The Care Quality Commission
  • Doctor
  • GP practice

Marylebone Health Centre

Overall: Good read more about inspection ratings

17a Marylebone Road, London, NW1 5LT (020) 7935 6328

Provided and run by:
Marylebone Health Centre

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Marylebone Health Centre on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Marylebone Health Centre, you can give feedback on this service.

30 September 2022

During an inspection looking at part of the service

We carried out an announced focused review at Marylebone Health Centre on 30 September 2022. Overall, the practice is rated as Good.

Safe - Not inspected, rating of good carried forward from previous inspection.

Effective – Requires Improvement.

Caring - Not inspected, rating of good carried forward from previous inspection.

Responsive - Not inspected, rating of good carried forward from previous inspection.

Well-led - Not inspected, rating of good carried forward from previous inspection.

Following our previous inspection on November 2019, the practice was rated as good overall for all key questions but requires improvement for providing effective services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Marylebone Health Centre on our website at www.cqc.org.uk.

Why we carried out this review

This was a focused review of information without undertaking a site visit inspection to follow up on the ‘requires improvement’ rating for providing effective services imposed on the previous inspection. At the last inspection we found;

  • The practice were not meeting targets for uptake of childhood immunisations.
  • The practice were not meeting targets for the uptake of cervical cancer screening.

We also followed up on ‘should’ actions identified at the last inspection. Specifically;

  • The practice should ensure all staff are aware of the system to circulate and record any action taken in relation to patient’s safety alerts.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Marylebone Health Centre on our website at www.cqc.org.uk

How we carried out the review

Throughout the pandemic, CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections different.

This review was carried out without visiting the location by requesting documentary evidence from the provider and speaking to staff members on the phone.

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • What we found when we inspected.
  • Information from our ongoing monitoring of data about services.
  • Information from the provider, patients, the public and other organisations.

We found that:

  • The practice made efforts to increase the uptake of childhood immunisation uptake. Data from NHS England showed improvements had been made on immunisation uptake since the last inspection.
  • The practice made efforts to increase the uptake of cervical cancer screening uptake. However, data from the UKHSA showed the practice were significantly below the required target for cervical cancer screening.

We also found that:

  • Staff members were aware of the system to circulate and record actions taken in relation to patient safety alerts.

Whilst we found no breaches of regulations, the provider should:

  • Continue to implement processes to improve the uptake of cervical cancer screening.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

12/11/19

During a routine inspection

We carried out an announced comprehensive inspection at Marylebone Health Centre on 13 November 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 and smear rates 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.
  • Staff demonstrated commitment and engagement with the vision for the service. They were proud to work for the organisation.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • There were innovative approaches to providing integrated person-centred care tailored to meet the needs of substance mis-use patients.
  • The practice promoted good health and prevention and provided patients with suitable advice and guidance.
  • 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
  • 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.

We saw the following areas of outstanding practice:

  • The practice held regular events in collaboration with the PPG. For example, they had held well men and well women’s walk-in days. Where patients, staff and people from the local community had access to GPs and nurses for screening, various health checks and healthy living advice. These sessions were attended by 20 -30 patients. People also received information about the benefits of gentle exercise and as a result of these one GP has started a weekly walking session where 6-8 patients regularly attend.
  • The practice facilitated educational events where healthcare specialists and professionals in the subject area were invited to give presentations to patients, staff and the local community. The most recent one focused on Alzheimer’s and Dementia.

The areas where the provider should make improvements are:

  • Continue to implement processes to improve the take up of childhood immunisations.
  • Continue to implement processes to improve take up of cervical smears.
  • Ensure all staff are aware of the system to circulate and record any action taken in relation to patient’s safety alerts.

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

9 December 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at 8:30am on 9 December 2014. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing safe, effective, caring and responsive services. It was also good for providing services for all population groups. We found the practice to be outstanding for being well led.

Our key findings across all the areas we inspected were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed, with the exception of those relating to infection prevention and control.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they were able to get an appointment when they needed one, but there was often a wait to see the GP of their choice. Urgent appointments were available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Governance and performance management arrangements were proactively reviewed and reflected best practice. There was a clear leadership structure with a strong focus on staff education and training. All opportunities for learning from internal and external incidents were maximised and shared with staff and the patient partnership group (PPG).
  • There were high levels of staff satisfaction and staff engagement, with staff at all levels actively encouraged to provide feedback and raise concerns. Staff felt supported and were offered training to upskill and develop within their roles. High standards were promoted and owned by all practice staff with evidence of team working across all roles. Staff achievement was celebrated and shared with the practice and patients.

We saw several areas of outstanding practice:

  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and the patient partnership group (PPG). The practice encouraged wider engagement from patients to ensure they were represented in PPG work. They proactively sought the opinion of people in different equality groups so that these patients could contribute to the development of surveys carried out by the PPG. A virtual patient representative group was also created to encourage representatives from different population groups to share their views on the service. Feedback was acted on in a timely manner and shared with patients and staff. The practice valued feedback from the PPG and engaged them in other areas of the service. For example, PPG representatives attended clinical commissioning group and locality meetings, and supported human resources as independent observers and decision makers during staff interviews.
  • The practice worked with other organisations to improve care outcomes, and tackle health inequalities. The practice helped organise health promotion events for patients, staff and the local community. For example, there was a monthly ‘Memory Café’ offered in partnership with the parish church (where the practice was located), and a local healthcare provider. The aims of the meetings were to provide practical information and support for patients living with dementia, their families and carers. The practice also hosted quarterly ‘Ask the Expert’ events which were jointly organised with a local healthcare provider. These were educational events where healthcare specialists and professionals in the subject area were invited to give presentations to patients and staff.
  • There was innovative leadership and a culture of continuous learning for all staff. There was a rolling programme of audits as demonstrated by the 17 clinical audits undertaken in the last year. Six of these were completed audit cycles where the practice was able to demonstrate the changes resulting since the initial audit and identify improved outcomes for patients. Audits were carried out based on the needs of the practice population and in response to feedback and performance.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider should:

  • Complete a comprehensive risk assessment to manage infection prevention and control.
  • Assess the competency of non-clinical staff who undertake chaperone duties and provide support where gaps are identified.
  • Have a system in place to show that emergency equipment has been checked.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice