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Jarvis Medical Practice - GPCC Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 23 April 2019

We carried out an announced comprehensive inspection at Jarvis Medical Practice - GPCC on 1 March 2019 as part of our inspection programme. The practice had previously been inspected on 4 March 2015 and had been rated good in all areas at that inspection.

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 and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as requires improvement overall and requires improvement for all population groups.

We rated the practice as requires improvement for providing safe services because:

  • Not all staff had completed safeguarding training and the safeguarding policy had not been fully personalised.
  • There were gaps in staff recruitment checks. For example, we saw no evidence that a full work history was always obtained or that gaps in employment history were not queried.
  • The infection control audit stated that all staff had received training in infection control, but this was not the case.
  • Significant events were not managed in a consistent way.
  • The practice health and safety risk assessment had not been completed, although the building management team had completed a separate one.
  • A two week wait referral from five working days prior to the inspection had not been actioned.

We rated the practice as requires improvement for providing effective services because:

  • There were gaps in staff training, including mandatory training.
  • Training information for locum GPs was not routinely kept. Training information for the business manager, who started work at the practice over two years ago, was in the form of a letter from their previous employer.
  • Although appraisals had been carried out it was difficult to tell when this had been done and there was limited input from some staff in their appraisals.
  • Where audits had identified a decrease in performance this was not explored, and further audit dates not arranged.

We rated the practice as good for providing caring services because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.

We rated the practice as good for providing responsive services because:

  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

We rated the practice as requires improvement for providing well-led services because:

  • Governance procedures were not always effectively managed. For example, the practice’s health and safety risk assessment had not been completed, the safeguarding policy was not personalised to the practice, and the business plan was for a different practice.
  • Clinical audits were not always effective or repeated appropriately.
  • The procedure for managing significant events did not ensure learning took place. Significant events were not reviewed at a later date.
  • Training was not up to date and training information for the locum GPs was not sought.

These areas affected all population groups so we rated all population groups as requires improvement.

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure recruitment procedures are established and operated effectively so only fit and proper persons are employed. Ensure specified information is available regarding each person employed.

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

Inspection areas


Requires improvement


Requires improvement






Requires improvement
Checks on specific services

People with long term conditions

Requires improvement

Families, children and young people

Requires improvement

Older people

Requires improvement

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)

Requires improvement

People whose circumstances may make them vulnerable

Requires improvement