Marlowe Park Medical Centre

We carried out an announced comprehensive inspection at Marlowe Park Medical Centre on 2 November 2021 under Section 60 of the Health and Social Care Act 2008, as part of our regulatory functions. The inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014. The overall rating for the practice was Good.

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 in line with all data protection and information governance requirements.

This included:

• Conducting staff interviews using the telephone / video conferencing.
• Requesting evidence from the provider.
• A short site visit.

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.

Our findings:

This practice is rated as Good overall.

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Requires Improvement

Are services caring? - Good

Are services responsive? – Good

Are services well-led? – Good

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

• The practice’s systems, practices and processes helped to keep people safe and safeguarded from abuse.
• There were systems and processes to help maintain appropriate standards of cleanliness and hygiene.
• Risks to patients, staff and visitors were assessment, monitored and managed.

We rated the practice as Requires Improvement for providing effective services because:

• Patients’ needs were assessed, but care and treatment were not always delivered in line with current legislation, standards and evidence-based guidance.
• The practice had a programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided. The pandemic had had a detrimental effect on the practice’s ability to deliver some care as well as treatment. However, improvements were required for some types of patient reviews as well as some subsequent follow up activities.

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

• Staff treated patients with kindness, respect and compassion.
• Staff helped patients to be involved in decisions about care and treatment.
• The practice respected patients’ privacy and dignity.

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

• The practice organised and delivered services to help meet patients’ needs.
• People were able to access care and treatment in a timely way.
• Complaints were listened to and used to improve the quality of care.

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

• There was compassionate and inclusive leadership at all levels.
• There were processes and systems to support good governance and management.
• The provider had systems to continue to deliver services, respond to risk and meet patients’ needs during the pandemic.
• The practice involved the public, staff and external partners to help ensure they delivered high-quality and sustainable care.
• There were systems and processes for learning, continuous improvement and innovation.

The areas where the provider must make improvements are:

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

The areas where the provider should make improvements are:

• Continue with plans for staff to attend the practical elements of basic life support training when they become available.
• Continue with plans to replace patient group directions (PGDs) that are out of date with updated versions once they become available from Public Health Screening.
• Revise management of safety alerts to ensure that all historic alerts are included.
• Revise documentation of complaints management to ensure that acknowledgement of complaints and outcome replies to complainants are recorded.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Please refer to the detailed report and the evidence tables for further information.