Marine Medical Group

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

The practice had a system in place to ensure patients were routinely invited for their annual NHS health checks. During these reviews, staff assessed individuals’ health, care, and wellbeing needs, and clinical staff used structured templates to support a comprehensive review of wider health and wellbeing. When patients did not respond to review invitations after several requests, their record was coded. This informed staff a review was due should the patient attend the practice for another matter. If not, patients were reinvited the following year for this preventative health check.

Feedback from people using the service was positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs.

Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. The provider had effective systems to identify people with previously undiagnosed conditions. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

Reception staff were aware of the needs of the local community. They used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present.

The practice generally delivered care and treatment in line with legislation and evidence-based guidance, though some areas required improvement.

For example, the clinical searches identified some patients prescribed medication primarily used to treat type 2 diabetes had not received all of the recommended monitoring as advised by the Medicines and Healthcare products Regulatory Agency (MHRA).

However, the service planned and delivered people’s care and treatment with them, including what was important and mattered to them.

The majority of feedback from people using the service was very positive, including the National GP Patient Survey where results were mostly above the national average. In other feedback from NHS Friends and Family Test patients said they felt involved in the assessment of their needs and staff understood their individual and cultural needs.

The practice provided us with a range of audits they had undertaken to enhance care. These included annual cyclical audits, which help staff review and improve how certain treatments and health checks were managed, as well as ongoing audits focused on the safe monitoring of medicines that carry higher risks.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. The practice had employed a new role of General Practice Assistant who linked in with a variety of external agencies to ensure information was appropriately shared. There were regular multi-disciplinary team meetings at the practice which included community staff such as district nurses, health visitors, midwives and palliative care nurses.

We spoke with the nursing homes aligned to the practice, who reported good levels of support from practice staff for their own team, patients, and families.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff focussed on identifying risks to patients’ health, including those in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity. They were able to refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The practice employed two social prescribers who worked exclusively with the Marine Medical Group, although their posts were funded by the Primary Care Network, which included this practice and one other. The social prescribers had set up regular sessions in local community hubs to engage with patients outside the surgery. A range of weekly groups and activities were available, also attended by professionals such as mental health practitioners and representatives from the Department for Work and Pensions, offering on‑the‑spot support and advice.

We observed that large community events were organised, including ‘Step into Spring’ and ‘Winter Wellness’ in 2025 and the forthcoming ‘Spring into Summer’ in March 2026. The two 2025 events were attended by more than 100 people at each. The events, supported by various partner organisations, offered practical help for families and promoted a range of health topics to improve awareness. The social prescribers were also actively involved in encouraging and supporting patients to take part in a variety of health screening programmes, including breast, bowel and cervical screening. Their work included contacting patients who had not attended, helping to identify and remove any barriers, and encouraging them to take up their screening invitation.

On Christmas Day 2025, the social prescribers organised a community Christmas dinner for 51 people in Blyth. Local funding supported the event and also provided gifts for all attendees. Using the remaining funds, they arranged an additional outing for 72 people to attend a pantomime at the local theatre.

Staff were proud to be an Armed Forces accredited practice and to provide dedicated support to serving personnel and veterans.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The practice met national targets for screening and immunisations, except for cervical screening test data for women aged 25 to 49 years and 50 to 64 years, with their respective intervals of 3.5 and 5.5 years, which fell slightly below the expected 80% target at 75.8% and 75.6%.

From the clinical notes we reviewed, we found that most people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.

We saw there were 129 patients currently with a learning disability registered with the practice. Staff had completed 108 annual learning disability reviews which was 84% of all patients, 15 had appointments booked and the remaining 6 were being contacted regularly to encourage reviews to be completed. For the last 2 years, a designated administrator has been responsible for coordinating appointments with patients or their carers. This approach has led to improved outcomes, as the administrator has developed an understanding of individual needs and the necessary adjustments to encourage attendance.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.

The practice had a chaperone policy in place and patients were offered a chaperone when carrying out examinations. Staff who carried out chaperone duties were trained for the role and had received a Disclosure and Barring Service (DBS) check.