Marden Medical Practice

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm.

At our comprehensive inspection in October 2014 we rated this key question as outstanding. Because of the assurance received from our review of information and our methodology at the time this rating was brought forward at the focused inspection carried out in October 2019. At this comprehensive assessment, the rating has changed to good. We found that some of those elements previously regarded as outstanding practice were now embedded throughout the majority of GP practices. Whilst the provider had maintained this good practice, the threshold to achieve an outstanding rating overall had not been reached.

This service scored 72 (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 had a proactive and positive culture of safety, based on openness and honesty. The practice had processes for staff to report incidents, near misses and safety events. Staff told us they were encouraged to raise concerns when things went wrong. They had access to a significant event policy and demonstrated a clear understanding of the process and were able to share an example of significant event that had occurred within the previous 12 months, the action taken and the learning.

During clinical meetings, the team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The practice had recorded 19 significant events within the previous 12 months. Those we sampled were detailed and actions clearly recorded. Lessons were learnt to continually identify and embed good practice.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. In the previous 12 months the practice had recorded 10 complaints. The written complaints we sampled had been investigated in line with the practice policy. A trend analysis had been undertaken and an action plan developed to address identified key themes. At the time of our site visit verbal complaints were not being recorded; however the practice had since implemented a verbal comments, complaints and compliments log to help identify any trends and themes.

The practice worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. There were systems in place for processing information relating to new patients. The practice worked with other providers to deliver shared care and when patients moved between services. Staff had access to a referrals policy and those spoken with demonstrated a clear understanding of the process. Referrals were made to consultant-led outpatient appointments using the NHS e-Referral Service (e-RS) where appropriate. We saw test results were managed in a timely way.

The practice worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that and shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and monitored these patients closely working in partnership with other organisations. Monthly child health meetings provided opportunity to discuss new patients, those on a child in need plan or on a protection plan, and the associated safeguarding concerns in addition to identifying the allocated social worker. Multi-disciplinary meetings were held with a range of professionals. Meetings facilitated tailored support plans, including coordination with social services and safeguarding actions.

Meetings were also held to discuss vulnerable patients and attended by the local hospice outreach team and the Primary Care Network (PCN) Cancer Coordinator. Meetings were recorded, and where relevant, information was shared with the local out-of-hours provider, for example patients identified at the end of their lives. The practice told us their aim was to make sure that vulnerable patients received the right level of care and attention to maintain their safety and improve their quality of life.

The practice worked with people to understand and manage risks. They provided care to meet people’s needs that was safe and supportive.

Staff could recognise a deteriorating patient and knew of action to take. Care navigators used a triage protocol to ensure patients were seen by the appropriate clinician. For example the duty GP for urgent appointments, an advanced nurse practitioner, on the day GP telephone triage or signposted to call 999 or AE depending on their presenting symptoms. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

We reviewed the arrangements in the event of a medical emergency. Staff we spoke with knew how to recognise and respond promptly to deteriorating patients. Staff received face-to-face training carried out by an external trainer on an annual basis. For those not able to attend the specific date, sessions were available for staff to attend via the Primary Care Network (PCN).

The practice held medicines in the event of a medical emergency and these were securely stored. We found some minor items of the suggested minimum and additional emergency equipment were not readily accessible, held or risk assessed, however this was immediately rectified during our site visit. There were arrangements in place to ensure medicines and equipment was checked and maintained, however these checks were not being carried out at the required frequency. The practice agreed to action this and had since sourced external advice.

The practice detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. The practice had named fire marshals and fire drills were regularly undertaken. A fire risk assessment to identify any potential risks and review fire safety control measures had been carried out by the provider in April 2025, with no issues identified.

A premises and security risk assessment was undertaken in August 2025, this concluded that the practice maintained comprehensive safety and security measures Key areas for ongoing attention were identified, with particular consideration being given to accessibility challenges posed by the building’s multi-storey layout without a passenger lift ensuring equitable patient access. There was a business continuity plan in place which was monitored and reviewed.

The practice made sure there were always enough qualified, skilled and experienced staff, who received support, supervision and development opportunities. The practice employed 37 staff and had 2 vacancies. One was for an administrator, which was an additional position to the administration team to monitor patient recalls in addition to a maintenance operative vacancy due to retirement, to support with any day-to-day premises issues.

Staff worked together well to provide safe care that met people’s individual needs. There were a range of clinical and non-clinical roles within the practice. Staff had access to training and clinical supervision policies to facilitate the effective supervision of staff.

Staff told us learning and development was discussed as part of their annual appraisals and during team meetings held. One member of staff told us how they had been supported by the practice with their career progression and was very much enjoying their new role. Another clinician had successfully trained and qualified as a General Practice Assistant (GPA), providing essential support in making urgent referrals to the care coordination centre, as well as handling referrals to social services and the safeguarding team.

All of the practice nursing team were involved in long term condition reviews and the 2 nurses responsible for carrying out diabetic reviews had completed training to equip them in their role in addition to the respiratory nurse.

We found staff were working within their agreed areas of competence. New staff received an induction to their work and probationary meetings were held, where their performance, learning and development was discussed. However, we found not all staff were up to date with their essential training. Following our visit the practice reviewed this and sent us an updated training matrix which showed 83% of staff had completed 100% of their allocated training modules. The other 17% were either on long-term sick leave, maternity leave or on the GP retainer scheme with allocated training modules to complete on a weekly basis as part of their reduced workload programme.

The practice had a detailed recruitment policy and procedure in place to ensure that only fit and proper staff were employed who are able to provide care and treatment appropriate to their role. The practice had employed 9 new staff in the previous 2 years. We sampled a selection of personnel records and found safe recruitment practices were followed with the required information readily available. Written assurances had been obtained from the Primary Care Network (PCN) for staff not directly employed by the practice in relation to recruitment, training and supervision.

The practice assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The practice had 2 designated infection, prevention and control (IPC) leads, and staff had had relevant training during their induction and then annually. The practice employed their own cleaner, cleaning schedules were in place and followed.

An IPC audit was carried out in October 2024, and an action plan developed to mitigate risks. The audit identified some required actions. For example, the seating in waiting room was upholstered but steamed cleaned on a regular basis and some elbow taps were not available in all clinical rooms. There was a plan in place to replace the seating and taps within a specific timescale. An IPC audit had also been completed for minor surgery in May 2025, which showed compliance. Areas of the practice we reviewed as part of our site visit were visibly clean. The practice published their IPC annual statement of June 2025 on their website.

The practice made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. Our remote clinical searches found 305 patients had received a medication review in the previous 3 months with reviews having been completed by a range of clinicians. Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training, and where appropriate were competency assessed on medicines optimisation. Staff felt confident managing the storage, administration and recording of medicines.

Prescription stationery was managed appropriately and securely. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Staff checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Waste medicines were recorded and disposed of appropriately. Staff stored medical gases, such as oxygen, safely. The provider had systems to manage and respond to safety alerts and medicine recalls and maintained a log of alerts and actioned taken, which included discussion at clinical meetings. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. Our clinical remote searches found these were well managed with processes in place to follow patients with long term conditions or who were prescribed medicine that required monitoring who failed to attend for their blood monitoring. Following our clinical searches the practice sent us details of the action they had taken in response to our findings. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was lower than national indicators. There was a programme of regular clinical audits of prescribing.