The Care Quality Commission
  • Doctor
  • GP practice

Manston Surgery

Overall: Inadequate read more about inspection ratings

Cross Gates Medical Centre, Crossgates, Leeds, West Yorkshire, LS15 8BZ (0113) 264 5455

Provided and run by:
Manston Surgery

Important: This service was previously registered at a different address - see old profile

All Inspections

During an assessment under our new approach

We carried out an announced focused assessment of Manston Surgery on 3 and 4 June 2024. This service was inspected in January 2024 and rated Inadequate. At that inspection we issued warning notices for breaches Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We assessed a total of 7 quality statements from the safe and well-led key questions. As part of this assessment, we requested documentary evidence from the provider to demonstrate compliance with the findings of our previous inspection. In addition, we visited the provider on 4 June 2024 and spoke with leaders and undertook observations at the practice. We did not review the ratings awarded to this provider at this assessment. The scores for the 7 quality statements have been combined with scores based on the key question ratings from the inspection in January 2024. Overall, we found that the practice had made improvements and had implemented some good practice. However, there were some areas which needed further embedding of systems and processes and we made recommendations to the practice where they could make continued improvement. The practice was proactive to our feedback and sent further documentary evidence after the assessment. Although improvements had been made since the previous inspection, our overall rating remains inadequate as this was a follow-up assessment of the enforcement action we took and not an assessment to change the overall rating. A further assessment will take place in due course to review all quality statements and the rating. Manston Surgery is a partnership providing services to a patient list of 8,220 patients. The practice holds a Primary Medical Services contract. The practice is situated within the NHS West Yorkshire Integrated Care Board and is part of a wider network of GP practices, known as Crossgates Primary Care Network.

23 January 2024

During a routine inspection

We carried out an announced comprehensive inspection at Manston Surgery on 19 and 23 January 2023. Overall, the practice is rated as inadequate.

Safe - inadequate

Effective - requires improvement

Caring - good

Responsive - requires improvement

Well-led - inadequate

Following our previous inspection in April 2016, the practice was rated good overall and for 4 of the 5 key questions. We rated the practice requires improvement for providing safe care. Following a focused follow-up inspection in March 2017, the practice was rated good for providing safe care.

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

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities and to follow up concerns reported to us.

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 shorter site visit.
  • Reviewing 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 did not have systems and processes that operated effectively to evidence compliance with requirements to demonstrate good governance.
  • Staff did not receive adequate training or support.
  • The culture of the practice did not enable staff to raise concerns.
  • 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.

We found 2 breaches of regulations. The provider must:

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

In addition, the provider should:

  • Take action to reduce the backlog of summarising of new patient notes.
  • Take steps to improve the number of NHS health checks offered to patients.
  • Implement a system for regular formal discussions with external stakeholders.
  • Implement a system of regular documented competency checks for dispensary staff.
  • Continue to take steps to improve patient experience with making appointments.

I am placing this service in special measures. Services placed in special measures will be inspected again within 6 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 6 months if they do not improve.

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

9 March 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Manston Surgery on 27 April 2016. We also visited the branch site in Scholes as part of our inspection. The overall rating for the practice was good. However; we rated the practice as requires improvement for providing safe care The full comprehensive report on the inspection can be found by selecting the ‘all reports’ link for Manston Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 9 March 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the issues that we identified in our previous inspection on 27 April 2016. This report covers our findings in relation to those requirements.

The practice has now met the legal requirements in the key question of safe and is now rated as good.

Our key findings were as follows:

  • The practice had comprehensive Standard Operating Procedures in place to support the staff working within the dispensary at the Scholes branch site.
  • The practice had a Standard Operating Procedure to cover the management of controlled drugs.
  • There was a system in place to routinely check stock medicines were within expiry date and fit for use. This was supported by a Standard Operating Procedure to govern the activity.
  • The practice had implemented a system to record near misses (a record of errors that had been identified and corrected before medicines had left the dispensary).
  • The practice had a system in place to record and investigate incidents. We saw minutes of meetings where these had been discussed.
  • There was a system in place to manage medicines safety alerts.
  • The practice had a documented record of when checks were carried out on the oxygen and defibrillator.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

27 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Manston Surgery on 27 April 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. However; documented learning from incidents was limited.
  • There were issues identified in the dispensary at the branch site. For example; staff did not keep a ‘near-miss’ record (a record of errors that have been identified before medicines have left the dispensary), standard Operating Procedures only covered basic aspects of the dispensing process and were limited in scope and detail and staff did not routinely check stock medicines were within expiry dates.
  • The staff we spoke with told us that regular checks were carried out to ensure the oxygen and defibrillator had been carried out. However, saw there was no formal record documenting these checks.
  • 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • 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.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

  • Ensure dispensing standard operating procedures are fit for purpose and cover all required processes.
  • Ensure there is a system in place for identifying and sharing learning from medicines management incidents.
  • Ensure that there are documented checks and records relating to medicines management to ensure the quality and safety of services

The area where the provider should make improvement are:

  • Manage controlled drugs in accordance with the relevant legislation

Keep a documented record of when checks are carried out on the oxygen and defibrillator.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice