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Archived: Marston Surgery Good

The provider of this service changed - see old profile

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Inspection Summary

Overall summary & rating


Updated 22 February 2019

We carried out an announced comprehensive inspection at Marston Surgery on 3 July 2018. The overall rating for the practice was good with requires improvement for providing safe services.

From the inspection in July 2018 the practice was told they must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition, the practice was told they should:

  • Demonstrate the impact of the changes made following implementation of improvements to the issues highlighted in the July 2017 annual national GP patient survey and in the new GP patient survey published 9 August 2018.
  • Make efforts to improve the uptake of cervical screening so the 80% coverage target for the national screening programme is achieved.
  • Continue to identify patients who are carers and improve facilities and services available for this client group.

The full comprehensive report on the July 2018 inspection can be found by selecting the ‘all reports’ link for Marsden on our website at

This inspection was an announced focused inspection carried out on 6 February 2019, to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 3 July 2019. This report covers our findings in relation to those improvements made since our last inspection.

Our judgement of the quality of care at this service is based 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.

The practice is rated as good overall and good for all the population groups.

We found that:

  • Infection prevention and control measures had improved. Staff had appropriate immunisation checks which were monitored by the practice. Clinical rooms had appropriate washable floors throughout.
  • The practice had increased the uptake for national screening programmes with the use of health promotion activity. The practice had identified a large percentage of its patient population were university residents that were only registered for one year. It had also identified that delays in the national screening programme administration system caused narrow timeframes to identify and see patients who were due for screening. The practice used the national screening programme prior notification lists to identify patients and invite them for screening using their own systems. This has increased the rate of patients receiving cervical screening to 79% which was in line with local and national averages.
  • The practice had continued with efforts to support carers. The practice had identified 0.3% of their practice population as carers. The practice included questions relating to caring in their registration forms and used the practice website to promote carer support. The practice had reviewed the registered carers list and had completed 24 face-to-face carers assessments. Appropriate support and referral was offered.
  • The practice was aware of the lower than average patient satisfaction scores from the GP patient survey regarding appointment availability and ease of making an appointment. They had worked with the patient participation group and improved their website to include an online booking facility to improve accessibility. The practice had also employed a workflow team to manage any online queries and messages. It was envisaged this would improve patient satisfaction over time.
  • The practice had recently agreed a contract for a new telephone system that would be implemented in the weeks following our inspection. This would include facilities for messaging, queuing and internal calling and the practice advised they expected marked improvements to patient satisfaction as a result.
  • The practice had increased their multi-disciplinary workforce to include physician’s assistants, physiotherapists, pharmacy technicians and advanced nurse practitioners. This had increased appointment capacity. Receptionists were trained to signpost patients to the most appropriate clinician. A patient survey was due to be undertaken in June 2019 to assess the impact of these changes.

There were areas where the provider should make improvements are:

  • Continue to monitor patient satisfaction scores around access to the service and embed initiatives to improve this.
  • Continue to proactively identify and support carers.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP Chief Inspector of General Practice

Inspection areas










Checks on specific services

People with long term conditions


Families, children and young people


Older people


Working age people (including those recently retired and students)


People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable