Dr Jinmi & Partners Also known as Houghton Regis 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

This means we looked for evidence there was a culture of openness in which there was a willingness to identify and learn from safety events. We looked for evidence people were protected from abuse and avoidable harm.

At our last inspection we rated this key question Inadequate.

At this inspection, the rating has changed to Requires Improvement.

This is because the service did not always:

• thoroughly investigate complaints and significant events to understand the reasons for them and to take actions to help prevent them happening again
• make sure patients received safe care and treatment from staff who had the required skills, knowledge and competency
• complete good quality medicines reviews with patients and did not always follow-up patients who did not respond to requests from the practice to book an appointment or arrange further investigations.

However, the practice

• had introduced systems to help safeguard people whose circumstances may make them more vulnerable to abuse, harm or neglect, and had plans for a ‘Domestic Abuse Champion’ role in the practice
• did process correspondence coming into and leaving the practice, including test results and referrals, appropriately and in a timely way in most cases
• was able to respond safely and effectively to a medical emergency or an acutely unwell or deteriorating patient
• had responded to risks in the care environment, including those to prevent or control the spread of infection
• did keep medicines requiring storage in a fridge appropriately and staff had the authorisation needed when administering medicines.

The service was in breach of legal regulation in relation to safe care and treatment. We have asked the provider for an action plan about how they will make sure all people using the service receive safe care and treatment.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us they felt comfortable to report concerns, safety incidents and near misses to leaders.

The provider had recorded and considered feedback given by CQC at the last inspection, in February 2025, as significant events.

The practice had recorded a further 8 significant events on their ‘summary spreadsheet’ since April 2025.

Seven of these events had been shared with staff in the practice’s monthly clinical governance meetings, which all staff were now invited to. Three further significant events, which were not on the ‘summary spreadsheet’ were discussed in the October monthly meeting. The provider had discussed the other significant event in an extraordinary meeting with the staff affected by it.

Complaints were also shared with staff in these monthly meetings.

Although the provider had investigated each significant event and complaint, the provider had not always identified and acted on all possible learning from them, and shared this with staff, to help prevent them happening again.

The practice had a system for recording and acting on safety alerts received into the practice, such as those from the Medicines and Healthcare Products Regulatory Agency (MHRA). The practice had introduced systems to identify patients affected by safety alerts and make sure action was taken to help protect them from harm, in line with the guidance.

However, these would benefit from further development to make sure that patients who do not respond to requests to book an appointment for the required monitoring are identified and action taken to help reduce the risks to them.

The practice processed referrals to other services in a timely way.

The systems to identify and monitor delayed referrals worked effectively, including urgent referrals, such as those for possible cancers.

All test results coming into the practice were reviewed by a doctor.

Since our last inspection, the practice had improved how they processed letters and test results coming into the practice. Letters were processed in a timely way and there were systems for highlighting information that needed to be reviewed by a doctor, such as changes to a person’s medicines, and urgent information, for example about a safeguarding concern.

The practice usually processed test results in a timely way, in most cases. Although staff described how they would attempt to contact patients several times, the process for making sure patients responded to requests for them to book an appointment or have further investigations when test results indicated this was needed did not always work effectively. This meant there were some patients who had not received the recommended follow-up for test results the practice had reviewed in September 2025 and earlier. Similarly, other patients had not responded to requests to have monitoring for their long-term condition.

Staff knew who the lead for safeguarding was in the practice and would report any concerns.

Information was available to support practice staff.

The safeguarding lead had reviewed all patients who had been recorded on the clinical records system as being at risk of abuse or neglect, and had created up-to-date registers of those who were still at risk of harm.

The safeguarding lead had given each patient on the registers a ‘red, amber or green rating’ based on the level of risk. This system could be further developed with clear information about what these ratings meant and to involve all appropriate people when deciding the rating, to help with information sharing and care planning, and make sure important information was not missed.

The practice had introduced new systems to identify when there were known risks about someone newly registering with the practice. The safeguarding lead reviewed these patients and made sure the appropriate flags were on the clinical records system for staff’s awareness and to help make sure the person was protected from avoidable harm.

The practice also made sure staff would be alerted through the clinical records system if someone may be more vulnerable because they lived with someone for whom there was a safeguarding concern or risk.

Practice staff discussed concerns with other services on an individual basis, such as with district nurses, health visitors, social workers, pharmacies, carers, community services and hospital services.

The practice shared information with clinicians in the practice in monthly clinical governance meetings about individuals for whom new concerns had been identified or where staff had specific concerns or updates. Minutes of these meetings were available for all practice staff to see. However, systems to make sure staff were kept up-to-date about people for whom risks were ongoing or whose circumstances may make them more vulnerable could be strengthened, to help make sure the support in place continued to work well to safeguard the individual from possible harm and to keep the registers up-to-date.

The practice had also discussed general queries in these meetings, for example how the practice would respond if a patient needed investigations but was not able to give their consent.

Leaders were also thinking about how they could support people whose circumstances may make them more vulnerable when they transitioned from children’s services to adult services.

All non-clinical staff and 8 of the 10 members of clinical staff employed by the practice had completed up-to-date and relevant training in safeguarding children. All staff employed by the practice had completed up-to-date and relevant training in safeguarding adults.

The practice kept all recommended medicines and equipment for use in an emergency and in line with the practice’s Emergency Trolley Policy.

This policy outlined the practice’s reasons for not keeping certain medicines and how any risk would be managed, such as describing alternatives the practice had in place.

Emergency medicines and equipment were in date.

Emergency medicines and equipment were kept in an organised way where certain medicines and pieces of equipment were grouped together and easy to find in an emergency. Emergency medicines and equipment were easily accessible and portable and were kept in a way that meant staff could see easily if they had been tampered with, for example an item used or removed.

Except for 1 week, the practice had recorded weekly checks of the emergency medicines and equipment since the beginning of July 2025.

All staff employed by the practice, except for 1 member of non-clinical staff, had completed up-to-date training in basic life support. The practice’s mandatory training policy stated all staff were required to complete training yearly. The practice told us a face-to-face training session had been booked to make sure staff remained up-to-date.

Although most staff were aware of actions to take if they encountered a deteriorating or acutely unwell patient, not all staff confidently recognised the signs of sepsis. Sepsis is a potentially life-threatening condition when the body overreacts to an infection and starts to damage itself. All staff except 1 clinical and 1 non-clinical member of staff employed by the practice had completed up-to-date training in sepsis awareness. Posters about sepsis were displayed throughout the practice.

We did not see evidence that staff always told patients what to do should their condition get worse or not improve. For example, when the practice had prescribed medicines for a flare-up of a patient’s asthma.

A new Fire Risk Assessment had been completed in April 2025 and the practice had actioned most of the recommendations in it.

Except for 2 separate weeks, the practice had recorded weekly checks of the fire alarm system since April 2025. There was a sign in the practice’s waiting area to inform people when they could expect to hear the alarm being tested, to help avoid any panic.

New emergency lighting had been installed in May 2025 and the practice had recorded monthly checks of the system since.

There were fire extinguishers throughout the building, which had been serviced in June 2025.

The practice had completed a fire drill in July 2025.

All staff employed by the practice had completed up-to-date training in fire safety.

New signs to inform people about who the fire wardens were had been installed, and the practice had added information about the fire assembly point on most of the signs informing people about what to do in the event of a fire.

Emergency exit routes were clearly signed and were clear. The practice checked daily that routes were clear and emergency exit doors were maintained.

Staff were aware of the emergency evacuation procedure and where they should assemble.

The Control of Substances Hazardous to Health (COSHH) Regulations legally require workplaces to take steps to control exposure to materials in the workplace that can cause ill-health or injury. The practice had carried out a new COSHH Risk Assessment in June 2025. This was specific to the practice and included safety data sheets (SDS) that provided information for staff and others about the substances held in the practice, such as the specific cleaning products stored and used in the practice.

The practice kept liquid nitrogen on site. This is a chemical used for some minor surgical procedures, and is considered in COSHH regulations to be a substance hazardous to health. Liquid nitrogen needs careful storing and handling due to the risks of death from asphyxiation, cold burns, frostbite and hypothermia. The practice had responded to some of the concerns raised at the last CQC inspection to help reduce the risks of accidents. For example, access to the liquid nitrogen was now restricted.

Electrical equipment had been tested for safety in August and September 2025 and medical equipment calibrated in November 2025, just before our site visit to the practice. Calibration is important to ensure the equipment provides correct readings to make sure patients receive appropriate care and treatment.

There were some arrangements in place to cover expected and unexpected staff absences and known busy periods.

Since our last inspection, the practice had recruited two specialist nurses, on a locum basis. Although 1 of these nurses worked at the practice, they were employed by the Primary Care Network to which Dr Jinmi Partners was a member. Recruitment checks help to protect people and systems by making sure people are suitable for the roles they are employed to do. Therefore, there is a requirement for providers to be able to show they can be sure recruitment checks have been completed, and in a way the practice feels is satisfactory, for all members of staff working at the practice, regardless of whether they are employed by another service or as a locum. The practice did not provide evidence they were aware satisfactory checks had been completed for both members of staff, including identification checks, references, a full employment history and Disclosure and Barring Service (DBS) check.

DBS checks identify whether a person has a criminal record or is on an official list of people that should not work in roles where they can have contact with children or adults that can be made vulnerable. These checks help to protect other staff and people using the service from abuse.

However, the practice provided evidence of DBS checks for other clinical and non-clinical staff. The provider had also requested enhanced level checks for all staff.

The practice did not provide evidence that all clinical staff, including registered and non-registered staff, had completed appropriate and up-to-date training to enable them to assess and treat patients safely and effectively. For example, for one nurse who did cervical smears, their training in cervical smear sample taking had expired in 2024. The provider did not provide evidence all staff who carried out reviews with patients with long-term conditions, such as asthma and Chronic Obstructive Pulmonary Disease (COPD), had up-to-date knowledge and skills.

Since the last inspection in February 2025, the provider had introduced systems to oversee the performance and competence of some staff. For example, the practice provided records of audits of the clinical consultations and prescribing practices for a member of staff who worked in an extended-scope role and had qualifications that allowed them to prescribe medicines without needing to ask a doctor, covering January to March 2025, and records of a supervision session with the practice’s pharmacy team. However, we did not see evidence these systems had yet become well developed and embedded into routine practise for all relevant staff, so the provider could be sure staff delivered care that was safe, effective and in line with up-to-date guidance, or identify areas for improvement.

Staff knew who the leads for infection prevention and control (IPC) were in the practice.

All staff employed by the practice had completed up-to-date relevant training in IPC.

The provider had made some changes since the last inspection in February 2025 and we observed staff using appropriate procedures.

The practice had carried out hand hygiene audits every 3 months since our last inspection, and had introduced 3 monthly audits of the sharps bins, to help make sure they were used safely and correctly.

Bins used for the disposal of sharps, such as needles and injections, were labelled correctly and used safely.

The practice’s IPC lead was supported by other practice staff and the Bedfordshire, Luton and Milton Keynes Integrated Care Board.

The IPC lead had completed a new IPC audit in July 2025, which had showed improvement since the previous audit that the practice had completed in February 2025. The practice had acted on most of the findings in the audit, for example had made improvements to make sure clinical waste was stored safely and securely, and had made some repairs to the building such as replacing holes in ceilings and water-damaged ceiling tiles. Some findings, such as having hand moisturiser in clinical rooms, had yet to be acted on.

The IPC lead was aware of further areas for improvement. For example, they told us about plans to attend further training and carry out monthly audits of the general environment and clinic rooms. These would include checking staff were completing the daily checklists in each room and that these accurately reflected the environment.

Although the practice appeared clean and tidy, clinical rooms would benefit from updated facilities, such as replacing tiles on walls to help reduce the number of areas where organisms may grow and make cleaning easier, and updating handwashing facilities.

Since the last inspection in February 2025, staff had been risk assessed and the practice had taken steps, working with a local occupational health service, to make sure the immunity status against various infectious diseases for all staff was known, in line with guidance from the UK Health Security Agency (UKHSA). This helps to protect staff, patients, visitors and the public from harm from the spread of infection.

Since our last inspection, the practice had introduced a system for monitoring the use of blank prescription stationery, to help reduce the risks associated with their potential misuse. However, the system would benefit from further development to make sure staff could identify any concerns and respond to them in a timely manner.

Staff administering medicines had the appropriate authorisation to do so. This included via the use of Patient Specific Directions (PSDs) and Patient Group Directions (PGDs). These are legal frameworks that allow healthcare workers to administer a certain medicine to a specific patient or groups of patients without the need for an appropriate clinician to issue individual prescriptions.

Some medicines, for example vaccines, need to be stored in a fridge to make sure they remain safe and effective to use. Since the last CQC inspection, the practice had introduced systems to be able to show medicines stored in the fridges had been kept within an acceptable temperature range.

Our searches of the practice’s clinical records system showed the practice monitored the health of patients prescribed medicines where monitoring is required because of the risks associated with taking the medicine.

However, we looked at medicine reviews the practice had recorded for 5 patients and found they had not always identified and addressed any concerns and areas where the patient’s health could be improved.

For example, reviews did not always include all medicines prescribed for the patient, did not always identify when patients were prescribed medicines that were not in line with current evidence-based best practice, and did not always trigger reviews of the patients’ long-term conditions when reviews were overdue or there had been a change in the patient’s condition.

The records for some medicine reviews were not thorough. For example, there was no evidence the person completing the medicine review had asked the patient about side-effects from their medicines, how they felt their medicines were working for them, or noted if the patient was taking their medicines as prescribed or had addressed any reasons if not.

We also found the practice had recorded they had completed medicine reviews for patients before any monitoring had been done, such as blood tests or the patient’s blood pressure. This meant the medicines reviews were not always effective, particularly when the monitoring showed the patient’s care and treatment may not be working as well as possible.