Manston Surgery

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We assessed all quality statements from this key question and our rating is Requires Improvement. Although the practice had made improvements since our January 2024 inspection, some systems and processes required further embedding to ensure consistency and resilience to support good governance and leadership. Leaders demonstrated that they understood the challenges to quality and sustainability and had developed a business and strategy plan that outlined some changes of partnership and plans for the practice to work collaboratively with another practice from within the primary care network.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us that the culture of the practice was improving, leaders were more approachable, and the environment felt more positive and supportive. The practice had held a recent session for all staff to reflect and update their visions and values. Leaders acknowledged that although there had been improvements, there was still a need to embed the culture further to ensure stability.

The practice had developed a clear vision and set of values with the staff to promote shared attitudes and behaviours within the work environment. Leaders were aware that the staff morale has been low following the January 2024 assessment. The practice had put together a strategy and business plan which included working collaboratively with another surgery to further drive improvement, stability and resilience.

Staff told us about the support from the South and East Leeds GP Group management team and how they had been visible and supportive. Although it had been a challenging time since the January 2024 assessment, staff said they felt the practice worked well as a team. Leaders we spoke with were knowledgeable about issues and priorities and had already made progress on working with other leaders within the primary care network as well as actively recruiting.

The leadership team acknowledged the challenges since the January 2024 assessment. The practice was currently without a practice manager but were receiving support from the South and East Leeds GP Group management team. The leadership team was responsive and proactive to feedback during the assessment process.

Staff told us they knew how to raise concerns and felt comfortable to do so. They were aware of the practice’s freedom to speak up guardian.

There were policies in place for freedom to speak up and duty of candour, which were accessible to staff. There was a nominated freedom to speak up guardian within the primary care network who would visit the practice weekly.

Staff reported that staffing issues had impacted on how staff had been managed within the practice and hoped for more structure and more opportunities for learning and development in the future.

The practice had policies in place to support staff health and wellbeing, staff had access to occupational health and an employee assistance program, and we saw that this was readily accessible for all staff. The practice had an equality and diversity policy and during the practice manager interview, staff shared examples of how staff with protected characteristics are supported.

Staff told us they had access to policies and procedures to support them within their role and advised information was cascaded as necessary, though this could also be improved.

Staff reported that at times they were required to undertake alternative tasks due to absences and were sometimes unaware of what they were responsible for. Some staff we spoke with were unclear about their role, responsibilities, and how they interact with other roles. Staff took patient confidentiality and information security seriously and that Data Security Awareness, was within the mandatory training module. Staff we spoke with told us they followed the practice’s confidentiality policy when discussing patients’ treatments. This was to ensure that confidential information was kept private, for example, patient information was never on view or patient documentation left in clinical rooms overnight.

The practice had made improvements, however there were still gaps in some systems and process which required further embedding to ensure consistency and resilience. In particular, some recruitment and medicines management processes. The practice had shared minutes from meetings and told us how regularly the various meetings occurred, as well as how they continued to meet outside of scheduled meeting times, such as when protected learning time was not scheduled, to support with staff rapport. Staff were aware that there were policies and procedures available and how to access them. There was a data protection and security system, and the practice had a data protection registration certificate. The practice had a business continuity processes and plan in place and this was visible in staffing areas.

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

There had been changes to staffing since our previous assessment, and the practice no longer had a practice manager. They had received support from the South and East Leeds GP Group staff to work on improvements required. Staff said that the relationships between managers and staff were improving and felt more supported. Some staff did feel uncertain about the future of the practice and that their roles and responsibilities might change as a result of collaborative working with a neighbouring practice. Staff could provide feedback through meetings, a suggestion box, annual appraisal and staff surveys. Leaders told us they used a range of methods to gather patient feedback. For example, from the National GP Patient Survey, Friends and Family Test, the primary care network patient participation group, complaints and compliments.

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

The practice engaged actively with their primary care network (PCN) and attended various meetings including the PCN board meetings. There was no practice patient participation group at the time of the assessment. However, the Primary Care Network had shared the information of those registered at Manston Surgery who might be interested in joining a practice PPG in the future and the practice planned to follow-up on this.

Staff and leaders were supported to undertake further training and acquire new skills and had the opportunity to be upskilled. Staff told us they hoped to expand more on learning and training adequate for their roles and knowledge development with the sustainability of the practice.

Leaders had shared a presentation of how the practice had implemented change and learning following the concerns raised at our previous assessment. A range of data was collected and reviewed to support service delivery and improvement with insight into what the practice needed to work on and how the practice might overcome ongoing challenges in the future.