Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection visit of Manor House Lane Surgery, on 23 June 2016. As a result of our comprehensive inspection a breach of legal requirement was found and the practice was rated as requires improvements for providing safe services.

This was a focussed desk based review of Manor House Lane Surgery carried out on 20 December 2016 to check that the provider had made improvements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Manor House Lane Surgery on our website at www.cqc.org.uk. The practice is now rated as Good for providing safe services.

Our key findings across the area we inspected was as follows:

• The practice had made improvements in the assessment of risks to patients, visitors and staff. For example, since our comprehensive inspection took place on June 2016, the practice had completed risk assessments for health and safety, fire, gas safety and legionella. (Legionella is a term for a particular bacterium which can contaminate water systems in buildings).The practice had commissioned an assessment of the premises to ensure the premise was accessible for patients with a disability and any risks were appropriately assessed and managed.

• Since our comprehensive inspection in June 2016, the practice had applied for disclosure and barring (DBS) checks for non-clinical staff members who chaperoned. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable). The practice policy on chaperoning had been updated with the recognised national guidelines and staff doing this role had received the appropriate training.

• At the previous inspection in June 2016 we found the practice had a low number of carers on the carers register. At the time of the inspection there were 68 carers on the register, which represented 0.6% of the practice list. The practice had reviewed the list and had actively encouraged patients to identify themselves if they were carers and the latest data provided by the practice showed an increase to the register, with 117 carers currently listed

• The practice had introduced a formal meeting schedule to ensure all staff received effective communication.

• The practice had actively encouraged patients to join a patient participation group (PPG) and we saw evidence to confirm that meetings had been held.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Manor House Lane Surgery on 23 June 2016. Overall the practice is rated as good.

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

• There was an effective system in place for reporting and recording significant events.
• The practice had visible clinical and managerial leadership and staff felt supported by management.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• 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. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• The premises proved a challenge due to lack of space and limited car parking, which the staff managed well.
• Staff worked with multidisciplinary teams to understand and meet the range and complexity of patients’ needs. We saw evidence that multidisciplinary team meetings took place every two months.
• The provider was aware of and complied with the requirements of the duty of candour.
• Governance and risk management arrangements were not robust. There were no risk assessments in the absence of disclosure and barring checks (DBS) for members of the reception team who occasionally chaperoned.
• Some staff who acted as chaperones were unaware of the recommended chaperoning guidelines when observing treatments and examinations.

• We found some of the practice policies required reviewing and updating in line with national guidance.
• As tenants of the premises, the provider had not assured themselves that risks to patients, visitors and staff had been appropriately assessed and managed.

• The practice was unable to provide sufficient evidence of seeking appropriate assurances for the employment of staff. For example, Disclosure and Barring Service (DBS) checks had been accepted for nursing staff from their previous employment

The areas where the provider must make improvement are:

• Ensure all staff are risk assessed in the absence of a Disclosure and Barring Service (DBS) check when carrying out chaperoning duties.
• Have a legionella risk assessment in place to mitigate risk and the spread of infection.

The areas where the provider should make improvement are:

• Ensure staff who chaperone are aware of and comply with recommended chaperoning guidelines when observing treatments and examinations.
• Consider how to proactively identify and support carers.
• Review effectiveness of keeping administration staff up to date with no regular meetings taking place.
• Ensure appropriate processes to assess, monitor improvement and mitigate risks in relation to both the safety and quality of the service, for example the use of risk assessment.
• Seek and act on feedback received from patients to demonstrate improvements to services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice