The Care Quality Commission
  • Doctor
  • GP practice

Manor Farm Medical Centre Also known as Dr Haczewski & Partners

Overall: Good read more about inspection ratings

Mangate Street, Swaffham, Norfolk, PE37 7QN (01760) 721786

Provided and run by:
Manor Farm Medical Centre

All Inspections

22 January 2024

During an inspection looking at part of the service

We carried out a targeted assessment of Manor Farm Medical Centre on 22 January 2024 without a site visit. Overall, the practice is rated as good. We rated the key question of responsive as requires improvement.

Safe –good – carried forward from previous inspection

Effective – good – carried forward from previous inspection

Caring – good – carried forward from previous inspection

Responsive – requires improvement

Well led – good – carried forward from previous inspection

Following our previous inspection in November 2022, the practice was rated good for safe, effective, good and well led and requires improvement for responsive. At this inspection, we rated the practice requires improvement for providing responsive services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Manor Farm Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this assessment as part of our work to understand how practices are working to try to meet demand for access and to better understand the experiences of people who use services and providers.

How we carried out the review

This assessment was carried out remotely. It did not include a site visit.

The process included:

  • Conducting an interview with the provider and members of staff using video conferencing.
  • Reviewing patient feedback from a range of sources
  • Requesting evidence from the provider.
  • Reviewing data we hold about the service
  • Seeking information/feedback from relevant stakeholders

Our findings

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 found that:

  • The practice had increased patient satisfaction for telephone access in the national GP patient survey since the 2023 national GP patient survey results.
  • The provider responded to patient feedback about telephone answering with the introduction of a new phone system. This had reduced telephony waiting times.
  • Services were tailored to meet the needs of individual people and were delivered in a way to ensure continuity of care.
  • The provider had implemented a sit and wait service twice daily that patients uptake had increased by over 50%.
  • We found that patients individual needs and preferences were central to the delivery of services.
  • Patients could not always access care and treatment in a timely way and appointments were accessible in a way that suited a patient’s individual need.
  • There was a dedicated team for learning disability patients for health reviews and patient consultations available.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

8 November 2022

During a routine inspection

We carried out an announced comprehensive inspection at Manor Farm Medical Centre on 8 November 2022. Overall, the practice is rated as good.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection on 31 March 2022, the practice was rated inadequate overall and for providing safe and well-led services, requires improvement for providing effective services and good for providing caring and responsive services. The practice was placed into special measures and issued with a warning notice relating to a breach of regulations.

A subsequent focused review was carried out on 11 July 2022 where we found that the practice was compliant with the warning notice and improvements had been made. This inspection on 8 November 2022 was a comprehensive inspection to follow up on the concerns identified during the inspection in March 2022.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Manor Farm Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out an announced comprehensive inspection as the practice was in special measures. This inspection was to review in detail the actions taken by the provider to improve the quality of care and to confirm whether legal requirements were now being met. The focus of this inspection included:

  • The key questions of safe, effective, caring, responsive and well led.
  • The follow up of areas where the provider ‘should’ improve identified in our previous inspection.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A short site visit.
  • Staff questionnaires.

Our findings

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 found that:

  • The practice had, with the support of the Integrated Care Board (ICB) and with additional external support from a GP and practice manager made significant improvements to provide 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.
  • 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-centred care.

The practice had fully engaged with the findings of our last report and had worked with the ICB and an external team to make changes, monitor and ensure those improvements were sustainable. Leadership had been strengthened and feedback from staff was positive about the changes and the future.

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

  • Continue to encourage uptake of cervical screening.
  • Continue to assess and monitor antibiotic prescribing in the practice.
  • Continue to embed and sustain the newly implemented systems and processes to provide safe and effective safe.
  • Continue to encourage the uptake of NHS health checks.

I am taking this service out of special measures. This recognises the improvements that have been made to the quality of care provided by this service.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

31 March 2022

During a routine inspection

We carried out an announced inspection at Manor Farm Medical Centre on 31 March 2022. Overall, the practice is rated as inadequate.

The ratings for each key question are:

Safe - Inadequate

Effective – Requires improvement

Caring - Good

Responsive - Good

Well-led - Inadequate

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Manor Farm Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection. We undertook this inspection at the same time as CQC inspected a range of urgent and emergency care services in Norfolk. To understand the experience of GP Providers and people who use GP services, we asked a range of questions in relation to urgent and emergency care. The responses we received have been used to inform and support system wide feedback.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short site visit

Our findings

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 Inadequate overall.

We found that:

  • The practice leadership had failed to ensure the practice was led and managed in a way that promoted the delivery of high-quality, person-centre care.
  • The practice did not provide care in a way that always kept patients safe and protected them from avoidable harm.
  • Not all patients received safe and effective care and treatment that met their needs.
  • The practice did not ensure that all medicines were prescribed safely to all patients.
  • The practice did not have clear oversight that staff had received appropriate competency assessments.
  • Complaints were listened and responded to but were not used to improve the quality of care.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider must:

  • Ensure care and treatment is provided in a safe way to patients
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition to the breaches of regulations, the provider should:

  • Continue to encourage uptake of cervical screening.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

As a result of the concerns identified we issued a Section 29 warning notice in relation to a breach of Regulation 12 Safe Care and Treatment.

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

07/11/2019

During an inspection looking at part of the service

We carried out an announced focused inspection at Manor Farm Medical Centre on 7 November 2019 as part of our inspection programme.

Following our Annual Regulatory Review of the information available to us, including information provided by the practice, we focused our inspection on the following key questions: Safe, Effective and Well-led.

Because of the assurance received from the Annual Regulatory Review we carried forward the ratings from the last comprehensive inspection for the following key questions: Caring and Responsive which are rated as good.

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 for providing effective and well lead services and requires improvement for providing safe services. All population groups were rated as good.

We found that:

  • 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.

We have rated the practice as requires improvement for providing safe services because;

  • Information about safety was not always comprehensive or actioned, risk assessments had not been carried out at the branch sites.
  • The practice did not have a process to ensure all staff had current protection against hepatitis B or active immunity from measles.
  • Not all staff had up to date training in safeguarding, infection control and basic life support.

The area where the provider must make improvements are:

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

The areas where the provider should make improvements are:

  • Continue to encourage and monitor the childhood immunisation uptake and numbers of eligible women attending for their cervical screening.
  • Review the process of exception reporting in order to demonstrate improved outcomes.
  • Embed formal monitoring systems are in place for blank prescription forms and handwritten pads to be tracked when distributed to rooms or individual clinicians.

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

5 January 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 20 November 2014. A breach of legal requirements was found. After the comprehensive

inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to ensuring robust processes were in place for the

dispensing and management of medicines. The practice did not have appropriate arrangements in place for managing medicines. The practice held stocks

of controlled drugs (medicines that require extra checks and special storage arrangements because of their potential for misuse) and had in place standard

procedures that set out how they were managed. However these procedures were not consistently followed by the practice staff. The practice made information available to us. We undertook a desk top inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports' link for on our website at www.cqc.org.uk.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

2 February 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Manor Farm Medical Centre on 02 February 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing safe, well-led, effective, caring and responsive services. It was also good for providing services for older people, people with long term conditions, families, children and young people, working age people (including those recently retired and students), people whose circumstances may make them vulnerable, and people experiencing poor mental health.

Our key findings across all the areas we inspected were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

However there were areas of practice where the provider needs to make improvements.

Action the provider MUST take to improve

The provider must ensure the recruitment policy is consistently followed in practice to ensure that staff were suitable to carry out the work they were employed to do. Ensure staff are employed with relevant background checks carried out.

Action the provider SHOULD take to improve:

  • Ensure staff receive training appropriate to their roles, and any training needs are identified and planned. For example, infection control, and health and safety.
  • Complete Control of Substances Hazardous to Health (COSHH) and health and safety risk assessments to ensure safe systems, processes and practice.
  • Dispensing staff should acknowledge and sign up to the written safe operating procedures for dealing with dispensing errors.
  • Ensure the cabinet used to store controlled drugs at Manor Farm Medical Centre, conforms to the requirements of the Misuse of Drugs (Safe Custody) Regulations (1973)
  • Establish up a system to oversee that the practice nurses and GPs remained fit to practice with their relevant professional body, prior to their employment and on an annual basis.
  • Ensure staff appraisals are held regularly to review performance and learning and development needs.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice