We carried out a review of the data available to us about Pimlico Health @ The Marven on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Pimlico Health @ The Marven, you can give feedback on this service.
We carried out a focused review of Pimlico Health @ The Marven on 20 December 2022. Overall, the practice is rated as Good.
Safe - not inspected, rating of good carried forward from the previous inspection.
Effective - Good
Caring - not inspected, rating of good carried forward from the previous inspection.
Responsive - not inspected, rating of good carried forward from the previous inspection.
Well-led - not inspected, rating of good carried forward from the previous inspection.
Following our previous inspection on 3 December 2019, the practice was rated good overall and for the key questions safe, caring, responsive and well-led and for four of the population groups (Older people; people with long-term conditions; people whose circumstances may make them vulnerable; and people experiencing poor mental health). The practice was rated requires improvement for providing effective services and for the working age people population group, and the families, children and young people population group.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Pimlico Health @ The Marven on our website at www.cqc.org.uk.
Why we carried out this review
We carried out this focused review to follow up ‘shoulds’ identified in the previous inspection. They were:
How we carried out the review
This review was carried out by requesting evidence from the provider and without visiting the location.
Our findings
We based our judgement of the quality of care at this service on a combination of:
We found that:
Whilst we found no breaches of regulations, the provider should:
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services
We carried out an announced comprehensive inspection at Pimlico Health @The Marven on 3 December 2019 as part of our inspection programme.
We based our judgement of the quality of care at this service is on a combination of:
We have rated this practice as good overall and good for population groups older people, long term conditions, vulnerable and mental health. However, we have rated them requires improvement for families and children and working age due to their childhood immunisation rates and cervical smears being lower than the national target.
We found:
The areas where the provider should make improvements are:
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 Pimlico Health @ The Marven on 9 December 2015. The practice was rated requires improvement for safe, with the overall rating for the practice being good. The full comprehensive report can be found by selecting the ‘all reports’ link for Pimlico Health @ The Marven on our website at www.cqc.org.uk.
We carried out this announced follow up comprehensive inspection on 24 October 2017. Overall the practice is now rated as good in all key questions.
Our key findings across all the areas we inspected were as follows:
The areas where the provider should make improvement are:
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Pimlico Health @ The Marven on 9 December 2015. Overall the practice is rated as Good
Our key findings across all the areas we inspected were as follows:
There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
Risks to patients were assessed and well managed, with the exception of those relating to waste management, medicines and equipment.
We saw two completed clinical audits driving improvement.
The majority of patients said they were treated with compassion, dignity and respect.
Urgent appointments were usually available on the day they were requested. There were issues around waiting times and privacy at reception but the practice had taken steps to address these.
The practice had a number of policies and procedures to govern activity, but some were overdue a review and the business continuity plan was not specific to the practice.
The practice had proactively sought feedback from patients and had an active patient participation group.
We saw several areas of outstanding practice including:
The GP mental health team was part of the primary care mental health team, Primary Care Plus (PCP) which was set up by Central London CCG in Westminster in 2011 to ensure safe and supported transitions for mental health patients out of secondary care. A Safer Discharge Protocol was used to facilitate this and patients were offered an enhance level of support. The practice was the first wave of roll out of this service and would feedback to other practices and assisted in the review of this process prior to its wider launch due in April 2016. The review showed 12 of the 24 patients discharged from secondary mental health services to the practice had been reviewed in the last 12 months and we saw evidence of 12 patient records showing how this service had benefitted their ongoing mental health care.
The areas where the provider must make improvements are:
Ensure clinical waste is managed in line with current legislation and guidance.
The practice must ensure the defibrillator (used to attempt to restart a person’s heart in an emergency) is available and fit for use at all times.
Ensure sufficient medicines are available in case of emergencies.
Ensure vaccines are stored appropriately and there is an appropriate policy in place and to ensure staff are trained and aware of this policy.
Ensure signed Patient Specific Directions (PSD) are issued into each patients notes by the prescriber to cover Health Care Assistants administering vaccinations after they have received suitable training.
Ensure they have a Legionella risk assessment and policy.
In addition the provider should:
Ensure there is a practice specific business continuity plan to deal with major disruptions to the service which contains up to date contact details for staff.
Ensure that privacy is maintained at the reception desk.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
People received care that ensured their safety and welfare. They were assessed and treated by a GP or nurse practitioner who was responsible for prescribing any medication required. Diagnostic tests were carried out if necessary and appropriately followed-up. There was a daily walk in clinic so that people could be seen when they were unwell. There were systems in place to deal with medical emergencies. All staff had received basic life support training and there was emergency medication available. Staff understood and acted upon concerns about safeguarding.
There were effective recruitment and selection processes in place. However the personnel files were not audited to ensure that all the necessary checks had been undertaken prior to employment.
There were systems in place to monitor the quality of the service people received and to protect people from the risk of abuse. The provider had to carry out audits and provide evidence in order to meet the Quality and Outcomes Framework (QOF) indicators. The provider obtained feedback from patients and attended meetings with other professionals, including other GPs and health professionals in the area, to share learning and ensure best practice.