Marden Medical Practice

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 comprehensive inspection in October 2014 we rated this key question as good. At the focused inspection in October 2019 we assessed this key question and continued to rate this question as good. At this comprehensive assessment, the rating remains the same.

This service scored 67 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them. There was a range of established referral pathways to ensure patients' needs were appropriately addressed in a timely and coordinated manner to include community services and secondary care providers. Patients were advised of the NHS Right to Choose (RTC) option for their preferred healthcare provider for their outpatient appointment referrals.

Visible markers were used within the clinical care records system to highlight any specific individual needs or those requiring additional support and team meetings provided an opportunity to discuss these patients. The provider had systems to identify people with previously undiagnosed conditions such as diabetes. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber via the Primary Care Network. The practice told us they also encouraged self-referrals and valued input from carers and family members, ensuring a holistic approach to identifying those in need of extra support.

Feedback from people using the service was mainly positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. The practice told us they identified patients who may need extra support through a combination of proactive measures and ongoing patient engagement. This included undertaking regular reviews of areas including their vulnerable patient register, clinical records, utilising patient alerts within the clinical system, monitoring for indicators such as frequent hospital admissions, long-term condition management challenges, or social and mental health concerns.

The practice planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards. Clinical records we saw demonstrated care was mainly provided in line with current guidance.

The practice had systems in place to ensure staff were up to date with evidence-based guidance and legislation. Regular clinical meetings were held where new guidance was discussed and monitored. The practice told us that opportunities for shared learning was provided through monthly educational meetings. These provided opportunities for a clinician to present either a recent change in guidance, an interesting case, or a quality improvement project to the clinical team. The practice also offered designated study leave days for clinicians to attend relevant courses, conferences, or training updates, ensuring they continue to deliver safe, high-quality, evidence-based care. Each GP was allocated a regular session for personal development and supported them with keeping ahead of any clinical changes and advances in general practice.

The remote clinical searches we undertook included reviewing the monitoring of patients with long-term conditions to assess if National Institute for Health and Care Excellence (NICE) recommendations were followed. We found these patients were generally well managed with processes in place to follow up patients who failed to attend for their blood monitoring. Overall we found most patients whose clinical records we sampled were receiving appropriate treatment, monitoring and review.

The practice worked well across teams and services to support people. 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 and regular multi-disciplinary team meetings were held. Patients had access to services provided by the primary care network (PCN), including social prescribers and extended access appointments.

The practice told us they were committed to supporting patients beyond clinical care by providing access to advocacy and support services. They told us they assisted patients connect with local and national NHS, local authority and voluntary organisations that offered guidance on a wide range of issues, including mental health, domestic abuse, housing, financial difficulties, and carers’ support. Staff listened and signposted patients to appropriate services.

The practice supported people to manage their health and wellbeing to maximise their independence, choice and control. They supported people to live healthier lives and where possible, reduce their future needs for care and support. The practice offered NHS health checks to patients aged 40–74 in combination with their Primary Care Network (PCN) who supported them with the checks.

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. The practice signposted patients to the ‘Healthy Lives Smoking Cessation’ service for support in quitting smoking. They told us they also carried out proactive searches to identify patients who may benefit from referral to the National Diabetes Prevention Programme, the Diabetes Remission Programme and the NHS Digital Weight Management Programme. The practice website contained information about a range of health conditions, including their symptoms and how they are treated.

The practice empowered patients to take control of their health. When visiting the practice patients were able to use a Patient Observation Device (POD) for self-monitoring of height, weight and blood pressure. Patients were also able to access a range of support offered through roles within the PCN including a mental health practitioner, physiotherapist, clinical pharmacist and social prescribers. The social prescriber helped signpost patients to local exercise and wellbeing groups, such as STIC (Strength Through Inclusion and Community). In addition patients struggling with sleep issues could be referred to a Sleep Group available through the PCN.

The practice monitored people’s care and treatment to improve it. Leaders told us staff contributed to feedback and ideas about monitoring and improving outcomes through regular practice and clinical meetings, where quality of care, patient safety, and service improvements were key discussion points. These meetings provided an open forum for clinicians and non-clinical staff to share observations, suggest new approaches, and review data from audits or quality improvement projects. A range of clinical and non-clinical audits were undertaken, which demonstrated improvement.

The practice had exceeded the 95% target in 2 of the 5 childhood immunisation indicators and had met the 90% minimum target in 3 indicators. The practice had arrangements in place to follow up immunisation appointments when a child was not brought, or the appointment cancelled and not rebooked. The practice told us all parents of children who were not up to date with vaccinations had been contacted and a clinical discussion had taken place. Unverified data supplied after our site visit showed an increase in uptake levels.

The most recently published data showed the practice cervical screening uptake for their eligible population aged 25 to 49 years old within the last 3.5 years was 77.3%. The uptake for their eligible population aged 50 to 64 years old within the last 5.5 years was 78.6%. The national target is 80% for both indicators. The practice demonstrated they were putting in place appropriate measures to improve uptake. They had recently trained an additional member of the nursing team to provide cervical screening, increasing both capacity and accessibility for patients. Unverified data supplied by the practice following our site visit showed an increase in uptake.

The practice had 76 patients with a learning disability. Of these 7 had received a health check since April 2025. The practice told us they had a well-established approach of delivering the majority of these checks in the second half of the year. This scheduling allowed them to allocate appropriate clinical time and resources to ensure that each patient received a high-quality, personalised health check with any necessary reasonable adjustments in place. The practice advised us they had consistently exceeded national targets for health checks and had recently started to implement a birthday recall system for this group of patients whilst still being flexible and accommodating reasonable adjustments.

Staff were able to share examples in relation to assessing capacity and obtaining consent and had received training for Mental Capacity and Deprivation of Liberty safeguards. The practice clinical system identified 160 live patients as having a ‘do not attempt cardiopulmonary resuscitation decision’. Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms were used. These forms are generally used for people with complex health needs and completed with the individual, family if desired and healthcare professionals about their care in the event of an emergency, retained by the person and scanned onto their clinical records. We sampled 5 patient records and found ReSPECT forms were available on all of the patient records. Two patients were considered as not having capacity to consent. However, there was no record of a completed mental capacity assessment being undertaken.

Where appropriate, patients were offered a chaperone for care and treatment with staff who had received training. Chaperone posters were displayed to inform patients of this service.