The Care Quality Commission
  • Doctor
  • GP practice

Archived: Dr JJC Marlborough's Practice Also known as Montague Practice

Overall: Good read more about inspection ratings

Simmons Street, Blackburn, Lancashire, BB2 1AX (01254) 617201

Provided and run by:
Dr JJC Marlborough's Practice

All Inspections

13 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

This is a focused desk top review of evidence supplied by Dr JJC Marlborough’s Practice also known as The Montague Practice for areas within the key question safe.

We found the practice to be good in providing safe services. Overall, the practice is rated as good.

The practice was inspected on 22 June 2016. The inspection was a comprehensive inspection under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (HSCA). At that inspection, the practice was rated ‘good’ overall. However, within the key question safe, areas were identified as requires improvement, as the practice was not meeting the legislation at that time; Regulation 12 safe care and treatment.

At the inspection in June 2016 we found that; comprehensive and complete pre-employment and

recruitment records were not maintained for all staff. The system for the management of emergency medicines and associated items was not effective and documentation in place to control the administration of medicines did not consistently detail required authorisations.

The practice supplied an action plan and a range of documents which demonstrated they are now meeting the requirements of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

22 June 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr JJC Marlborough’s Practice (also known as The Montague Practice) on 22 June 2016. 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 a system in place for reporting and recording significant events.
  • Risk management activity was undertaken within the practice. However, supporting documentation was not comprehensively completed and weaknesses were evident in associated systems and processes.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available. However, information related to complaints was limited in content and included potentially misleading references to external organisations and did not include reference to the Parliamentary Health Service Ombudsman.
  • Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice worked well with the clinical commissioning group medicines optimisation team to ensure prescribing was in accordance with best practice.
  • 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.
  • The provider was aware of the requirements of the duty of candour. However further action was required to ensure practice documentation supported compliance with this duty.

The areas where the provider must make improvement are:

  • Ensure risks to patients are comprehensively identified and managed. With particular regard to:

    • Pre-employment and recruitment records.

    • Management of emergency medicines, needles and syringes; and

    • Staff authorisations for the administration of medicines.

In addition the provider should:

  • Ensure adequate records of patient safety alert dissemination and associated action are created and maintained.

  • Ensure complaints policy, procedures and information made available to patients is consistent with recognised guidance and contractual obligations for GPs in England.

  • Review and amend the practice incident recording form to ensure it supports compliance with the duty of candour.
  • Clearly define the infection prevention and control lead role and responsibilities to enable the effective oversight and scrutiny of associated activity.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

17 April 2014

During an inspection looking at part of the service

During this inspection we reviewed the areas where we had found non-compliance in October 2013. We established that improvements had been made and the issues highlighted in the last report had been addressed.

We found that staff had accessed safeguarding training relevant to their role and contact with vulnerable people. Information was now available about the Mental Capacity Act 2005 to help staff understand their responsibilities with regard to this legislation. A whistleblowing policy was in place so staff were aware of how they could raise concerns about poor practice.

Disclosure and Barring Service (DBS) checks for staff had been risk assessed and were underway. A system was also in place to record and check the registration details of all clinical staff with their awarding bodies.

The practice complaints procedure was on display in the waiting area and in the practice leaflet. This was now more accessible to patients.

A patient survey had recently been conducted and there were plans to review the outcome of the survey at the next staff meeting. Risk assessments and audits had begun, these would ensure risks were identified and dealt with in a timely manner.

We did not speak to any patients during this inspection.

15 October 2013

During a routine inspection

During our inspection we spoke with five people who had attended for appointments, two GPs, the practice manager, a health care assistant and one member of reception staff.

People told us they were fully involved in discussions and decisions about their treatment and said they were listened to. People told us they could request an appointment either by dropping into the practice or by telephone.

People spoke highly of the way they were treated by staff and were happy with the treatment and support shown to them. Comments from people included, 'I've always found it brilliant here' and 'We feel like it's family here; it's such a good practice'.

The practice had policies and procedures in relation to safeguarding children and adults. However, we found improvements needed to be made to ensure people were protected when they visited the practice.

Staff told us they enjoyed working at the practice and felt supported by other members of the team. One person commented, 'I love my job. I like being in this environment'.

The provider had some systems in place for monitoring the quality of service provision. However, we found further work was needed to demonstrate compliance with this outcome.