- GP practice
St Mark's Medical Centre
All Inspections
9 January 2023
During a routine inspection
We carried out an announced remote inspection of St Mark’s Medical Centre on 9 January 2023. The practice is rated as inspected not rated overall and for all of the domains.
On the day of the planned inspection, CQC announced that some previously planned inspections would be paused following measures announced by the Secretary of State to address winter pressures in health and care services.
We previously carried out an announced inspection at St Mark’s Medical Centre on 7 March 2019. Overall, the practice was rated good.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for St Mark’s Medical Centre on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was carried out on 9 January 2023 due to emerging risk from concerns raised with the CQC. In response to the winter pressures in the NHS the inspection site visit was cancelled before the date it was due to take place to support the provider to use their resources and time in the most productive way for people, therefore the ratings from the previous inspection in March 2019 have not been changed. This was an unrated inspection because we were unable to corroborate the evidence provided to us during the remote part of the inspection as we did not undertake a site visit. We looked at specific information in the some of the following key questions:
- Safe
- Effective
- Caring
- Responsive
- Well led
How we carried out the inspection
We collected information in a variety of ways.
This included:
- Conducting staff interviews using video conferencing.
- Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider.
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 found that:
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- Patients could access care and treatment in a timely way.
- The practice understood it’s patient population and adjusted how it delivered services to meet the needs of it’s patients.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
The provider should:
- Improve the uptake of cervical cancer screening and childhood immunisations.
- Document discussions with patients as part of medication reviews.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services
7 March 2019
During a routine inspection
We carried out an announced comprehensive inspection at St Marks Medical Centre on 7 March 2019 as part of our inspection programme.
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 and for all population groups.
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.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
Whilst we found no breaches of regulations, the provider should:
- Introduce a formalised system for the review of consultations and prescribing for non-medical prescribers.
- Increase the number of carers identified to ensure these patients are offered appropriate advice and support.
We saw areas of outstanding practice:
- The provider had introduced innovative IT systems for communication, task management, monitoring of care and treatment processes and monitoring effectiveness of care delivery through reports and audits. This led to improvements such as better communication, team problem solving, and the effective management of alerts and changes in guidance.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
14 July 2015
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Dr Hedley and Partners (St Marks Medical Centre) on 14 July 2015. Overall the practice is rated as good.
Specifically, we found the practice to be good for providing effective, caring and responsive and well led services. It was also good for providing services to meet the needs of all population groups of patients. It required improvement for providing safe services.
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 those relating to recruitment checks, infection control monitoring and building maintenance.
- Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff training was not monitored effectively and there was no system in place to identify when training needed to be updated.
- 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 and easy to understand.
- Patients said they found it easy to make an appointment and that 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.
- 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:
- Take action to ensure its recruitment policy, procedures and arrangements are consistently applied to ensure necessary employment checks are in place for all staff and the required information in respect of workers is held.
- Take action to put in place monitoring and audit systems to ensure infection control practices are safe and effective. To minimise the risk of cross contamination and spread of infection including those that are health care associated.
The provider should:
- Take action to monitor the work load of the administration staff to ensure tasks such as non-urgent referrals to secondary care are sent in a timely manner.
- Take action to ensure that staff training needs and completed training are clearly recorded on a system that indicates the dates training is to be provided or is due.
- Take action to ensure reception and administration receive an update to their safeguarding training.
- Take action to ensure the practice management team receive an annual appraisal to support the practice to continue to develop and improve services for patients.
Professor Steve Field CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice