Archived: Marks Gate Health Centre

We carried out an announced comprehensive inspection at Marks Gate Health Centre on 10 June 2019 as part of our inspection programme. At this inspection we rated the provider as requires improvement for the key questions of safe, effective and well-led. Which lead to an overall rating of requires improvement.

Breaches of regulatory requirements were found, and requirement notices were issued in relation to patient safety and good governance.

The reports of all the previous inspections can be found by selecting the ‘all reports’ link for Marks Gate Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced full comprehensive inspection undertaken on 25 September 2019.

This report covers our findings in relation to those requirements

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

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• Leaders and staff could demonstrate the capacity and skills to deliver quality, sustainable care
• Risk assessments relating to the safety of patients and staff had been conducted.

We rated the practice as requires improvement for providing effective services because:

• High levels of exception reporting of patients with some long-term conditions demonstrated a risk to effective patient care. Strategy introduced to tackle this issue had not been in place long enough to show improvement.

These areas affected all population groups so we rated all population groups as requires improvement.

The areas where the provider must make improvement are:

• 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:

• A documented strategy to allow measurement of practice progress against strategy.
• Consider revision of current timescale for review of practice policies and procedures.

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

We carried out an announced comprehensive inspection at Marks Gate Health Centre on 10 June 2019 as part of our inspection programme.

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 requires improvement overall.

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

• The practice did not have clear systems and processes to keep patients safe in the case of an emergency.
• There was limited monitoring of safety systems and records, specifically risk assessments for fire and infection control.

We rated the practice as requires improvement for providing effective services because:

• High levels of exception reporting of patients with some long-term conditions demonstrated a risk to effective patient care.
• Not all staff had undergone an annual appraisal.

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

• Leaders did not always demonstrate the capacity and skills to deliver high quality, sustainable care.
• While the practice had some vision, that vision was not clearly communicated with all staff and was not supported by a credible strategy.
• The overall governance arrangements were ineffective.
• The practice did not have clear and effective processes for managing risks, issues and performance.
• We saw little evidence of systems and processes for learning, continuous improvement and innovation.

These areas affected all population groups so we rated all population groups as requires improvement.

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

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Review awareness of safety systems and records and health and safety procedures relating to the premises.
• Review performance in childhood immunisations.
• Review arrangements for the provision of information about support groups and how to complain on the practice’s website and on display on the premises.
• Review the practice's performance in the national GP patient survey as part of quality improvement activities and overall governance.

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