Jubilee Medical Group

We carried out an announced comprehensive inspection at Jubilee Medical Group between 15 and 17 May 2023. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring – Good

Responsive – Good

Well-led – Good

Following our previous inspection in February 2022 the practice was rated Requires Improvement overall and for the key questions Safe and Effective.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Jubilee Medical Group on our website at www.cqc.org.uk

Why we carried out this inspection

The practice had been previously rated as Requires Improvement in February 2022. This inspection was to follow up breaches of regulations 12: Safe care and treatment, 18: Staffing and 19: Fit and proper persons employed as identified in our previous inspection.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing facilities.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A short site visit to the main surgery and the branch surgery.

Our findings

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 Good overall

At our last inspection the practice was rated as Requires Improvement because:

• There was insufficient monitoring of a small number of patients who were prescribed medicines.
• There was a lack of monitoring of staff immunisations and risk assessments had not been undertaken to mitigate risks associated with a lack of immunisation.
• The recording of investigations and action taken as well as the wider learning for significant events, complaints and safety alerts needed to be improved.
• Although the provider did have a system in place to record and act on safety alerts, we identified one alert which had been issued in the past that had not been acted on.
• We found gaps in processes relating to the monitoring of vaccine fridge temperatures to ensure those medicines remained safe to use .
• Staff recruitment files did not contain all of the required information.
• Medicine reviews and non-urgent referrals were not always completed in the required time frames.
• There was a lack of formalised staff clinical supervision.
• Staff training was not up to date, including safeguarding, basic life support, infection prevention and control, and sepsis.

At this inspection we found that:

• Patients who were prescribed medicines were being monitored appropriately.
• The practice required all staff members to provide evidence of their immunisation status. This was recorded into a spreadsheet. Risk assessments had been completed for those staff members whose immunisation was not known or had declined the immunisation.
• The recording of significant events, complaints and safety alerts was clear and detailed. We saw minutes to meetings where these were discussed for wider learning.
• All safety alerts were acted upon. We saw evidence of the action taken which was centrally recorded.
• Fridge temperatures were being monitored twice daily. We found no gaps in the recording and staff we spoke with were aware of the process to follow if they noticed a gap in the logbook or if a temperature went out of range.
• The staff recruitment files we reviewed contained all of the required information.
• Patients who were prescribed medicines were being monitored and reviewed in the required timescales. Non urgent referrals were 1 week behind and were being monitored to ensure there were no further delays in sending.
• Clinical supervision had been formalised and included the salaried GPs.
• Staff training was up to date, this including safeguarding, basic life support, infection prevention and control, and sepsis.
• The practice had clear systems, practices and processes to keep people safe and safeguarded from abuse.
• There were adequate systems to assess, monitor and manage risks to patient safety.
• The practice had systems for the appropriate and safe use of medicines, including medicines optimisation and high risk medicines.
• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
• There were evidence of systems and processes for learning and continuous improvement.
• Patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.

Whilst we found no breaches of regulations, the provider should:

• Further implement ways to improve cervical screening to meet the UK Health and Security Agency uptake target.
• Further implement ways to improve child immunisation uptake.
• Implement ways to improve the detail recorded in medicine reviews.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care