The Care Quality Commission
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St Johns Wood Medical Practice

Overall: Requires improvement read more about inspection ratings

Hospital of St John & St Elizabeth, Brampton House, 60 Grove End Road, St John's Wood, London, NW8 9NH (020) 3657 9449

Provided and run by:
St Johns Wood Medical Practice

All Inspections

During an assessment under our new approach

Date of Assessment: Remote clinical searches were carried out on 29 April 2026 and the site visit took place on 30 April 2026.

St John’s Wood Medical Practice is a GP Practice registered as a partnership since its CQC registration in April 2013. The practice was last assessed in August 2017. This comprehensive assessment was undertaken because of the length of time since the last assessment and the information of concern made available to CQC related to patient care.

St John’s Wood Medical Practice is a GP Practice that delivers General Medical Service (GMS) to approximately 24,423 patients in the London Borough of Westminster under a contract held with NHS England. The National General Practice Profile stated that the population make up for this location is 56.5% White, 18.8% Asian, 5.5% Black, 5.8%% Mixed and 13.3% other non-white ethnic groups.

Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population is in the 8th decile (8 of 10). The lower the decile, the more deprived the practice population is relative to others. This practice is in the eighth decile indicating it is in a less deprived area on the national scale. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.

The assessment process findings are as follows:

Safe: There were concerns with how people and staff were kept safe and protected from harm and abuse. The practice recorded significant events and shared learning with staff to support ongoing improvement. Most risks were understood and managed appropriately by the team. However, the safeguarding policy was not specific to the practice and not all household members were coded on the safeguarding register. There was also no evidence that routine audits of emergency medicines and emergency equipment were carried out. In addition, there were gaps in staff training and in monitoring the safety of the environment. For example, current fire safety and legionella risk assessments were only provided to CQC after the site visit.

Effective: People were involved in the assessment of their needs. Patients were invited for their health checks reviews. The practice generally delivered services in line with good practice but not all guidelines were always followed, for example, acting on the guidance for consent when healthcare assistants (HCAs) administer vaccines to patients. The practice worked with relevant stakeholders to achieve best outcomes for the patient population. Information was shared with the patients to ensure they made an informed decision about their health care needs. There was a system of recall for cervical screening and childhood immunisations among the patient population who did not engage with the health offers; however, the impact of the system of recall was not yet known.

Caring: People were treated with kindness and compassion by the clinical staff. The dignity and privacy of patients were respected. Staff felt valued and appreciated. Staff wellbeing was treated with the utmost importance by the service.

Responsive: People received services that were in line with the Equality Act. Interpreting services were made available to patients who needed them. Complaints were handled appropriately and in a timely manner.

Well-led: The leadership and the management of the practice operated an open-door policy and shared vision of the practice with the staff. The leadership and management had a clear understanding of equality, human rights and safe compassionate care. Staff understood their roles and responsibilities and felt supported. However, there were gaps in governance and oversight arrangements. In particular, there was insufficient monitoring of maintenance checks undertaken by the building owner, and a lack of formal auditing of emergency medicines and emergency equipment within the practice.

We found breaches of regulation in relation to safe care and treatment (Regulation 12) and good governance (Regulation 17). We have asked the provider for an action plan in response to the concerns found at this assessment.

3 August 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at St Johns Wood Medical Practice on 25 November 2014. The overall rating for the practice was good, however the rating for providing safe services was requires improvement. The full comprehensive report on the November 2014 inspection can be found by selecting the ‘all reports’ link for St Johns Wood Medical Practice on our website at www.cqc.org.uk.

This inspection was undertaken to check the provider had taken the action we said they must and should take and was an announced comprehensive inspection on 3 August 2017. Overall the practice is still rated as good and the rating for providing safe services has improved from requires improvement to good.

Our key findings were as follows:

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events. The practice had taken the action we said it should take at our November 2014 inspection to record in the minutes of governance meetings evidence of discussion of and the communication of lessons learned from, significant events and complaints.
  • The practice now had clearly defined and embedded systems to minimise risks to patient safety. It had taken the action we said it should take at our November 2014 inspection in relation to medicines management. However, we identified some shortcomings in the arrangements for vaccine stock management and prescription security.
  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment. The practice had taken the action we said it must take at our November 2014 inspection to address gaps in training and appraisal and ensure staff training records were fully completed.
  • Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and improvements were made to the quality of care as a result of complaints and concerns.
  • Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had adequate facilities and equipment to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.
  • Appropriate governance arrangements were in place and the practice had taken the action we said it should take at our November 2014 inspection to review all practice policies and procedures, including the practice’s business continuity plan, to ensure they remain up to date and relevant.

However, there were also areas of practice where the provider needs to make improvements.

The provider should:

  • Ensure a record is kept of serial numbers of batch numbers of prescriptions, to secure full monitoring of their use; and ensure prescriptions left in printers are appropriately secured.
  • Raise staff awareness of the practice’s infection control policy.
  • Continue with efforts to improve uptake of childhood immunisations in relation to national targets.
  • Improve staff understanding of practice values and ensure consistency in the documentation of the mission statement.
  • Consider how best to ensure staff were aware of and understood updated practice policies.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

25 November 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at St Johns Wood Medical Practice on 2 5 November 2014 . Overall the practice is rated as Good.

Specifically, we found the practice to be good for providing, effective, caring, responsive and well-led services. It was also good for providing services to the six population groups we looked at: older people; people with long-term conditions; families, children and young people; working age people (including those recently retired and students); people whose circumstances may make them vulnerable; and people experiencing poor mental health (including people with dementia);

We found the practice requires Improvement for providing safe services. 

Our key findings were as follows:

  • The practice worked in collaboration with other health and social care professionals to support patients’ needs and provided a multidisciplinary approach to their care and treatment.
  • The practice promoted good health and prevention and provided patients with suitable advice and guidance.
  • The practice provided a caring service. Patients indicated that staff were caring and treated them with dignity and respect. Patients were involved in decisions about their care.
  • The practice provided appropriate support for end of life care and patients and their carers received good emotional support.
  • The practice understood the needs of its patients and was responsive to these. It recognised the needs of different groups in the planning of its services.
  • The practice learned from patient experiences, concerns and complaints to improve the quality of care

However there were areas of practice where the provider needs to make improvements. 

Importantly, the provider must:

  • Ensure recruitment and training records are fully completed to ensure patients are fully protected from the risks of unsafe or inappropriate care and treatment by the accurate maintenance of records about staff employed to carry out the regulated activities.

In addition the provider should:   

  • Record in the minutes of governance meetings evidence of discussion of and the communication of lessons learned from, significant events and complaints.
  • Arrange for all staff to receive formal training in safeguarding of vulnerable adults and ensure the child protection training planned for administrative staff not currently trained is completed.
  • Ensure the assurances provided to the local PHE/NHS England immunisations coordinator are adhered to and the policy for ensuring medicines were kept at the required temperatures is followed at all times.
  • Monitor the updated automatic protocol for the management of patients who have been prescribed high risk medicines to ensure the records of reviews and action taken were fully completed.
  • Review the practice’s consent policy to ensure mental capacity was appropriately taken into account and take steps to raise staff awareness of how the policy applied to children aged under 16 who have the legal capacity to consent.
  • Communicate the practice’s chaperone policy more clearly to patients in clinical areas.
  • Ensure in the staff appraisal process, learning and professional development needs were clearly linked to the appraisal review in all cases.
  • Systematically review all practice policies and procedures, including the practice’s business continuity plan, to ensure they remain up to date and relevant.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice