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Inspection carried out on 19 February 2019

During a routine inspection

This practice is rated as Good overall. (Previous inspection – 30 March 2016: Rating Good)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Manor Surgery on 19 February 2019 as part of our inspection programme.

At this inspection we found:

  • The practice had clear systems to manage risks to patients and staff. When incidents occurred, the practice learned from them and improved their processes.
  • The practice proactively monitored the effectiveness and appropriateness of the care it provided to ensure treatment was appropriate.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients were able to access the appointment system and reported that they could access care when they needed it.
  • The practice continuously reviewed the needs of its patient population and adapted processes to improve services for its population.

There were areas where the provider should consider making improvements:

  • Review systems to monitor the exception reporting of patients with long term conditions from national data submissions.
  • Continue to identify means of improving cervical screening uptake and monitoring external uptake.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Inspection carried out on 30 March 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Manor Surgery on 30 March 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • There was a policy and system in place for receiving medicine safety alerts.
  • The practice maintained appropriate standards of cleanliness and hygiene in most areas.
  • The arrangements for managing medicines, including emergency drugs and vaccines, in the practice kept patients safe (including obtaining, prescribing, recording, handling, and security). 
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Staff demonstrated that they had the skills, knowledge and experience to deliver effective care and treatment.
  • Appropriate consent for treatment was sought.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Staff took a large number of measures to preserve confidentiality. However, improvements were required to ensure confidentiality was maintained for one of the consulting rooms. This was planned as part of current building works.
  • Information about services and how to complain was available and easy to understand.
  • The majority of patients said they found it easy to make an appointment with a GP. Urgent appointments were available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was an overarching leadership structure and staff felt supported by management. However, there was limited clinical leadership for nursing staff.
  • The practice had proactively sought feedback from patients and had an active patient participation group.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider should make improvement are:

  • Record fridge temperatures on a daily basis.
  • Document risk assessments on all long standing reception staff who do not have a DBS check.

  • Take additional measures to preserve confidentiality outside consultation rooms.
  • Implement appropriate cleaning schedules for blinds and high level surfaces.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice