St James Medical Practice

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

At our last assessment, we rated this key question as Requires Improvement. At this assessment, the rating has changed to Good.

This service scored 71 (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 made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Patient survey feedback from July 2026 showed that 93% of patients felt 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 local average of 91% and the national average of 92%. In addition, 96% of patients felt the healthcare professional they saw had all the information they needed about them, compared with a local average of 91% and a national average of 92%.

Reception and clinical staff demonstrated a good understanding of the local population and used digital alerts within patient records to highlight important information, such as the need for longer appointments, interpreter services, or other reasonable adjustments. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. The practice had increased the length of routine appointments to 15 minutes, with longer appointments available where required to meet patients' individual needs.

The provider had effective systems to identify people with previously undiagnosed conditions and ensure they received appropriate assessment and follow-up care. Care plans and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) records were completed and regularly reviewed. Systems were in place to identify and support carers, and patients requiring additional non-clinical support could be referred to services such as a social prescriber. All patients with a learning disability were invited for an annual health check, and annual reviews were undertaken for eligible patients to support the ongoing management of their health needs and any long-term conditions.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

During the remote clinical review, we carried out a search to identify people with asthma who had been prescribed 2 or more courses of rescue steroids in the past 12 months. The search identified potentially 22 out of 570 people. We reviewed a random sample of 5 clinical records and found that 3 out of 5 patients had follow up to check response to treatment in an appropriate timescale following their acute exacerbation and 2 patients required further action. However, prior to the assessment, the practice had completed an asthma audit and implemented a process to strengthen follow-up arrangements after exacerbations and courses of oral corticosteroids.

We carried out a clinical search on patients who had hypothyroidism and had not received the appropriate monitoring in the past 18 months. The search identified potentially 5 patients out of 224 were overdue monitoring and required a thyroid function test. Review of these records showed that the patients had already been identified by the practice, recall processes had been initiated, and proportionate escalation had been undertaken where patients had not responded to invitations for monitoring.

Our remote clinical search identified the practice had 81 out of 554 patients with diabetes whose latest HbA1c (blood glucose) level was consistently high. We reviewed 5 patients and found appropriate monitoring in place.

We carried out a clinical search on patients prescribed Bisphosphonates for 5 years or more to determine whether a review had been carried out (these are medicines used to strengthen bones, prevent fractures, and slow down bone loss). The search identified 11 patients. We found appropriate action had been taken.

Further reviews of the clinical system identified people with chronic kidney disease (CKD) 4 and 5 who had not received monitoring in the last 9 months. The search identified 2 patients potentially overdue monitoring. We reviewed 5 clinical records and found appropriate monitoring in place.

Overall, we found the remote clinical searches we undertook demonstrated the monitoring of patients with long-term conditions had not always followed the National Institute for Health and Care Excellence (NICE) recommendations. We discussed these findings with the provider, including some of the challenges associated with their patient population. In response, the practice demonstrated ongoing work to improve compliance through regular audits of monitoring requirements. They also provided examples where prescribing had been appropriately restricted or adjusted when patients did not attend the required monitoring. In addition, the practice undertook regular audits to support quality improvement. Clinicians, including nursing staff, were provided with protected time each week to attend nursing meetings where challenging cases were reviewed, learning was shared, and best practice was discussed to promote consistent and effective patient care.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff told us that they had access to the information they need to appropriately assess, plan and deliver people’s care, treatment and support and they had enough information to plan and refer people and receive subsequent results and information following referral. There were effective systems and processes in place to support the sharing of information between the practice and other services, helping to ensure continuity of care. Regular multidisciplinary team meetings were held to coordinate patient care effectively. These included palliative care meetings and diabetes specialist reviews involving secondary care clinicians, enabling collaborative decision-making and joined-up care for patients with complex needs.

The Primary Care Network (PCN) helped to support the practice by providing links to pharmacists, a migrant social prescriber, physicians associate, first contact mental health worker and dietician.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

The service demonstrated a good understanding of the challenges affecting its local population, including high levels of deprivation within the community. Staff recognised the importance of supporting people to improve their health and wellbeing and actively promoted healthy lifestyles and positive healthcare choices.

Systems were in place to identify and monitor vulnerable patients, with alerts and recall processes used to support ongoing review and self-management of health needs. Staff focused on identifying and addressing risks to patients’ health, including those approaching the end of life, those at risk of developing long-term conditions, and patients with caring responsibilities. The practice supported national health priorities, including initiatives to support smoking cessation and obesity reduction , and signposted patients to local services providing information, education and personalised support. Patients were also encouraged to participate in national screening programmes and childhood immunisation initiatives.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

The practice was performing in line with national averages for both bowel and breast cancer screening; however, the practice had not met national targets for cervical screening and childhood immunisations. For example, uptake of cervical screening was significantly below the national target of 80% in both eligible age groups (25 to 49 years and 50 to 64 years) with ranges of 58% and 65%. Childhood immunisation performance was also below target of 95%, with ranges between 79% and 89% across the measured indicators.

Leaders demonstrated a clear understanding of the challenges presented by the diverse and deprived population served by the practice and were able to explain the barriers some people faced in accessing preventative healthcare. The practice had implemented measures to improve uptake, such as targeted recall methods, including providing information, discussing concerns and misconceptions, supporting informed decision-making, and tailoring conversations with a range of clinicians such as GP’s and nurses.

The practice had an established programme of clinical and non-clinical audits and action plans aimed at driving continuous improvement in patient care and operational efficiency. For example, the practice reviewed benzodiazepine prescribing month by month and had an action plan in place to improve immunisation, cervical screening and antibiotic prescribing.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. There were policies and procedures in place such as mental capacity and best interest meetings. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.