Archived: Marlborough Park Avenue Branch Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Marlborough Park Avenue Branch Surgery on 25 August 2015. Overall the practice is rated as good.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Risks to patients were assessed and well managed, with the exception of some relating to recruitment checks and infection prevention and control.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Most patients we received feedback from told us they found it easy to make an appointment
• 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 proactively sought feedback from staff and patients, which it acted on.

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

Importantly the provider must:

• Ensure recruitment arrangements include all necessary employment checks for all staff.
• Ensure appropriate infection prevention and control audits are completed of the practice premises and there are appropriate systems in place to prevent the spread of infections.

In addition, the provider should:

• Ensure information is available in the practice premises to help patients understand the complaints system.
• Ensure the patient participation group is publicised within the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice