The Care Quality Commission
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Archived: Marine Lake Medical Practice

Overall: Requires improvement read more about inspection ratings

The Concourse, Grange Road, West Kirby, Wirral, Merseyside, CH48 4HZ (0151) 625 9171

Provided and run by:
Marine Lake Medical Practice

Important: This service is now registered at a different address - see new profile
Important: The partners registered to provide this service have changed. See old profile
Important: The partners registered to provide this service have changed. See old profile
Important: The partners registered to provide this service have changed. See old profile

All Inspections

22 November 2022

During an inspection looking at part of the service

We carried out an announced focused inspection at Marine Lake Medical Practice on 21 and 22 November 2022. Overall, the practice is rated as requires improvement.

Safe – Requires improvement

Effective - Requires improvement

Caring - Not inspected, rating of good carried forward from previous inspection

Responsive - Partially inspected, rating of good carried forward from previous inspection

Well-led - Good

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Marine Lake Medical Practice on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities. We undertook this inspection as part of a random selection of services and due to emerging risk.

We inspected the key questions of:

Safe, Effective and Well Led. We also assessed access to GP services under the key question- Responsive.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

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.
  • A short site visit.

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:

  • The provider did not have effective systems in place for the monitoring of high-risk medicines or for documenting and acting on safety alerts.
  • Patients with long term conditions did not always receive effective management of their care and treatment.
  • There were sufficient staff who were suitably qualified and trained.
  • Patients were treated with respect and were involved in decisions about their care.
  • The practice understood its patient population and adjusted how it delivered services to meet the needs of its patients.
  • Patients could access care and treatment in a timely way.
  • The practice was led and managed effectively, leaders were accessible and supportive.
  • There was an effective governance framework in place in order to gain feedback and to assess, monitor and improve the quality of the services provided.
  • The provider was aware of the requirements of the Duty of Candour.

We found a breach of regulations. The provider must:

  • Ensure care and treatment is provided in a safe and effective way to patients.

In addition, the provider should:

  • Implement a system whereby non-medical prescribers prescribing is monitored, reviewed and assessed.
  • Improve the uptake of eligible people for cervical cancer screening.
  • Take steps to train all non-clinical staff to a minimum competency level 2 in safeguarding
  • Implement a system whereby patient test results for those receiving dual care and carried out by secondary care, were obtained and documented on the practice’s record.

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

1 May 2018

During a routine inspection

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

7 January 2015

During a routine inspection

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