24June 2022
During a routine inspection
We carried out an announced inspection at Dr C M Marsh and Partners (also known as Grovehurst Surgery) on 24 June 2022. Overall, the practice is rated as Good.
Safe – Requires Improvement
Effective - Good
Caring - Good
Responsive - Good
Well-led - Good
Why we carried out this inspection
This was an announced comprehensive inspection to provide the practice with an up to date rating. At our previous inspection on 18 November 2015, the practice was rated Good overall.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Dr C M Marsh and Partners on our website at www.cqc.org.uk
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 with consent from the provider and in line with all data protection and information governance requirements.
This included:
- Conducting staff interviews using video conferencing,
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider,
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider,
- A short site visit,
- Staff surveys.
Our findings
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 Requires Improvement for providing safe services.
We found that:
- Our clinical record searches found improvement was required in relation to the safe management and monitoring of high risk medicines.
We rated the practice Good for providing effective, caring, responsive and well-led services.
We found that:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- Patients received effective care and treatment that met their needs.
- Where our clinical record searches found improvement was required in relation to the safe management and monitoring of high-risk medicines and patients with long-term conditions; the practice had made improvements and had a clear, comprehensive and realistic action to address this.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
- The way the practice was led and managed promoted the delivery of person-centre care.
We found one breach of regulations. The provider must:
- Ensure care and treatment is provided in a safe way to patients.
The provider should:
- Continue with their action plan to ensure ongoing improvement in relation to; the safe management and monitoring of high-risk medicines and patients with long-term conditions
- Continue with their action plan to ensure that all historical safety alerts were being routinely reviewed to ensure that patients being newly prescribed certain medicines were highlighted in the system to ensure the guidance was applied.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.