The Jersey 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 the last assessment in March 2017, we rated this key question as good. At this assessment, the rating has changed from good to requires improvement. The service was in breach of legal regulation in relation to safe care and treatment (regulation 12). We found concerns with security of visitors to the building, gaps in recruitment processes, gaps in staff training, and learning from events to ensure good practice.

This service scored 50 (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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns to about safety and investigated and reported safety events. Managers encouraged staff to raise concerns when things went wrong. However, lessons from complaints were not always clearly recorded after investigation. Events were not always assessed to correctly designate them as significant events and to learn from them to prevent a recurrence. Lessons were not always shared with staff during staff meetings or recorded in the minutes to embed it into daily practice.

The service 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 service worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way.

The service did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. Staff were trained on safeguarding procedures at the right level appropriate to their roles. The practice had a safeguarding policy, but it lacked information about who staff could report concerns to in addition to the safeguarding lead. Children on the safeguarding register did not have safeguarding alerts linked to their parents. Our review of the safeguarding register looked at 5 patient records; a record did not have household members linked leaving the patients at increased risk of harm and another record did not identify who was responsible for the child in a care facility and another patient on the safeguarding register had already been deducted from the practice. Following the site visit, the service sent CQC updated safeguarding policies with names of the safeguarding lead and deputy added.

The service worked with people to understand and manage risks. Emergency equipment was available and maintained. Staff were trained on how to respond to emergencies.

The service did not always detect and control potential risks in the care environment. Risk assessments were completed but they did not always make sure facilities supported the delivery of care. For example, the recommended review date for the Legionella risk assessment was August 2025 but there was no evidence of completion. The service escalated this to the building owner only during the preparation for the CQC assessment in January 2026 and not at the next review date which was August 2025. This showed a lack of oversight of the required risk assessments for the premises used for the delivery of patient care.

Another example was the action plan recommendations from the health and safety risk assessment completed by an external provider in July 2025. It was recommended that the copy of the fire risk assessment should be kept by the service but was not seen on site. We asked the service to send a copy but this was not sent to CQC. This showed the service was nottaking necessary action to reduce the fire risks to the building to ensure a safe environment for staff and patients. There was an absence of a system for visitors to sign-in which further demonstrated a lack of the provider’s awareness and control in relation to fire risk within the organisation. The service informed CQC that the building was maintained by the landlord and all documents remained with the property owner until requested. Following the site visit, the service informed CQC that a visitors’ book would be purchased.

There were parts of the premises that were not clean during the site visit. The emergency cord on the accessible toilet / baby changing area was broken and if a patient required to use it, would not be reachable when on the toilet seat or floor. In addition, there was some debris not removed from the cupboard that could be used to cause harm if in the hands of an unstable patient. There was a business continuity plan in place which was monitored. The service informed CQC following the site visit that, the concerns highlighted had been passed on to the building owner.

There were a range of clinical and non-clinical roles within the practice. Staff training was not up to date, learning needs and development of staff was not managed appropriately. However, staff were working within their agreed areas of competence. Safe recruitment practices were not always followed. For example, no proof of identity checks seen in 5 staff files reviewed by CQC and only 1 staff file had evidence of references obtained prior to starting employment. Staff were qualified, skilled and experienced. They received support but appraisals were not always regular. Staff who acted as chaperones did not have chaperone training. No record of sepsis training completion in 4 of the staff records reviewed, however staff we spoke to showed awareness of actions to take related to sepsis symptoms in a patient.

The service assessed and managed the risk of infection. The practice had a designated infection prevention and control lead, and all staff had relevant training, however, they did not always detect and control the risk of it spreading and share concerns with appropriate agencies promptly. For example, the light cord in one of the staff toilets was a risk of infection - it was visibly dirty - and this was not escalated to the building owner until after the site visit completed by CQC. Infection prevention and control audits completed by the service did not detect this risk.

The service 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. 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, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines.

During the site visit, it was noted that the prescription stationery needed to be managed more appropriately and securely. Following the site visit, the service informed CQC that the clinic rooms will be locked before start and end of each GP session pending printer locks arrangement.

Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, and vaccines. However, there was no risk assessment recorded for not storing an emergency medicine; Diclofenac injection (a non-steroidal anti-inflammatory drug, used to reduce pain, swelling and stiffness). Following the site visit, the service informed CQC that it was removed from the emergency drug list because of the risk of gastrointestinal bleed but no risk assessment document was shared with CQC. There was no sharps box in the resuscitation equipment bag when we checked during the site visit, we referred the provider to the Resus UK guidance. Following the site visit, the service informed us that this had been added because of the feedback received.

Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. 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 local and national averages. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.