The Care Quality Commission
  • Doctor
  • GP practice

The Manor Street Surgery

Overall: Good read more about inspection ratings

Manor Street Surgery, Manor Street, Berkhamsted, Hertfordshire, HP4 2DL (01442) 875935

Provided and run by:
The Manor Street Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about The Manor Street Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about The Manor Street Surgery, you can give feedback on this service.

14 September 2021

During a routine inspection

We carried out an announced inspection at The Manor Street Surgery. Overall, the practice is rated as Good.

The ratings for each key question are as follows:

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led – Good

Following our previous inspection on 10 December 2020, the practice was rated Inadequate overall and for the safe, effective and well-led key questions due to ineffective systems to manage medicines safely, low numbers of care plans for those in vulnerable groups and lack of oversight of non-medical prescribers.

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

Why we carried out this inspection

This inspection was a comprehensive follow-up inspection to follow up on the breaches of regulation and the areas the practice should improve that were identified at the previous inspection.

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 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 good overall.

We found that:

  • The practice had made significant improvements since our previous inspection, despite the challenges presented during the COVID-19 pandemic. The practice had addressed all the concerns raised in their recent warning notice.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm. In particular we found improvements in the management of high-risk medicines and medicines used in the treatment of asthma, systems for ensuring cleaning was completed and with the monitoring of referrals.
  • We found improvements in the care and treatment provided, for example in relation to patients with learning disabilities. However, we found patients on the mental health register who were overdue their mental health reviews.
  • We found improvements to the systems for maintaining oversight of the competence of non-medical prescribers through regular audit.
  • Staff received regular opportunities for learning and development.
  • Not all staff received regular appraisals, most notably non-clinical staff. We also found a lack of formal opportunities for non-clinical staff to be involved in discussions about the service and provide feedback.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice scored highly in the latest national GP patient survey in questions relating to patient experience and access and was rated as third in the county for patient satisfaction. Online feedback was equally as positive.
  • 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.
  • While we found the practice was largely well managed and promoted the delivery of high-quality, person-centred care, there were some areas that still needed improvement.

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

  • Complete portable appliance testing in line with recommendations or ensure appropriate risk assessments are in place.
  • Provide sepsis awareness training or guidance for non-clinical staff.
  • Undertake regular appraisals and provide formal opportunities for all staff to be involved in discussions about the service and to provide feedback to support improvement.
  • Implement systems for monitoring external appraisals and revalidation for clinical staff with their professional bodies to ensure they are up to date.
  • Improve the recall and monitoring of patients with poor mental health and uptake of cervical screening.
  • Introduce systems for recording of verbal complaints and suggestions to help support service improvement.

I am taking this service out of special measures. This recognises the significant 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 Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

10 December 2020

During an inspection looking at part of the service

The service is rated as Inadequate overall.

We carried out an announced comprehensive inspection at The Manor Street Surgery on 7 August 2019. The overall rating for the practice was good, however it was rated as requires improvement for providing safe services and a requirement notice was issued. The December 2020 inspection was triggered through our ongoing monitoring of risk.

The full comprehensive report on the August 2019 inspection can be found by selecting the ‘all reports’ link for The Manor Street Surgery on our website at www.cqc.org.uk.

We took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering how we carried out this inspection. We therefore undertook some of the inspection processes remotely and spent less time on site. We conducted staff interviews on 8 December to 10 December 2020 and carried out a site visit on 10 December 2020.

Our judgement of the quality of care at this service is based 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.

The practice is rated as Inadequate overall.

(previously rated as good in August 2019)

We rated the practice as inadequate for providing safe services because:

  • Clinical records we looked at showed that high-risk medicines were not appropriately managed, and we saw evidence that patients had not received the appropriate blood testing prior to prescribing. Following the inspection, the practice told us that they had employed a member of staff to redesign the system to call patients for blood monitoring appointments.
  • Clinical records we looked at showed that patients diagnosed with asthma with high use of short-acting inhalers did not have the appropriate actions or follow up. Following the inspection, the practice told us that all patients with overdue blood monitoring and high inhaler use had been booked for the relevant appointments.
  • Cleaning schedules were not signed to ensure cleaning had been completed.
  • There was no monitoring of routine referrals to ensure appointments had been booked or attended.

We rated the practice as inadequate for providing effective services because:

  • The system to review medicines on repeat prescriptions was ineffective. For medicine reviews that had been completed, there was no associated documentation to detail what actions had been taken or conversations with patients or carers.
  • Low numbers of care plans were in place for vulnerable patients such as those with a learning disability, dementia or a cancer diagnosis. The practice told us this was due to a reduction in face to face contacts during the COVID-19 pandemic and they had plans to review all patients with a learning disability in January 2021.
  • Oversight of non-medical prescribers was lacking, and the practice did not conduct specific audits of their consultation and prescribing practices.
  • Quality improvement activities were lacking regarding medicines management and areas of concern had not been identified by the practice.

We rated the practice as good for providing caring services because:

  • Patients told us that staff treated them with care and compassion.
  • National GP Patient Survey results were in line with local and national averages.
  • The care home that the practice supported were positive about the care and treatment they had received, particularly during the COVID-19 pandemic.

We rated the practice as good for providing responsive services because:

  • Patients told us that they were able to access appointments in a timely way.
  • The practice had significant positive variation within the National GP Patient Survey for telephone access.
  • The practice managed complaints in a timely way and we saw that these were used to improve services.

We rated the practice as Inadequate for providing well-led services because:

  • The systems to manage medicines safely were ineffective. This included systems for patients on repeat medicines, high-risk medicines and those suffering from asthma.
  • The practice had some plans in place to complete care plans for those with a learning disability however, there was no plans in place to address care plans for other vulnerable groups such as carers or those with dementia.
  • Concerns raised at the August 2019 inspection in relation to oversight of non-medical prescribers had not been addressed by the practice.

The areas where the provider must make improvements as they are in breach of regulations are:

  • 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.

The areas where the provider should make improvements are:

  • Continue to ensure that water temperatures are taken monthly to mitigate the risk of legionella.
  • Continue to increase patient uptake for childhood immunisations and cervical screening. Ensure that results for cervical screening are tracked and patients are contacted where necessary.
  • Continue to complete effective care planning and ensure contemporaneous records, particularly for patients in vulnerable groups, to ensure clinical situation and current management is documented.
  • Continue to improve systems to monitor routine referrals to ensure these appointments have been booked or attended.

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 population group, 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.

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

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

7 August 2019

During an inspection looking at part of the service

We carried out an inspection of this service due to the length of time since the last inspection. Following our review of the information available to us, including information provided by the practice, we focused our inspection on the following key questions: safe, effective, responsive and well-led.

Because of the assurance received from our review of information we carried forward the ratings for the following key question: caring.

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 rated the practice as requires improvement for providing safe services because:

  • The practice’s systems and processes to keep people safe were not always comprehensive.

Please see the final section of this report for specific details of our concerns.

We rated the practice as good for providing effective, responsive and well-led services because:

  • Patients received effective care and treatment that met their needs. The practice routinely reviewed the effectiveness and appropriateness of the care it provided. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • 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-centred care and an inclusive, supportive environment for staff. There was a focus on continuous learning and improvement at all levels of the organisation. Where we identified any concerns during our inspection, the practice took action to respond or plans of action were developed to ensure any issues were resolved.

The area where the provider must make improvements is:

  • Ensure care and treatment is provided in a safe way to patients.

Please see the final section of this report for specific details of the action we require the provider to take.

The areas where the provider should make improvements are:

  • Adhere to the intercollegiate guidance on safeguarding competencies so that staff complete the appropriate level of safeguarding training for their roles.
  • Continue to take steps so that existing infection prevention and control, and health and safety processes are strengthened. This includes those relating to water temperature testing and monitoring adherence to the cleaning colour coding system.
  • Continue to strengthen systems and processes in relation to monitoring two week wait referrals, inviting children to receive their immunisations and appropriately exception reporting patients.
  • Continue to take steps so that the competence of nurses to administer medicines under Patient Group Directions (PGDs) is assessed and signed by a GP or pharmacist.
  • Continue to take steps so that all patients prescribed high-risk medicines receive the required blood tests on time, and the results are available to the practice before these patients are prescribed their medicines.
  • Implement a system so that nursing staff who prescribe medicines complete monitoring audits of their own prescribing as part of their continuing professional development.
  • Make the complaints process and procedure available on the practice’s website.

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

23 March 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at the Manor Street Surgery on 23 March 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 with young children, working age people, those whose circumstances make them vulnerable and those patients suffering with mental health problems.

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.
  • 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.

We saw one area of outstanding practice:

  • The practice demonstrated genuine commitment to learning, sharing experiences and ways to improve patient outcomes by holding a ‘Journal Club’ and regular meetings. GPs and nurses met monthly and focussed on a specific topic which one member of the team would have researched and shared information and best practice with the team that provided an opportunity for discussion and learning. Guest speakers were also invited to update the team on the latest service developments available for patients.

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

Importantly the provider should:

  • Ensure that all staff complete the training in adult safeguarding, infection control and fire training as planned.
  • Carry out a new infection control audit as agreed when training is completed to include the risk assessment and mitigation of risk due to absence of elbow taps in clinical rooms.
  • Carry out a formal risk assessment for all staff who act as a chaperone if they do not have a Disclosure and Barring Service (DBS) check.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice