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