Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at 9.00am on 26 March 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing safe, effective, caring, and responsive services and for being well-led. We found the practice to be good for providing services for the population groups of older people, people with long-term conditions, families, children and young people, working age people (including those recently retired and students), people whose circumstances may make them vulnerable

and

people experiencing poor mental health (including people with dementia).

Our key findings across all the areas we inspected were as follows:

Systems were in place to manage risk and there was a rota in place to ensure there were sufficient staff to keep patients safe. Arrangements were in place to ensure staff absences were covered.

Patient’s needs were assessed and care planned and delivered in line with current legislation.

Patients were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.

There was good continuity of care and patients found it easy to make an appointment.

Patient feedback from the Friends and Family Test (FFT), comment cards received and patients we spoke with on the day of our inspection was consistently positive about the service received.

There was a clear leadership structure in place and staff were supported in their roles.

There were areas of practice where the provider needs to make improvements. 

The provider should:

Carry out a legionella risk assessment.

Provide staff with access to and training in the use of an automated external defibrillator (used to attempt to restart a person’s heart in an emergency) in accordance with the Resuscitation Council (UK) recommendations for primary care.

Ensure all practice policies and procedures are reviewed and updated annually.

Ensure practice meetings are formalised and minuted with actions.

Ensure annual appraisals are completed for non-clinical staff.

Introduce a whistleblowing policy.

Formalise a vision and strategy and share with staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Colin Marks on the 25 April and 16 May 2018. At this inspection we rated the practice as good overall and for the key questions of safe, caring, responsive and well-led with the exception of effective which we rated requires improvement. The full comprehensive report on the inspection can be found by selecting the ‘all reports’ link for Dr Colin Marks on our website at www.cqc.org.uk.

We carried out an announced focused inspection at Dr Colin Marks on the 5 December 2018. This inspection was carried out to review the actions taken by the practice and to confirm whether the practice was providing an effective service and was now meeting legal requirements.

The overall rating for the service is Good.

The key question was rated as:

Are services effective? - Good

At this inspection, we found:

• The provider had purchased a training package for non-clinical staff and introduced a monitoring system to ensure non-clinical staff completed the necessary training for their roles. The provider had set dates for staff to complete the training package by the 20 January 2019. Staff had protected time to complete their training.
• The provider had completed the non-clinical staff appraisals, this included reviewing their educational development.
• The practice had a small team and information was shared regularly between the team. In addition, the provider had introduced quarterly practice meetings. Meetings had occurred in July and October 2018.
• The provider had put in place a system to monitor the management of safety alerts.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

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