Manor Park Medical Practice

On this page

• 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

During our assessment of this key question, staff provided evidence of keeping track of policies and procedures and had regular staff meetings. However, outstanding summarising notes remain a concern as there are around 5,000 notes yet to be summarised.

This service scored 62 (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.

Staff knew to access practice policies and procedures on their online system. There were named leads in place for key areas such as complaints and staff were clear about their roles and responsibilities. There was sufficient clinical capacity to support demand, particularly as there was always an on-call GP on hand. Staff also told us they were involved with PCN initiatives such as enhanced access services, addressing health inequalities work and the implementation of cardiorespiratory diagnostics in primary care. The practice also participated in hypertension and diabetes research projects and hoped to become a research hub in the next five years. The practice has been accepted to participate in the Modern General Practice scheme, meaning staff will have access to training to help improve care navigation and to support patients in using the NHS app. However, when the provider took over the contract in January 2022, they inherited around 5,000 patient notes that needed summarising. Although, the practice employed a dedicated coder to summarise the notes of any newly registered patients within two weeks of receiving the hard copy notes, there remained around 5,000 notes that need summarising from prior to January 2022. Although the practice ran searches and prioritised the known high risk patients such as those on the safeguarding register or patients identified with long- term conditions, there was a risk that where a patient's notes were not summarised, key care and treatment information could be missing or not available to staff, impacting patients care. Following our assessment, we requested an action plan from the provider that outlined how they planned on addressing these concerns. The provider has been unable to share an action plan with us and therefore, the risk remains. This is ineffective governance as it still leaves patients at risk of slipping through the net.

Although the practice had a summarising policy, this was not always adhered to and as a result, around 5,000 notes remain not summarised. During the onsite inspection, the provider showed evidence of a spreadsheet to keep track of when documents were due for review. Practice policies and procedures were available to staff on team net and notified of any updates during meetings. Clinical meetings were held every two weeks whereby all clinical staff and management were invited, discussing the following topics: deaths, significant event analysis, complaints, and safeguarding concerns. During the operational meetings, patient participation group feedback was also discussed leading to improvements and a smoother patient journey. The practice had a three-tier governance system. First, the staff member would perform the required checks, secondly, the practice manager checks that these tasks have been completed correctly and finally the GP partners check that governance arrangements are being followed every 2 to 3 months. There was always a GP partner on site to manage risk, supervise staff and take any actions needed. Regular clinical and staff meetings were held which clinical concerns, emerging risks, improvements and learning were discussed. There was also evidence of quality assurance activity and clinical auditing to make improvements.

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.