Manston Surgery

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• 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

We assessed 1 quality statement in the well-led key question: Governance, management and sustainability. During the assessment we spoke with leaders, reviewed documentary evidence and made on site observations. Overall, we found improvements in relation to the review of operational policies, an effective communication system to keep staff informed and to discuss safety and quality outcomes, for example, incidents and complaints, and processes in relation to staff appraisals, supervision and training. The scores for this quality statement has been combined with scores based on the well-led key question ratings from the inspection in January 2024. Although the assessment of this quality statement indicated that improvements had been made since the inspection in January 2024, 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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

Leaders told us they had reviewed and addressed the findings of our January 2024 inspection in relation to a failure to ensure effective governance systems and processes. In particular, the review of operational policies, an effective communication system to keep staff informed and to discuss safety and quality outcomes, and processes in relation to staff appraisals, supervision and training. The practice told us that their governance structure now included (1) a regular review of policies; (2) a meeting structure which included a monthly clinical and staff meeting; (3) appraisal schedule with nominated appraisers based on clinical and non-clinical roles; (4) supervision by the duty doctor of staff employed by the primary care network; (5) mandatory training by role, which included the appropriate level for clinical and non-clinical staff and the frequency of updates.

We reviewed several policies and found they had been reviewed and included a version number, date and review date. However, we found some policies were generic and did not accurately reflect the systems and processes in place at the practice. 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 saw all staff appraisals were up-to-date apart from one staff member who was currently not at work. The practice had discussed supervision and oversight of staff employed by the primary care network. The practice confirmed that the daily duty doctor was responsible for their supervision. The practice planned to include clinical notes and prescribing audits for these staff as part of their mandatory clinical audit schedule. We saw the practice had reviewed mandatory training, which now included sepsis awareness, mental capacity act and health and safety which had not been present at our previous inspection. We saw that the practice used a training tracking system to ensure staff had undertaken training and alert them to when update training was required.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.