St Johns House Medical Centre

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 last assessment, we rated this key question as good. At this assessment, the rating has changed to requires improvement as not all systems and processes for medicines management were operating effectively.

This service scored 62 (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. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Patients felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) felt the practice took concerns seriously and proactively made improvements to the service. The practice had processes for staff to report incidents. Managers encouraged staff to raise concerns that were later discussed in meetings. Learning from incidents and complaints resulted in changes that improved care for others.

The practice worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored. The practice worked with other providers and services to ensure continuity of care, including when people moved between different services. The local integrated care board told us they did not have any concerns about the practice. There were systems in place for managing incoming correspondence for patient’s medical records, including processing information relating to new patients. Staff ensured pathology and blood test results were reviewed and actioned in a timely manner. There was a system for patient referrals to specialist services. Staff understood the referral system and were able to tell us about the process when dealing with two week wait referrals, ensuring they were followed up accordingly. Triage systems were in place for staff to follow. The practice showed evidence of a new care navigation system with plans to implement this in August to support the reception and administration team when triaging calls. Staff told us they were looking forward to the new streamlined way of working which will help confidently signpost and advise patients.

The practice worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately. Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. Systems were in place to ensure safeguarding concerns were dealt with immediately. Staff knew how to identify, report and act when dealing with safeguarding concerns and worked well with other healthcare professionals to ensure the concerns were addressed appropriately. Staff were aware who the safeguarding lead was for adults and children. The practice maintained a list of vulnerable people and reviewed this list daily. Vulnerable people were coded and had alerts added to their records. Staff were informed when an alert was added to a record. Safeguarding concerns were discussed weekly during multi-disciplinary team meetings. The practice had a chaperone policy in place to maintain patient privacy during intimate examinations. Posters were displayed in consultation rooms and waiting areas.

The practice did not always work well with people to understand and manage risks. Some patients did not receive the information needed that related to the potential risks of their medicine, including what actions to take if their condition deteriorated. Some patients diagnosed with asthma did not have a follow up appointment to review their condition when necessary. In the latestNational GP Patient Survey, 92% of respondentsfelt they were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment. This was higher than the national average of 91%. Emergency equipment was available and well maintained.

The practice detected and controlled potential risks in the care environment. The practice had policies and procedures to ensure equipment, facilities and technology supported the delivery of safe care. The building was purpose built, and 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. There was a business continuity plan in place which was monitored and reviewed. During the onsite visit, the premises were visibly clean and tidy. Portable appliance testing and calibrations were up to date. Health and safety risk assessments had been completed. Systems were in place to check fire equipment including fire alarms and fire extinguishers. Fire evacuation drills were completed, and a fire register was on display. There was a business continuity plan in place and this was reviewed annually.

The practice made sure there were enough qualified, skilled and experienced staff that worked well together to provide safe care and meet people’s individual needs. Leaders explained their recruitment processes to ensure appropriate numbers of suitably trained staff were employed to support the delivery of good quality care which met the needs of the patients. There were a range of clinical and non-clinical roles within the practice. Staff were working within their agreed areas of competence. We reviewed personnel files during the onsite visit and found that some necessary recruitment documents were missing for some staff members such as a copy of their photo identity and references. Not all staff had completed their mandatory training. Staff were happy within their roles and were given opportunities to learn and develop whilst being supported to do so. However, there was no evidence of appraisals. The practice was responsive to these findings and assured us the recruitment process will be strengthened. We reviewed patient feedback, and this did not identify any concerns with staffing levels. Patients were complimentary about the staff and were positive about the way staff treated them.

The practice assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns promptly. The practice had a designated infection, prevention and control (IPC) lead and staff were aware of this. Staff had completed appropriate IPC training relevant to their role. Staff told us they knew their roles and responsibilities around IPC. Cleaning schedules were in place and followed to ensure the premises and equipment were kept clean. Clinical rooms had adequate provision of personal protective equipment (PPE) and handwashing facilities. IPC policies were in place and IPC audits were completed regularly and the appropriate actions were taken when necessary to mitigate any risks.

Staff regularly checked medicine stock levels and expiry dates, including emergency medicines. Fridge temperatures were monitored on a regular basis and staff knew what action to take if the temperature was out of range. Medical gases such as oxygen were stored safely. We saw evidence of clinical audits to improve patient care.

As part of our assessment, remote clinical searches were conducted by one of our GP Specialist Advisors. During the clinical searches, we found that not all systems and processes worked effectively as not all medication reviews and monitoring were completed in line with best practice. We found the following:

Medicine reviews were coded but some patient records lacked detail to provide clarity about what was discussed.

The following long-term conditions were not being monitored in line with National Institute for Health and Care Excellence (NICE) guidelines;

Asthma: Our clinical record searches reviewed the number of patients with asthma who had been prescribed two or more courses of rescue steroids in the last 12 months. We identified a total of 58 patients and reviewed a random sample of 5 patient records. We found that 3 out of 5 patients had not been followed up within a timely manner. Two out of the 5 patients reviewed were not up to date with their annual review.

Chronic Kidney Disease (CKD): Our clinical record searches reviewed the number of patients with Chronic Kidney Disease Stages 4 or 5 who have not had their urea and electrolytes (U+E's) monitored in the last 9 months. We identified a total of 60 patients and reviewed a random sample of 5 patient records. We found that all 5 patients had not had their U+E’s tested within the last 9 months. Four out of 5 patients were incorrectly coded as stage 3 CKD.

Hypothyroidism (when the thyroid gland does not produce enough thyroid hormone that can lead to tiredness and weight gain): Our clinical record searches reviewed the number of patients with hypothyroidism who had not had a thyroid function test (TFT) monitoring within 18 months. We identified a total of 503 patients with hypothyroidism. We identified a total of 13 patients who did not have a thyroid function test (TFT) monitoring within 18 months. We reviewed a random sample of 5 patients records and found that all 5 patients were prescribed thyroxine between May 2025 and July 2025 without having the appropriate blood test monitoring beforehand.

High risk medication; Methotrexate (an immune system suppressant drug): We reviewed a random sample of 5 patients and found that all 5 patients had been monitored appropriately before being prescribed this medication. However, the dose of the medicine prescribed stated ‘weekly’ instead of stating the exact day to take the medicine.

Medicines and Healthcare Products Regulatory Agency (MHRA) safety alerts: There was not an effective process in place for recording and sharing medicine safety alerts. Our clinical record searches indicated that safety alerts were not always actioned in line with guidance. We identified a total of 9 patients that were prescribed Clopidogrel (a medicine used to reduce the risk of a heart attack or stroke) with Proton Pump Inhibitor (a medicine used to reduce stomach acid production). We reviewed a random sample of 5 patients and found that all 5 patients were not informed of the risks, there was no evidence of any discussions had with the patients.