Manor Road Surgery

Updated 12 February 2019

Manor Road Surgery is located in a large semi-detached house converted for sole use as a surgery. The property is located in a mainly residential area of Beckenham, in the London Borough of Bromley. Services are provided from one location at 14 Manor Road, Beckenham, BR3 5LE.

Bromley Clinical Commissioning Group (CCG) is responsible for commissioning health services for the locality. The practice has 5700 registered patients. The practice age distribution is similar to the national average with a slightly lower than average number of patients 5 to 24 years and slightly higher than average number of patients 30 to 65 years. The surgery is based in an area with a deprivation score of 9 out of 10 (10 being the least deprived). The practice is registered with the CQC as a partnership. Services are delivered under a General Medical Services (GMS) contract.

The practice is registered with the CQC to provide the regulated activities of family planning; surgical procedures; maternity and midwifery services; treatment of disease, disorder and injury and diagnostic and screening procedures.

Clinical services are provided by two full time GP partners (one female and one male) and a part-time salaried GP (female). There is a locum nurse and a permanent HealthCare Assistant (HCA). Overall the practice provides 22 GP sessions each week. The practice also employs a range of non-clinical support staff comprising of a practice manager, administrators and receptionists.

The practice is a training practice and has one F2 doctor (A Foundation doctor is a grade of medical practitioner in the United Kingdom undertaking the Foundation Programme – a two-year, general postgraduate medical training programme which forms the bridge between medical school and specialist/general practice training) working there.

The practice is open between 8am and 6.30pm Monday to Friday. Pre-booked and urgent appointments are available Monday to Friday from 8am to 6.30pm. The practice has opted out of providing out-of-hours (OOH) services. Patients needing urgent care out of normal hours are advised to contact the OOH number 111 which directs patients to a local contracted OOH service or Accident and Emergency, depending on the patient’s medical urgency.

Updated 12 February 2019

We carried out an announced comprehensive inspection at Manor Road Surgery on 19 December 2018 as part of our inspection programme.

At the last inspection in November 2017 we rated the practice as requires improvement for providing safe, effective, responsive and well-led services because:

• No fire drills were being conducted.
• There were no cleaning schedules or records.
• Prescriptions were left in the printers overnight and not locked away.
• A health and safety risk assessment and fire risk assessment had not been conducted since 2012.
• A legionella risk assessment had not been conducted since 2012.
• There was no evidence that audits were driving improvements to patient outcomes.
• The practice was not conducting meetings, consequently records were not kept.
• The patient information leaflet contained out of date information.
• Appraisals for non clinical staff had not taken place since April 2016.
• The Infection Control lead had not had any infection control training.

At this inspection, we found that the provider had satisfactorily addressed these areas.

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 and good for all population groups.

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

• Continue to review medication optimisation for patients prescribed antibiotics, and patients with hypertension.
• Review information that is provided to patients that experience bereavement.
• Review accessibility of information leaflets in other languages and in easy read format.
• Consider undertaking a premises/security risk assessment.
• Review the practice mission statement and staff understanding of it.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP  

Chief Inspector of General Practice

Updated 12 February 2019

Updated 12 February 2019

Updated 12 February 2019

Updated 12 February 2019

Updated 12 February 2019

Updated 12 February 2019