Manor and Park Group Practice

We carried out an announced comprehensive inspection at Manor Park Medical Centre on 10 December 2019 as part of our inspection programme.

We decided to undertake an inspection of this service following our annual review of the information available to us, including information provided by the practice. This inspection looked at the following key questions:

• Are services at this location safe?
• Are services at this location effective?
• Are services at this location caring?
• Are services at this location responsive?
• Are services at this location well led?

We based our judgement of the quality of care at this service on a combination of:

• wwhat 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 requires improvement overall with requires improvement in responsive and well led and requires improvement for all population groups.

We rated this practice requires improvement in responsive because:

• Patients had extreme difficulty accessing care and treatment and reported they were not able to get through easily to the practice by telephone.
• The provider was aware of patient feedback from complaints. However, this had not driven adequate change to improve access for patients.

We rated the practice requires improvement in well led because:

• Risk assessments and actions to mitigate risks with regard to staff levels and the number of staff answering the phone and appointment numbers was not effective.

We rated the practice as good for providing safe, effective and caring services because:

• 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 way the practice was led and managed promoted the delivery of high-quality care. The provider was aware of access issues and had taken steps to address it. However, at the time of the inspection patient feedback was overwhelming about difficulties accessing an appointment and the changes implemented had not addressed this adequately.

The areas where the provider must make improvements are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Ensure the recruitment information recorded for all members of staff is in line with Regulation 19, Schedule 3 of the Health and Social Care Act.
• Ensure all staff are trained to the appropriate safeguarding level for their role as recommended in the intercollegiate safeguarding guidance (Safeguarding children and young people: roles and competencies for healthcare staff).
• Implement a system for checking the medical fridges when the nurse is absent and review Public Health England guidance with regard to availability of a second thermometer in one of the medical fridges at the main site.
• Take action to review and follow their complaints policy to reflect NHS complaints guidance.

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