP location or the branch site. The practice had commenced more face to face appointments in recent weeks.
The practice is open 8am to 6pm Monday to Friday with the exception of Thursdays when they close at 12 noon. The provider offers appointments during extended opening hours on Thursday and Saturday mornings. The main site is currently closed on Wednesday afternoons and Thursdays for the COVID-19 vaccination clinic. Patients can be seen at the branch site during this time.
The practice has opted out of providing out of hours services (OOHs) for their patients. When the practice is closed patient calls are automatically transferred to the Sheffield Out of Hours Service which is located at the Northern General Hospital.
Updated
3 September 2021
We carried out an announced comprehensive follow up inspection at Manor and Park Group Practice on 29 July 2021. Overall, the practice is rated as good. The rating for each key question is:
Safe - Good
Effective - Good
Caring - Good
Responsive – Requires Improvement
Well-led - Good
Following our previous inspection on 10 December 2019, the practice was rated requires improvement overall and for the key questions responsive and well-led. It was rated good for safe, effective and caring services. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Manor and Park Group Practice on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a comprehensive follow up inspection which covered all key questions including areas where breaches of regulation and ‘shoulds’ were identified in 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 and by sending staff a short questionnaire to complete.
- 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 short 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 and requires improvement for all population groups.
We found that:
- 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. However, attainment for the management of several long term conditions, childhood immunisation and cervical cytology screening fell below local and national averages.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
- Patient feedback with regard to access had shown some improvement since the previous inspection, although patients still reported difficulty getting through to the practice by telephone.
- The way the practice was led and managed promoted the delivery of high-quality, person-centered care.
Whilst we found no breaches of regulations, the provider should:
- Continue to follow the action plan to improve access, particularly by telephone to the practice and in relation to patient satisfaction in general.
- Implement a system to monitor tasks on the clinical system in a timely manner.
- Continue to improve data for management of long term conditions and screening which were below local and national averages.
- Implement a system to monitor registration with the professional bodies for clinical staff on a regular basis.
- Follow policies and risk assessments to ensure staff receive training in infection, prevention and control (IPC) and fire safety at appropriate intervals.
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