We carried out a review of the data available to us about The Manor Practice on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about The Manor Practice, you can give feedback on this service.
We carried out an announced comprehensive inspection at The Manor Practice on 6 November 2019 as part of our inspection programme.
We based our judgement of the quality of care at this service on a combination of:
We have rated this practice as good overall and good for all population groups.
We found that:
The practice should:
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
We undertook an announced focused inspection of The Manor Practice on 15 September 2016. We found the practice to be good for providing safe services and for being well-led. The practice is rated as good overall.
We had previously conducted an announced comprehensive inspection of the practice on 26 November 2015. As a result of our findings during that visit, the practice was rated as good for being effective, caring, and responsive, and requires improvement for being safe and well-led. This resulted in a rating of requires improvement overall. We found that the provider had breached three regulations of the Health and Social Care Act 2008: Regulation 12(2)(h) Safe care and treatment, Regulation 19(3)(a) Fit and proper persons employed, and Regulation 17(2) Good governance. You can read the report from our last comprehensive inspection at http://www.cqc.org.uk/location/1-572958578. The practice wrote to us to tell us what they would do to make improvements and meet the legal requirements.
We undertook this focused inspection on 15 September 2016 to check that the practice had followed their plan, and to confirm that they had met the legal requirements. This report only covers our findings in relation to those areas where requirements had not been met previously.
Our key findings on 15 September 2016 were as follows:
An infection control audit had been completed and staff were receiving infection control training.
Personnel files contained the required information about employees.
Fire and legionella risk assessments and a business continuity plan were in place.
Governance arrangements were in place to support the delivery of good quality care.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at The Manor Practice on 26 November 2015. Overall the practice is rated as requires improvement.
Our key findings across all the areas we inspected were as follows:
The practice had undergone significant change in the previous 12 months. There had been changes to GP partners and to other key personnel including the Practice Manager. There had been a change in the ownership of the premises. In addition to these changes, the practice had taken on some 5,000 additional patients on a caretaking basis in June 2015 when a neighbouring practice closed.
There was a new leadership team in place that was at an early stage of developing strategy and plans to take the practice towards its aims for the service. It was at the start of establishing a new governance framework that would support the delivery of the strategy and plans and good quality care.
Shortfalls we identified at our previous inspection of the practice in September 2014 had been remedied. Other shortfalls were identified at this inspection however, which reflected the pressures the practice had experienced in recent months.
There was an open and transparent approach to safety and a system was in place for reporting, recording and learning from significant events. However, the provider did not have policy and procedures in place to guide staff in the handling of notifiable safety incidents in accordance with the Duty of Candour.
Some risks to patients were assessed and well managed. More robust arrangements needed to be put in place for some other risks.
Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
The majority of patients said they were treated with compassion, dignity and respect. They felt cared for, supported and listened to.
Patients said they could get an appointment when they needed one, including urgent same day appointments, but would have to wait longer to see a preferred GP.
To meet increased demand on the service the practice had extended its opening hours and was providing a walk in service with an advanced nurse practitioner. It had upgraded its electronic patient record and telephone systems.
Information about services and how to complain was available and easy to understand.
The practice did not have an active patient participation group.
The areas where the provider must make improvements are:
Ensure there are fire and legionella risk assessments and a major incident business continuity plan in place for the practice.
Ensure there is an annual infection prevention and control audit and that all staff receive infection control training relevant to their role.
Ensure recruitment information in relation to each person working for the service as specified in Schedule 3 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 is available for staff who joined the practice after 01 April 2013.
Ensure governance arrangements are in place to support the delivery of the provider’s strategy and plans for the practice and good quality care, including patient participation mechanisms.
In addition the provider should:
Put in place policy and procedures to guide staff in the handling of notifiable safety incidents in accordance with the Duty of Candour.
Consider the ways in which the practice’s new electronic patient record system could be used to keep comprehensive patient notes.
Chief Inspector of General Practice
At our previous inspection on 18 February 2014, we found shortfalls with the infection control system in place. These included cleaning completed twice a week, lack of elbow taps and flooring and curtains that could not be cleaned. On this visit on 9 September 2014, we found that the cleaning schedule had been increased to twice a week and he floors had been deep cleaned. However there were still shortfalls. The elbow taps had not yet been installed. We also found shortfalls in the quality of cleaning provided in the consulting rooms.
People who use the service were protected from the risk of abuse, because the provider had ensured that staff were appropriately trained and they were aware of the steps to take, to identify and prevent abuse from happening.
People were not protected from the risk of infection because the fabric of the building did not allow for effective cleaning of floors, walls and furniture. Inadequate maintenance of the building, including the buildings worn flooring and wall covering, unsuitable blinds and fabric furniture meant that people who use the service, staff and visitors were not protected against the risks of unsuitable premises.
Systems and processes ensured that people's complaints were handled and responded to appropriately.
Managers were in the process of planning for the future refurbishment and development of the service and some minor building works were underway.