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Inspection carried out on 5 April 2019

During a routine inspection

We carried out an announced comprehensive inspection at the Manor Practice on 5 April 2019 as part of our inspection programme.

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 for providing safe, effective, caring, responsive and well led services. All the population groups have been rated as good.

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

  • The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice had good facilities and was well equipped to treat patients and meet their needs. The premises were clean and hygienic.
  • Staff treated patients with compassion, kindness, dignity and respect.
  • The practice sought feedback from patients, which it acted on.
  • Patient satisfaction was mostly higher than the local and England average in the national GP patient survey.
  • Staff enjoyed working for the practice and felt well supported. They had the training they needed to carry out their roles effectively.
  • The practice monitored the quality of care it provided and could demonstrate improved outcomes for patients.
  • Leaders were visible and approachable.
  • There was a clear vision to provide high quality care to patients.

The areas where the provider should make improvements are:

  • Look at ways to improve the uptake of cervical screening for eligible patients.
  • Review areas in the quality and outcomes framework where exception reporting is higher than average.
  • Undertake regular formal reviews of clinical decision making and non-medical prescribing by staff employed in advanced roles.
  • Provide feedback to patients about action taken in response to suggestions posted in the comments box.
  • Consider undertaking the practice’s own survey of patient views.

Dr Rosie Bennyworth BS BMedSci MRCGP


Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Inspection carried out on 7 January 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 6 January 2015. A breach of legal requirements was found during that inspection within the safe domain. As a result of this inspection a requirement notice was issued.

After the comprehensive inspection, the practice sent to us an action plan detailing what they

would do to meet the legal requirements in relation to the following:

Ensure that records of identification checks are included in staff personnel files.

We undertook this focused inspection on 7 January 2016 to check that the provider had followed their action plan and to confirm that they now met legal requirements. This report only covers our findings in relation to this requirement.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link on our website at www.cqc.org.uk

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

  • The practice had clearly defined and embedded systems, processes and practices in place to keep people safe and safeguarded from abuse. This included the recruitment policies and procedures.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 6 January 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Manor Practice on 6 January 2015.  Overall the practice is rated as good.

Specifically, we found the practice to be good for providing safe, effective, caring and responsive and well-led services. It was also good for providing services for the care of older people, people with long term conditions, families, children and young people, the working-age people, of people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia).

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

  • Staff understood and fulfilled their responsibilities to raise concerns and to report incidents.

  • Information about safety was recorded, monitored, appropriately reviewed and addressed.

  • Risks to patients were assessed and well managed.

  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.

  • Staff had received training appropriate to their roles and any further training needs had been identified.

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

  • Information about services and how to complain was available and easy to understand.

  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.

  • There was a clear leadership structure and staff felt supported by management.

  • The practice proactively sought feedback from staff and patients.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider must:

  • Ensure that records of identification checks are included in staff personnel files.

In addition the provider should:

  • Ensure that risk assessments are in place to assess the need for criminal record checks for non-clinical staff.
  • Improve the quality of record keeping to ensure that outstanding actions from infection control audits are undertaken.
  • Ensure there is a robust policy review system in place.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice