Manchester Road 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

We looked for evidence people were protected from abuse and avoidable harm. At our last inspection, we rated this key question as good. At this assessment, the rating has changed to requires improvement.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service did not always detect and control potential risks in the care environment. They did not make sure that equipment and facilities supported the delivery of safe care.

The premises were located in a converted residential property that has 2 storeys. All clinical areas were situated on the ground floor with staff offices and a kitchen on the first floor.

The fire risk assessment was not comprehensive and the provider was not able to demonstrate that this had been carried out by a suitably competent person. The fire risk assessment did not provide adequate assurance that the existing fire detection system and escape arrangements were sufficient to support the safe evacuation of people in the event of a fire. The premises had no fire alarm, emergency lighting or trained fire wardens. The provider told us that a fire risk assessment had recently been completed by a competent person and that they intended to act on their findings when they received the report.

The health and safety risk assessment did not assess all potential risks presented by the environment such as the fish tank located in the corridor.

A disability access audit had been completed prior to this assessment. This was not comprehensive and did not include a detailed review of the accessibility of the premises and services. The audit completed had not identified that the path to the premises had uneven flag stones that may make navigation with a wheelchair difficult and there was no emergency pull cord in the toilet designated for people with a disability.

A legionella risk assessment was in place and water temperature was being tested weekly. Water analysis was being carried out less frequently than recommended in the risk assessment. The provider told us that they had discussed the frequency with the author of the risk assessment, however, this change to recommendation had not been documented.The provider sent an independent IPC assessment to us following the inspection and receipt of the draft report. This stated that the provider was compliant with the required standards.

The provider had undertaken checks of the building and equipment, including gas safety, electrical wiring, smoke detection, fire extinguishers and medical and electrical equipment. An annual fire drill was completed.

Records were made of the checks of temperature of the vaccine fridge. A record had not been made of the action that the provider told us they had taken when the fridge exceeded the minimum temperature.

The service made sure there were enough qualified, skilled and experienced staff, who received support and development.

The service had 3 GPs and a practice nurse. In addition, appointments were available with staff managed by the Primary Care Network (PCN). This included clinical pharmacists, advanced nurse practitioners, mental health nurses, paramedics, physiotherapists and social prescribers.

Overall, leaders ensured staff were up to date with their training which the service had deemed mandatory. Some staff were overdue training updates and a date to undertake this had been identified. The service followed safe recruitment procedures overall when employing staff. This included identity checks, review of qualifications and a criminal records check. The system to make sure a consistent record is made of the physical and mental fitness of staff to perform their role needed improvement.

The service assessed the risk of infection but did not always take appropriate action to prevent it.

The service had cleaning schedules available, which outlined how staff should clean the building and its equipment. The service monitored this to maintain oversight of cleaning arrangements. Staff had undertaken IPC training.

An annual and a 6 monthly assessment was undertaken, however, not all the identified actions had been completed. The outstanding actions related to the recommended replacement of carpets and wallpaper in clinical areas. There was no schedule for the cleaning of the carpets, and no assurance could be given as to when it was last cleaned. There was a visible stain to the carpet in the corridor.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.