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

This service scored 75 (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 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. The provider had processes for staff to report incidents, near misses and safety events. Managers encouraged staff to raise concerns when things went wrong. The practice had a significant events policy which was accessible to all staff members. Staff felt there was an open culture, and that safety was a top priority.

Since the last inspection, learning had been strengthened through regular clinical and practice meetings, where learning and service developments were routinely discussed. Standing agenda items included significant event analysis (SEA), complaints and safeguarding. Over the previous 12 months, the practice had completed and reviewed 15 SEAs. Staff understood the reporting process and were able to describe examples where significant events had been shared to promote learning and improve the quality of care.

The practice had effective systems for recording, investigating and responding to complaints. When concerns were raised, staff apologised and provided appropriate support to those affected. In the previous 12 months, the practice had reviewed 10 complaints. Complaints and significant events were reviewed annually to identify themes, trends, learning opportunities and areas for improvement. We reviewed complaint records and found concerns were generally managed consistently, with appropriate investigation, oversight and responses provided. Information on how to raise concerns was readily available in the practice and on the practice website. However, we noted that responses did not always include information about escalation to the Parliamentary and Health Service Ombudsman (PHSO) where patients remained dissatisfied. The practice acknowledged this and agreed to ensure this information is included in future correspondence.

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.

Effective systems were in place for processing information relating to new patients including the summarising and coding of new records. The service worked with other providers to deliver shared care and when patients moved between services.

Systems were in place to ensure that all patient information, including laboratory test results and referrals, was reviewed and actioned in a timely manner. Referrals to specialist and urgent services, including two-week wait (2WW) referrals, were managed through a clearly defined process. The provider confirmed that these processes were monitored and there was a duty and buddy system in place to maintain patient safety. In addition, staff provided patients with appropriate safety netting advice regarding worsening or deteriorating symptoms.

The provider was part of the Primary Care Network (PCN) and attended regular meetings with other agencies across the locality to share and discuss information relating to patient care and treatment. There were a range of structured meetings in place. These included multi-disciplinary, governance, safeguarding, clinical and practice team meetings.

The service 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 arrangements were established, with clear leadership and accountability. A named GP safeguarding lead was in place, supported by safeguarding policies and procedures. Staff had access to relevant guidance and information, had completed appropriate safeguarding training, and demonstrated a good understanding of their safeguarding responsibilities. The practice maintained a register of vulnerable patients and responded appropriately to safeguarding concerns, working collaboratively with external agencies and partner organisations to help protect people at risk.

There were systems in place for the renewal of Disclosure and Barring Service (DBS) checks. DBS checks identify whether a person has a criminal record or is on an official list of patients barred from working in roles where they may have contact with children or adults who may be vulnerable.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The practice had a clear system for managing appointment requests and other patient queries, ensuring people were prioritised according to clinical need. Reception and administration staff who handled calls to the practice and arranged appointments with the clinical team were aware of potential red flag symptoms and had been given guidance on identifying such patients. A duty doctor was available each day and staff knew when to notify a GP or other clinicians with concerns about a patient who may be acutely unwell and/or deteriorating.

Emergency medicines and equipment were available, regularly checked and maintained. Staff recognised signs of patient deterioration and understood the action required in an emergency. They were also aware of the location of emergency equipment, including oxygen and the automated external defibrillator (AED).

Staff demonstrated understanding of emergency protocols and had completed face to face training in Cardiopulmonary resuscitation (CPR). The practice also held registers to support patients who were vulnerable or who had mobility or communication needs.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The premises were managed by a private landlord and the GP practice operated under a shared tenancy arrangement with other healthcare providers.

Contracts were in place to ensure the premises were clean and well maintained. Policies and procedures were in place to support the effective management of health and safety. The practice undertook regular environmental and health and safety audits, with identified actions monitored and addressed promptly. For example, during our assessment, we observed some signs of wear within the premises, including cracks in parts of the building's walls. The practice told us this had been appropriately escalated to the landlord and was being investigated at the time of the assessment.

All electrical equipment had been appropriately calibrated, and safety tested in line with regulations. Legionella monitoring was in place. Fire safety policies and checks were in place. Clear signage around the building supported people and staff in the event of an emergency evacuation. Premises security systems were in place and routinely monitored.

Staff had been provided with training in health and safety related topics such as fire safety, infection control, basic life support and resuscitation training. The practice maintained a business continuity plan that provided structured guidance in the event of significant service disruptions, including IT system failures.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met patients’ individual needs.

Since the last assessment in 2023, the practice had strengthened clinical leadership oversight by reviewing and improving its supervision and governance arrangements. A structured programme of clinical supervision and audit activity was in place, providing effective oversight, support and assurance that staff were working within their agreed scope of practice and maintaining appropriate clinical standards. This included arrangements to oversee and support trainee doctors.

The practice also benefited from a multidisciplinary team within its Primary Care Network (PCN), including pharmacists, a migrant social prescriber, a physician associate, a first contact mental health worker and a dietitian. Systems and processes were in place to ensure these staff were safely recruited, suitably trained and working within the scope of their roles. We found that staff demonstrated a good understanding of their roles and responsibilities and worked within the scope of their competence.

There was oversight for staff training which was up to date, and effective processes were in place to identify, monitor and support learning and development needs. We saw evidence of induction programmes and appraisals to support ongoing professional development. Staff we spoke to told us that training and development were supported and aligned with both individual career aspirations and the needs of the service.

At the previous inspection, we identified gaps in staff immunisation records. At this assessment, we found that the practice had reviewed the immunisation status of all employed staff and had strengthened its recruitment processes. Appropriate Disclosure and Barring Service (DBS) checks were in place for all staff, supported by clear recruitment policies and procedures.

However, we found that some recruitment records, primarily relating to long-standing members of staff, contained gaps and required further review and updating. The practice had already identified this issue and was taking action through a review of legacy personnel files, alongside the migration of records to an electronic system to improve the completeness of staff records.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

At the last assessment in 2023 we identified that actions had not been taken to address the potential risks identified relating to infection prevention and control (IPC). At this assessment, we found these areas had been reviewed regularly.

At this assessment an infection control audit had been completed to identify potential risks. The audit had been completed in November 2025, and the practice had achieved 98% overall. The action plan had identified a daily checklist for the treatment room. We found this had been acted on and all clinical rooms had a QR code displayed to ensure rooms were appropriately checked, cleaned and appropriately stocked.

The practice had a designated infection, prevention and control lead and all staff had completed training relevant to their role. Staff were aware of the systems and processes to follow to ensure clinical specimens were handled safely.

The environment was visibly clean, well maintained and appropriately equipped to support the delivery of safe care. Clinical rooms were stocked with the necessary equipment and supplies, including personal protective equipment (PPE), pedal bins and hand hygiene facilities. Cleaning arrangements were effective, with schedules and monitoring processes demonstrating that routine cleaning tasks were completed and appropriately documented. Cleaning equipment and substances subject to the Control of Substances Hazardous to Health (COSHH) regulations were stored securely, with relevant documentation in place to support safe working practices and minimise the risk of infection.

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.

As part of the assessment, we carried out remote clinical searches to review how patients’ medicines were monitored and if the appropriate care and treatment was being received.

We reviewed the monitoring of patients prescribed methotrexate, a high-risk medicine commonly used to treat autoimmune conditions such as rheumatoid arthritis. Our clinical search identified 23 patients receiving methotrexate, of whom 2 did not initially appear to have the required monitoring in place. Further review established that both patients were under the care of secondary care specialists and appropriate monitoring arrangements were in place. However, we found that records for patients prescribed methotrexate did not consistently document the day of the week the medicine should be taken, in line with national guidance. We discussed this with the practice, which acknowledged the issue and agreed to take action to ensure prescribing records were updated accordingly.

As part of the assessment, we reviewed the number of people who had been prescribed medicines to reduce the risk of blood clots forming called direct oral anticoagulants (DOACs), who had not received monitoring in the past 12 months. The search identified 71 patients on these medicines who did not have an up-to-date creatine clearance (this is a medical measurement that shows how well your kidneys filter waste from your blood). We reviewed 5 clinical records and found 4 of these patients had the appropriate monitoring and 1 patient required further review.

We reviewed patients with a potential missed diagnosis of diabetes. Our searches identified 15 patients. A review of 5 patient records found that 3 had been managed appropriately, 1 patient was actively undergoing further investigation, and 1 patient had been recalled for follow-up but required additional action to ensure appropriate management.

Further reviews of the clinical system identified people with a missed diagnosis of chronic kidney disease (CKD) 4 and 5. The search identified 5 patients. We reviewed their clinical records and found 1 patient had been recalled and 1 was overdue urea and electrolyte monitoring (this is a routine blood test that measures the amounts of minerals and salts such as sodium, potassium, and chloride in your body).

The practice worked with the clinical pharmacists from the local Primary Care Network (PCN) to monitor people and the prescribing of medicines. The practice had systems in place to action MHRA safety alerts and. We carried out a clinical search to identify women of childbearing age who were prescribed teratogenic medicines, which have the potential to increase the risk of birth defects. We reviewed 5 patients prescribed these medicines who required a Pregnancy Prevention Programme (PPP) and an annual risk acknowledgement form and found appropriate monitoring in place.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.Prescribing data reviewed as part of our assessment showed the practice continued to perform well in antibiotic prescribing, achieving positive outcomes compared with both local and national averages and ranking among the highest-performing practice locally. Prescribing for psychotropic medicines and hypnotic medicines showed negative variation in comparison to national averages, however the practice was aware of this and taking action.

Emergency medicines, vaccines and medical equipment had clear monitoring processes in place. We saw fridge temperatures were routinely monitored and vaccines reviewed at random were in date and stored appropriately. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

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 and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately. We saw evidence that lockable printers were in place for additional security.