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Pimlico Health @ The Marven Good


Inspection carried out on 3 Dec 2019

During a routine inspection

We carried out an announced comprehensive inspection at Pimlico Health @The Marven on 3 December 2019 as part of our inspection programme.

We based our judgement of the quality of care at this service is 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 good for population groups older people, long term conditions, vulnerable and mental health. However, we have rated them requires improvement for families and children and working age due to their childhood immunisation rates and cervical smears being lower than the national target.

We found:

  • 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. The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • They offered home visits and urgent appointments for those with enhanced needs and complex medical issues.
  • Staff demonstrated commitment and engagement with the vision for the service. They were proud to work for the organisation.
  • The practice promoted good health and prevention and provided patients with suitable advice and guidance. The practice had a ‘village’ meeting approach to care for their most vulnerable patients. Weekly meetings were held which were attended by a multi-disciplinary team to discuss and care plan patients with complex needs.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation. They effectively used the skills and abilities of their staff team to provide innovative and accessible care, treatment and support to their patients
  • They were a training practice and one GP trainee was based at the practice at the time of our inspection. They also provided mentorship to nurse practitioners.
  • There was a commitment and appetite to work with external partners
  • The service had comprehensive business development strategy and quality improvement plan that effectively monitored the service provided to assure safety and patient satisfaction.

The areas where the provider should make improvements are:

  • Continue to implement processes to improve the uptake of childhood immunisations.
  • Continue to implement processes to improve uptake of cervical smears.
  • Ensure the nurse completes training in relation to their role of infection prevention and control lead.
  • Continue to implement processes to identify and support carers.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection carried out on 24 October 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Pimlico Health @ The Marven on 9 December 2015. The practice was rated requires improvement for safe, with the overall rating for the practice being good. The full comprehensive report can be found by selecting the ‘all reports’ link for Pimlico Health @ The Marven on our website at

We carried out this announced follow up comprehensive inspection on 24 October 2017. Overall the practice is now rated as good in all key questions.

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.
  • The practice had clearly defined and embedded systems to minimise risks to patient safety.

  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment. .
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients we spoke with 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.
  • 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. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider should make improvement are:

  • Continue to identify and support patients with caring responsibilities so their needs can be met.
  • Review patient feedback including the results of the national GP patient survey with a view to improving the service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 9 December 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Pimlico Health @ The Marven on 9 December 2015. 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 an effective system in place for reporting and recording significant events.

  • Risks to patients were assessed and well managed, with the exception of those relating to waste management, medicines and equipment.

  • We saw two completed clinical audits driving improvement.

  • The majority of patients said they were treated with compassion, dignity and respect.

  • Urgent appointments were usually available on the day they were requested. There were issues around waiting times and privacy at reception but the practice had taken steps to address these.

  • The practice had a number of policies and procedures to govern activity, but some were overdue a review and the business continuity plan was not specific to the practice.

  • The practice had proactively sought feedback from patients and had an active patient participation group.

We saw several areas of outstanding practice including:

The GP mental health team was part of the primary care mental health team, Primary Care Plus (PCP) which was set up by Central London CCG in Westminster in 2011 to ensure safe and supported transitions for mental health patients out of secondary care. A Safer Discharge Protocol was used to facilitate this and patients were offered an enhance level of support. The practice was the first wave of roll out of this service and would feedback to other practices and assisted in the review of this process prior to its wider launch due in April 2016. The review showed 12 of the 24 patients discharged from secondary mental health services to the practice had been reviewed in the last 12 months and we saw evidence of 12 patient records showing how this service had benefitted their ongoing mental health care.

The areas where the provider must make improvements are:

  • Ensure clinical waste is managed in line with current legislation and guidance.

  • The practice must ensure the defibrillator (used to attempt to restart a person’s heart in an emergency) is available and fit for use at all times.

  • Ensure sufficient medicines are available in case of emergencies.

  • Ensure vaccines are stored appropriately and there is an appropriate policy in place and to ensure staff are trained and aware of this policy.

  • Ensure signed Patient Specific Directions (PSD) are issued into each patients notes by the prescriber to cover Health Care Assistants administering vaccinations after they have received suitable training.

  • Ensure they have a Legionella risk assessment and policy. 

In addition the provider should:

  • Ensure there is a practice specific business continuity plan to deal with major disruptions to the service which contains up to date contact details for staff.

  • Ensure that privacy is maintained at the reception desk.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection carried out on 20 September 2013

During a routine inspection

We spoke with four people and looked at the patient survey report from early 2013. People described the practice as �a little community within the local community� and were very satisfied with their care and treatment. People felt that they were given sufficient information by their GP and said they could get an appointment when they wanted one. If a person required an interpreter, this was arranged. There was a range of information on display in the waiting area and on the practice website.

People received care that ensured their safety and welfare. They were assessed and treated by a GP or nurse practitioner who was responsible for prescribing any medication required. Diagnostic tests were carried out if necessary and appropriately followed-up. There was a daily walk in clinic so that people could be seen when they were unwell. There were systems in place to deal with medical emergencies. All staff had received basic life support training and there was emergency medication available. Staff understood and acted upon concerns about safeguarding.

There were effective recruitment and selection processes in place. However the personnel files were not audited to ensure that all the necessary checks had been undertaken prior to employment.

There were systems in place to monitor the quality of the service people received and to protect people from the risk of abuse. The provider had to carry out audits and provide evidence in order to meet the Quality and Outcomes Framework (QOF) indicators. The provider obtained feedback from patients and attended meetings with other professionals, including other GPs and health professionals in the area, to share learning and ensure best practice.