Manor and Park Group Practice

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

The practice had a clear vision and credible strategy to provide high quality, person-centered care although improvement was required in equity of access to an appointment and by telephone. There were positive staff cultures with all staff reporting that they felt supported by the GPs and management. Governance structures and systems were in place although some required review. For example, policies did not always reflect what was happening in the practice and improvement to some monitoring systems was required. There was compassionate, inclusive and effective leadership at all levels and the practice involved the public, staff and external partners to sustain high quality care. There was evidence of systems and processes for learning and continuous improvement.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a business plan and had an access recovery plan which they had submitted to their commissioners detailing their plan to improve access. They were aware of patient feedback regarding access and were continually reviewing this and had set up a focus group and had an action plan in place to address it. Staff attended regular team meetings including clinical, nursing, multidisciplinary and full team meetings. All meetings were minuted, these were shared with staff. All staff had received equality and diversity training. The practice had a raising concerns (whistleblowing) policy and there were systems to ensure compliance with the requirements of the duty of candour in place.

Leaders we spoke with had a shared vision and strategy to provide patients with high quality care. They acknowledged there had been some set-backs with regard to shortages of clinical staff but they had managed to successfully recruit GPs and advanced care practitioners and were fully staffed clinically as of 1 January 2024. Staff we spoke with told us that there was a positive team culture within the practice and that they felt very supported by both the GPs and practice manager. They told us they were able to contribute to discussions about service improvements, incidents and complaints. All staff we spoke with were proud to work for the service and had a vision to deliver high quality patient care. They reported that they felt able to raise concerns with leaders without fear of retribution and they knew how to access the whistleblowing policy.

Staff told us they received regular appraisals and were given opportunities to discuss development and any training needs during their appraisal. They told us management had an ‘open door’ policy and they could approach leaders at any time if they required support. All staff reported that they had received the training they required for their role and were up to date with their training. Leaders told us they had discussed succession planning. All staff reported a positive, open culture. They all said they felt part of a team and could approach the practice manager and GPs with any queries or concerns. They all said they felt very supported.

Appropriate recruitment checks were completed for staff. We reviewed 3 personnel files and found appropriate checks had taken place including disclosure and barring (DBS) checks. Induction records were completed and staff had shadowing and competency checks recorded on file. Records showed all staff had received an annual appraisal or had a date scheduled.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The clinical searches we carried out on the practice’s clinical system showed good patient care though some processes required review. For example, they did not have a system to ensure follow up of patients with asthma prescribed emergency steroids as recommended in national guidance. Some coding and recording in records required review. For example, staff told us that they discussed the risks associated with some medicines though we could not see evidence this was recorded. We were assured by speaking to staff and reviewing the clinical system that medicine alerts were being appropriately actioned. However, there was no monitoring overview of these so it was difficult for staff to recall what action had taken place for historic medicine alerts or how they monitored any changes made had been maintained. The service had a business continuity plan in place and we saw evidence of this being used effectively. There were effective arrangements for identifying, managing, and mitigating risks with the exception of a risk assessment for one emergency medicine not stocked. There were clear arrangements in place for the availability, integrity and confidentiality of data, records and data management systems.

Staff knew how to access practice policies. There was a suite of policies accessible to staff on the practice’s computer system, although we observed some did not correlate with what staff were doing or included inaccurate information. For example, referencing a dispensary which they did not have, wording in the chaperone policy was vague and the safeguarding policy included an error in one section. The provider shared an updated safeguarding and incident policy during the assessment. The chaperone policy required review and the practice manager told us this would be looked at. The practice manager told us policies were reviewed annually. There were named leads in place for key areas and staff were clear about their roles and responsibilities. Staff told us they could provide feedback and had opportunities to raise concerns or suggest new ideas to leaders.

The practice worked with commissioners. For example, they had carried out some quality improvement work in December 2023 to review prescribing of proprietary medicines. Leaders attended regular primary care network meetings to discuss ways they could implement more coordinated and integrated health and social care for people closer to home.

People were able to access support at the practice rather than be referred elsewhere. For example, a mental health worker recruited through the primary care network held clinics at the practice.

The practice manager attended peer support meetings to share good practice in the locality.

The provider engaged with patients when any changes were being proposed. For example, leaders had recently trialled a total GP triage system in October and November 2023, they planned to implement this in May 2024 following consultation with patients. The provider used the national friends and family test to gain feedback from patients and reviewed the national GP patient survey results. They had created an access recovery plan for their commissioners. The provider made external notifications regarding serious incidents when necessary. For example, damage made to the building following a car going into the side of it.

Staff told us that leaders encouraged development. For example, they had supported a healthcare assistant through the nurse associate course and were supporting an administrator with a practice management course. The clinical pharmacist was being supported through a pathway scheme with weekly clinical supervision from a GP and regular sessions with the nurses. The pharmacist also attended a peer working group to share ideas to bring back to practice. For example, they were working on a quality improvement project with one of the GPs to look at the sick day rules for patients to check their knowledge and understanding.

We saw clinical audits had driven improvement for individual patients, however, we did not see any 2 cycled audits. This was discussed with leaders. We reviewed nurse led audits, for example, cervical cytology results. We saw evidence of monitoring of data, for example the telephone call monitoring logs. The service used patient mumbles and grumbles and responded to them as they would a complaint and had a log of these to identify any themes and trends where improvement could be made. They reviewed incidents which were discussed with staff for learning. For example, the wrong vaccine was given to a patient, we saw the patient was given an explanation and an apology and ways to prevent this happening again were discussed with staff.