This practice is rated as Good overall. (Previous inspection January 2015– Good)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Marine Lake Medical Practice on 1 May 2018 as part of our inspection programme.

At this inspection we found:

• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There were systems in place to mitigate safety risks including health and safety, infection control and dealing with safeguarding.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The practice sought patient views about improvements that could be made to the service; including having an active patient participation group (PPG) and acted, where possible, on feedback.
• Staff worked well together as a team, knew their patients well and all felt supported to carry out their roles.
• There was a focus on learning and improvement at all levels of the organisation. However the staff training matrix did not easily demonstrate required training achieved and could not be easily monitored
• The provider was aware of the requirements of the duty of candour.

The areas where the provider should make improvements are:

• Review the implementation of the safeguarding policies so that staff are aware of the up to date policies, procedures and guidance contained within them.
• Review the staff training plan and matrix, to reflect required training and development needs and to ensure training is monitored so that all staff are appropriately trained and up to date.
• Review and risk assess the system for the storage of paper patient records.
• Review audits to include an annual programme/plan of audits based on local, national and service priorities
• Review the storage of clinical waste bins to ensure they are secured.
• Review the control and management of policy documents in order to ensure all policies and procedures are kept up to date.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Letter from the Chief Inspector of General Practice

This is the report of findings from our inspection of Marine Lake Medical Practice. The practice is registered with the Care Quality Commission (CQC) to provide primary care services. We undertook a planned, comprehensive inspection on 7 January 2015 and we spoke with patients, relatives, staff and the practice management team.

The practice was rated as Good.

Our key findings were as follows:

• Staff understood and met their responsibilities to raise concerns and report incidents, risks and near misses. Lessons were learned and communicated widely to support improvement. There were enough staff to keep people safe.

• Patient’s needs were assessed and care was planned and delivered in line with current legislation. Staff received training appropriate to their roles and further training needs have been identified and planned.
• Patients were treated with compassion, dignity and respect and they were involved in care and treatment decisions.
• The practice reviewed the needs of their local population, the practice were responsive to patients’ needs and wishes.
• The practice had clear leadership, staff felt supported by management. There were systems in place to monitor and improve quality and identify risk. This included good engagement with patients.

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

The provider should:

• Ensure action plans are drawn up for patient safety incidents and patient complaints so that closer monitoring can take place at each risk management meeting.
• Ensure that all patient complaints are responded to within an acceptable timescale.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice