Manston Surgery

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We assessed 6 quality statements in the safe key question: Learning culture; Involving people to manage risks; Safe environments; Safe and effective staffing; Infection prevention and control; and Medicines optimisation. During the assessment we spoke with leaders, reviewed documentary evidence and made on site observations. Overall, we found improvements had been made. In particular the practice had: (1) initiated a meeting structure to keep staff informed and discuss outcomes in relation to incidents and complaints; (2) undertaken a risk assessment outlining the range of emergency medicines held; (3) undertaken premises risk assessments, although there were some outstanding actions which the practice were addressing; (4) implemented systems and processes to ensure safe and effective staffing, which included recruitment checks and mandatory training. However, not all staff had completed the identified mandatory training; (5) nominated an infection prevention and control (IPC) lead, put an IPC policy in place, undertaken IPC audits and initiated a process to maintain staff immunisation status. However, there remained some gaps in these records; (6) put systems and processes in place to ensure medicines were regularly checked and had not expired. The scores for the 6 quality statements have been combined with scores based on the safe key question ratings from the inspection in January 2024. Although the assessment of these quality statements indicated that improvements had been made since the last 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.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders told us they had reviewed and addressed the findings of our January 2024 inspection in relation to a failure to ensure details of complaints and significant events, and the associated learning, was shared with the wider team. Following the inspection in January 2024 leaders told us they had initiated a meeting structure which included a monthly clinical and staff meeting. A standing agenda had been implemented which included incidents and complaints.

We saw that there was an incident and a complaints policy in place, which were accessible to staff. The practice demonstrated that systems and processes were in place to manage these. The practice provided a selection of meeting minutes undertaken since our last inspection. We saw evidence that complaints and incidents had been discussed. We saw that staff had access to minutes of meetings.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

Leaders told us they had reviewed and addressed the findings of our January 2024 inspection in relation to a failure to ensure that risk assessments were in place to support decisions about which medicines should be available at the practice for emergency use. At this assessment we saw that the practice had undertaken a formal documented risk assessment for both locations outlining the range of medicines held. Where the practice had made a decision not to hold certain medicines there was a formal rationale in place, in line with guidance.

The practice had a Primary Care Emergency Drug Policy and a Resuscitation Policy in place. We saw that the Resuscitation Policy lacked detail. We discussed with the practice consolidating their policies to form one comprehensive policy which included all aspects of medical emergency management at the practice. We reviewed processes around the management of emergency medicines and saw there was a system in place to monitor stock levels and expiry dates of emergency medicines. We observed that the practice was equipped to respond to medical emergencies (including suspected sepsis) and staff training had been provided in emergency procedures.

Leaders told us they had reviewed and addressed the findings of our January 2024 inspection in relation to a failure to ensure that the premises used by the service were both safe to use for their intended purpose and were used in a safe way. In particular, ensuring appropriate premises risk assessments had been undertaken and required action taken, and designated fire marshals has been trained for their role. The practice told us that a Legionella and health risk assessment had now been undertaken at the branch site, which had not been in place at our previous inspection. In addition, a fire risk assessment had been undertaken of both premises and staff who had been nominated as a fire marshal had undertaken face to face training by an external trainer in March 2024.

At our on site assessment on 4 June 2024, we made general observations around the practice in relation to health and safety, Legionella and fire safety. We saw records for fire alarm testing and evacuation drills, and water sample and temperature testing records. We reviewed documentation held by the practice which gave an overview of facilities management responsibilities between the practice and the landlord. The practice told us they were in process of clarifying with the landlord individual responsibilities for premises management to ensure all aspects were covered. We reviewed training records and saw that the practice had included health and safety and moving and handling training as part of their mandatory training schedule which had not been present at our last inspection.

The practice had engaged an external contractor to undertake a Legionella risk assessment at the branch site in April 2024, which included an action plan. The practice had not commenced the recommended remedial actions at the time of our assessment. However, immediately after the inspection the practice sent evidence that they had engaged an external contractor to complete the remedial actions. We will review these outcomes at our next assessment. The practice had undertaken their own health and safety risk assessment for branch site. The risk assessment was combined with the main surgery risk assessment. As the risk assessment was not site specific it was not possible to determine if all hazards had been identified and risks assessed with regards the layout and activities undertaken at each premises. The practice had undertaken their own fire risk assessment at the branch site in May 2024. We noted that the premises did not have an installed fire detection and warning system and used smoke alarms to alert to a fire. We saw these were checked regularly. The fire risk assessment did not clearly assess and document whether these arrangements were adequate for the premises. We discussed with practice if the nominated responsible person for fire and health and safety had the appropriate competence and training to undertake these nominated roles. The practice told us they were considering engaging an outside contractor to undertake a health and safety and fire risk assessments to ensure compliance. We will review these outcomes at our next assessment.

Leaders told us they had reviewed and addressed the findings of our January 2024 inspection in relation to a failure to ensure that safe recruitment checks were in place and staff training was up to date and included all appropriate mandatory training. Leaders told us they had reviewed their recruitment systems and processes and developed a check list to ensure appropriate documentation was in place for staff prior to their commencement. In addition, the practice had identified mandatory training by role, which included the appropriate level for clinical and non-clinical staff and the frequency of updates. The practice told us they used a training tracking system to ensure staff had undertaken training and alert them to when update training was required.

We reviewed the recruitment files of 2 staff members who had commenced since our last inspection in January 2024. We found that references and Disclosure and Barring Service (DBS) checks had been obtained prior to commencement. The practice could also demonstrate that a CV, interview summary, signed contract and proof of identity was in place in line with guidance. We saw there was a recruitment policy in place. However, this did not include the recruitment check list. We discussed with the practice reviewing their policy to ensure it accurately reflected their new recruitment processes. We saw the practice had now undertaken a DBS check on all their existing staff to a level relevant to their role. We reviewed the practice’s Staff Development Policy which outlined all training modules the practice had selected as mandatory. This now included sepsis awareness and mental capacity act training, which had not been present at our previous inspection. We reviewed staff training records and found 85% of staff had now completed sepsis awareness training and all GPs had undertaken mental capacity act and deprivation of liberty standards (DoLS) training. The practice was aware that there were some gaps in staff training and were prioritising this.

Leaders told us they had reviewed and addressed the findings of our January 2024 inspection in relation to a failure to ensure that appropriate infection prevention and control (IPC) measures were in place. In particular, a formally documented IPC lead, IPC policies, IPC audits of both locations and a record of staff vaccination in line with guidance. At this assessment we found an IPC Policy in place which included the IPC lead. We met with the IPC lead at our on site assessment who told us they were booked on an external IPC training course in November 2024 to support them in their role. The IPC lead told us they had dedicated time to undertake this role. The practice had undertaken IPC audits at both locations. The practice had been working with existing staff and occupational health services to ensure they maintained an up-to-date record of staff vaccinations. However, we saw there were some gaps in their records. The practice was aware of this and continued to work towards compliance. We will review these outcomes at our next assessment.

At our on site assessment on 4 June 2024, we found appropriate standards of cleanliness and hygiene were met. The practice was visibly clean and tidy. We found posters around the practice including sharps injury, handwashing and clinical waste to support good practice. We saw a poster on the staff noticeboard with details of the infection prevention and control (IPC) lead.

An infection prevention and control (IPC) audit had been undertaken at Manson Surgery in March 2024 and Scholes Surgery in April 2024. We saw that the practice had acted upon the majority of actions identified in the IPC audits. However, we noted that there were some outstanding actions for Scholes Surgery regarding cleaning provision but there was no timeline for completion. The practice told us they were addressing these actions. We will review these outcomes at our next assessment.

Leaders told us they had reviewed and addressed the findings of our January 2024 inspection in relation to a failure to ensure the proper and safe management of medicines and equipment at the practice. In particular, at our last inspection we found some expired equipment stocked at both sites and there was no oxygen warning sign displayed where oxygen was stored. The practice told us they had implemented a check list system to monitor stock levels and expiry dates of emergency equipment and medicines, which were checked on a weekly basis.

At our on site assessment on 4 June 2024, we reviewed all emergency medicines and a random selection of medical consumables used by the practice and found no expired stock. We saw there was an oxygen warning sign on the door where oxygen was located.

We reviewed processes around the management of emergency medicines and saw there was a system in place to monitor stock levels and expiry dates of emergency medicines and equipment.