Manston 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 assessed all quality statements from this key question and our rating is Good. Overall, we found the practice provided safe care and treatment for patients and the practice promoted a culture of openness and collaboration. Staff were encouraged and supported to raise concerns and there were systems in place to ensure people were safe and safeguarded from abuse. The practice had been working to ensure that they had good systems and processes in place for the management of facilities, equipment and infection prevention and control. There was evidence of systems and processes to support safe recruitment, however we found some gaps in how the practice captured documentation at the point of recruitment to ensure competencies, training for role-specific activities and the immunisation status of staff was obtained. However, the practice provided additional information after the assessment which showed progress towards compliance in these areas. There were systems and processes in place to support medicines management. However, we found a gap in the management and oversight of Patient Specific Directions. After the assessment the practice sent information on their plan to address this. Prescribing outcomes were in line with local and national averages. A review of a sample of patient clinical records found that patients’ medicines management and treatment were safely managed by the practice.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

As part of the assessment process, we reviewed patient feedback from the National GP Patient Survey and the NHS Friends and Family Test. We did not receive any feedback through our Give Feedback on Care process on the Care Quality Commission’s website. From the patient feedback that we did receive, there were no specific views or concerns regarding this quality statement.

Leaders told us that they encouraged staff to report incidents and involved them in the outcome, when necessary. Staff we spoke with were able to explain the process of how they would report an incident or who they would seek guidance from to do so. They told us that learning was shared from incidents and complaints and that they felt able to raise and discuss concerns. Staff and leaders explained that the practice was working hard to create an open and transparent environment.

The practice had systems and processes in place that were underpinned by policies to support the management of incidents and complaints. During the assessment we reviewed a sample of incidents and saw they had been acted upon, learning shared, and there was evidence that the practice had applied the duty of candour. We saw that the practice had systems and processes in place to receive, disseminate and act upon patient safety alerts and there was a log maintained which included action taken. A review of a sample of clinical records indicated that patient safety alerts were actioned in line with guidance. We saw evidence in meeting minutes that incidents and complaints had been discussed, and that those minutes had been shared with staff.

As part of the assessment process, we reviewed patient feedback from the National GP Patient Survey and the NHS Friends and Family Test. We did not receive any feedback through our Give Feedback on Care process on the Care Quality Commission’s website. From the patient feedback that we did receive, there were no specific views or concerns regarding this quality statement.

Staff and leaders told us there were systems in place for the management of referrals, clinical correspondence, pathology results and summarising of new patient records to ensure safety and continuity of care for patients. They told us that clinicians made appropriate and timely referrals in line with protocols and up-to-date evidence-based guidance. Staff we spoke with understood the referrals process and how to manage correspondence.

Feedback received from NHS West Yorkshire Integrated Care Board indicated that there was no indication of concern in this area.

The practice had formal policies in place to manage clinical correspondence, pathology results, referrals and summarising of patient records. Test results and patient correspondence were managed in a timely manner and the practice had been upskilling existing staff to support staff absence. We saw systems were in place for the safety-netting of patients who had undertaken cervical screening to ensure a result had been received by the service. The practice had a process in place for the summarising new patient medical records and 99.5% of these had been completed. At the time of the assessment, the practice had not completed an audit of the summarising process to ensure medical records were summarised in line with their policy. After the assessment, the practice advised us they had added a summarising audit to their annual schedule. During our on-site visit, we reviewed the 2-week wait referrals process and found that substantive GPs were responsible for monitoring their referrals. We asked the practice about their oversight of this process to ensure all patients had attend their appointments and that an outcome had been received by the practice. At the time of our assessment there was no formal oversight process. However, immediately after the assessment the practice undertook an audit of all urgent 2-week wait referrals to ensure that patients had been seen. In addition, the practice implemented changes to their process to add an additional level of safety netting to ensure referrals were sent in a timely manner and that patients had attended for their appointment. From a selection of patient records reviewed, we saw that patient consultations contained appropriate information and demonstrated that care and treatment was being delivered in a safe way.

As part of the assessment process, we reviewed patient feedback from the National GP Patient Survey and the NHS Friends and Family Test. We did not receive any feedback through our Give Feedback on Care process on the Care Quality Commission’s website. From the patient feedback that we did receive, there were no specific views or concerns regarding this quality statement.

Staff and leaders told us about the safeguarding systems and processes that were in place, which included having nominated leads, policies, training, risk registers, meetings, and coding and flagging of vulnerable patients on their clinical system. They told us there were processes in place to follow-up on children who had not been brought to their appointments and if they were involved with child protection services. Staff feedback indicated that all staff knew who the safeguarding leads were and how to access safeguarding policies and procedures. Staff we spoke with confirmed they had undertaken safeguarding children and adult training and those who acted as a chaperone were able to describe their role and responsibility.

Feedback received from NHS West Yorkshire Integrated Care Board indicated that there was no indication of concern in this area.

The practice had safeguarding leads, and a policy covering both adults and children in place. We saw confirmation that staff had received training in line with Intercollegiate Guidance for safeguarding children and adults. In addition, the prevention of radicalisation, female genital mutilation and chaperoning training formed part of the practice’s mandatory training schedule for staff, dependent on their role. A review of a sample of clinical records showed there was a system in place to identify vulnerable patients and we saw evidence of safeguarding alerts and appropriate codes on the records of children, their siblings and vulnerable adults. We saw staff who acted as a chaperone were trained for the role and had received a Disclosure and Barring Service (DBS) check. During the on-site assessment we observed notices displayed in the practice to advise patients that a chaperone service was available, if required.

As part of the assessment process, we reviewed patient feedback from the National GP Patient Survey and the NHS Friends and Family Test. We did not receive any feedback through our Give Feedback on Care process on the Care Quality Commission’s website. From the patient feedback that we did receive, there were no specific views or concerns regarding this quality statement.

Staff were aware of the location of the emergency medicines and medical equipment, for example oxygen and the automated external defibrillator (AED). Staff told us they had completed face-to-face mandatory training for basic life support and anaphylaxis. Non-clinical staff were aware of ‘red flag’ presenting symptoms, such as sepsis, and action to take. Staff we spoke with were aware of how to raise an alarm in the event of an emergency. There were individual alarms in clinical rooms and staff could also use the panic alarm system integrated into their clinical system.

The practice had policies for medical emergencies and at our on-site assessment we observed that the practice was equipped to respond to medical emergencies. We reviewed processes around the management of emergency equipment and medicines and saw there were regular checks in place, which were recorded.

Leaders had implemented a system to ensure that the upkeep of the premises and equipment were undertaken to required timescales. This included oversight of those undertaken by the landlord. In response to feedback from a previous inspection, the practice had organised external premises risk assessments and completed remedial actions to ensure premises and equipment were safe at both sites. Staff told us that they were satisfied with the health and safety arrangements within the practice.

The facilities and premises were appropriate for the services being delivered. At our on-site assessment we observed the premises to be clean, accessible and appropriate for the activities being carried out. A lift was available for staff and patients and there was appropriate signage in place, such as for fire escapes.

We reviewed premises and facilities documentation and found fire maintenance records in place. For example, fire alarm system checks for Manston Surgery, smoke alarm checks for Scholes Surgery and fire extinguisher checks for both sites. There was a fire policy and fire safety procedures in place which included regular fire alarm testing, fire evacuation drills and fire marshals, who had received training. There was evidence of portable appliance testing (PAT), calibration of medical equipment, a Gas Safety Certificate and an Electrical Fixed Installation Condition Report (EICR) for both locations. We saw evidence of a lift operating and lifting equipment regulations (LOLER) certificate for Manston Surgery. An external fire risk assessment and Legionella risk assessment had been completed for both sites and remedial actions completed. The practice had undertaken their own health and safety and control of substances hazardous to health (COSHH) risk assessments. Following the on-site assessment, the practice sent over some additional information and updates regarding the premises and equipment, including evidence of liaising with external contractors to rectify outstanding work to be completed.

As part of the assessment process, we reviewed patient feedback from the National GP Patient Survey and the NHS Friends and Family Test. We did not receive any feedback through our Give Feedback on Care process on the Care Quality Commission’s website. From the patient feedback that we did receive, there were no specific views or concerns regarding this quality statement.

Staff and leaders told us that staffing levels were being monitored and they had been recruiting as well as upskilling current staff. Leaders told us there were systems and processes in place for recruitment, induction, appraisals and training, which were supported by policies and procedures accessible to staff. Leaders told us that mandatory training had been identified for clinical and non-clinical staff and there were systems in place to monitor when updates were due.

The practice had a policy in place for recruitment. During our on-site assessment we reviewed 4 clinical staff’s recruitment files (which included a locum GP) and 3 non-clinical staff recruitment files. Overall, we found documentation to support safe recruitment. For example, job applications, contracts, photographic identification, disclosure and barring service (DBS) checks, professional registration checks and references. However, we found some gaps in records for some clinical staff. For example, interview summaries, immunisation status and competency and training records for role-specific activities. Although the practice was able to provide these documents after the assessment, systems and processes outlined in their recruitment policy and procedures to ensure all paperwork was available and checked prior to commencement of employment had not been followed. Following the on-site assessment, the practice sent a recruitment check list which they planned to use for future recruitment to ensure all required documentation was received and checked during the recruitment process. Mandatory training had been completed for most substantive and locum staff and there was a system in place to alert staff to update training.

As part of the assessment process, we reviewed patient feedback from the National GP Patient Survey and the NHS Friends and Family Test. We did not receive any feedback through our Give Feedback on Care process on the Care Quality Commission’s website. From the patient feedback that we did receive, there were no specific views or concerns regarding this quality statement.

Staff knew who the nominated lead for infection prevention control (IPC) was and how to access relevant policies. Staff we spoke with confirmed that they had received infection prevention control training relevant to their role. We spoke with the nominated IPC lead at our on-site assessment who told us they had dedicated time to undertake this role and had undertaken additional training to support them in the lead role.

On the day of the on-site assessment, we observed the premises to be clean, tidy and clutter-free. The practice had a waste segregation and management system in place, and we found posters around the practice, including sharps injury, handwashing and clinical waste to support good practice. The cleaner’s cupboard contained appropriate colour-coded equipment and cleaning materials. However, the storage of equipment posed a potential risk of cross-contamination. The practice immediately contacted their external contracted cleaning company to rectify this and told us they would include a review of the cleaning equipment cupboard as part of their ongoing infection prevention and control (IPC) audits.

There were comprehensive infection prevention and control (IPC) policies in place, which were accessible to staff. IPC audits had been completed for both sites. We saw that there had been some areas of non-compliance noted on the IPC audit undertaken at the branch site. At the time of the on-site assessment the practice had not indicated on their action plan any timescales of when any remedial action would be undertaken. The practice had attempted to capture the immunisation status of all clinical and non-clinical staff which included referral to their occupational health provider. At the time of the assessment there remained some gaps in records for both existing staff and staff that had been employed since our previous assessment. The practice was in the process of updating their records and undertaking individual risk assessments for those staff who could not provide evidence of the required immunisations. After the assessment the practice provided individual staff risk assessments and confirmed that their occupational health provider would be visiting the practice in December 2024 to complete staff immunisations. The practice had updated recruitment paperwork to ensure that the immunisation status of all staff was documented prior to commencement of employment.

As part of the assessment process, we reviewed patient feedback from the National GP Patient Survey and the NHS Friends and Family Test. We did not receive any feedback through our Give Feedback on Care process on the Care Quality Commission’s website. From the patient feedback that we did receive, there were no specific views or concerns regarding this quality statement.

Staff and leaders explained the systems they had in place to ensure medicines were stored, prescribed and dispensed safely. The practice did not hold any controlled drugs. The practice operated a dispensary service from the branch site. We spoke with the lead dispenser who demonstrated evidence of their training as an accuracy checker and told us they were supported by a GP who undertook regular audits and competency checks as part of their supervision.

As part of our assessment, a Care Quality Commission GP specialist advisor (SpA) conducted a series of remote clinical searches of patient records to assess the practice’s procedures around prescribing and medicines management. This included the management of patients prescribed disease-modifying antirheumatic drugs (DMARDs) and some medicines requiring monitoring, as well as the management of patient safety alerts, medicines usage, medication reviews and potential missed diagnoses. The results showed the practice had systems in place to ensure patients were appropriately monitored and safety alerts about medicines were implemented. There was a process in place for the safe handling of requests for repeat medicines and evidence of effective medicines reviews for patients prescribed repeat medicines. The practice had a process and clear audit trail for the management of information about changes to a patient’s medicines including changes made by other services. At our on-site assessment, we found the practice held appropriate emergency medicines safely and monitored stock levels and expiry dates. Vaccines were appropriately stored, monitored and transported in line with guidance to ensure they remained safe and effective. Medical gases, such as oxygen, were stored safely with appropriate warning signage.

There were medicines policies in place covering repeat prescribing, controlled drugs and vaccine management. The practice held appropriate emergency medicines and had a system in place to monitor stock levels and expiry dates. Blank prescription stationery was securely stored, and their use was monitored in line with national guidance. There were clear Standard Operating Procedures for the dispensary which covered all aspects of the dispensing process. We saw that these were regularly reviewed. There were systems and processes in place to ensure staff had the appropriate authorisations to administer medicines under a Patient Group Direction. However, we found staff did not always have the appropriate authorisations to administer medicines under a Patient Specific Direction (PSD). In response to this, the practice completed an audit of patients administered medicines under a PSD and implemented a process to ensure all PSDs were in place and approved in a timely manner in line with guidance.

Data showed that the practice had systems in place to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Outcomes from our clinical notes review and prescribing data reviewed confirmed this.