Dr Jinmi & Partners Also known as Houghton Regis Medical Centre

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence the practice was led effectively and in a way that was inclusive, supported improvement and innovation and made sure patients received care that was safe and effective.

At our last inspection we rated this key question Inadequate. At this inspection, the rating has changed to Requires Improvement.

This is because some governance and assurance systems were not yet in place or would benefit from further development. It was too soon to know if the systems and processes introduced had become embedded into routine practise.

Although leaders were engaging with support available, they remained relatively inexperienced. Whilst leadership of the practice had improved, it was too soon to know if leaders had developed the skills and knowledge needed to be able to lead the practice effectively without this support.

However, the service had responded to the needs of patients and the community.

Staff told us leaders were visible, approachable, open and transparent. Staff told us they felt able to share their ideas and staff had been involved in developments in the practice.

Staff told us they felt able to raise concerns. There were arrangements for staff to speak up if needed.

The service was in breach of legal regulation in relation to good governance. We have asked the provider for an action plan about how they will make sure systems and processes are embedded into routine practise and work effectively to enable the practice to provide a consistently safe and effective service.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider shared with us the practice’s mission statement and values as well as their vision and plans for the future of the practice.

This included succession planning.

However, leaders also told us about the challenges due to the uncertainty about the future of the practice following the last CQC inspection. For example, the provider explained this had meant they had not recruited staff on a permanent basis, as this would not be fair to the member of staff, and although they had investigated alternatives to storing liquid nitrogen, had not invested in a safer alternative.

Staff were aware of the findings of the last CQC inspection and consistently appeared to care about the future of the practice and the changes made to improve the quality and safety of the service.

Staff told us leaders and managers were visible, approachable, open and transparent.

Staff told us they felt able to make suggestions about the running of the practice.

We were told leaders had listened to staff feedback about not having enough staff to do some administrative tasks, and that staff were being trained to be able to help.

Leaders were aware of challenges affecting the service, and had responded to them. For example, increasing access to mental health support for patients, improving support for people experiencing domestic abuse, and the impact of moving to a new ‘Total Triage’ appointment booking process.

The provider had also responded to improve care for patients living with long-term conditions. For example, since the last inspection the provider had recruited staff with specialist knowledge about the management of diabetes, asthma and COPD.

These staff told us practice leaders had been honest with them about the findings of the last inspection and their reasons for not offering them permanent positions in the practice.

These staff also told us practice leaders had been supportive in giving them the time they felt they needed, for example offering 20 or 30 minute appointments.

Since the last inspection, the practice had also changed how they recorded and shared some types of information within the practice. The practice had started to use a nationally recognised tool. Leaders were aware of the impact for staff and had taken a step-by-step approach to introducing the changes, for example recording temperatures for the medicines fridges using ‘QR codes’. Leaders told us they were hoping to use the programme for recording more types of information in the future, such as complaints and significant events.

Whilst practice leaders remained relatively inexperienced, the support they were engaging with was having a positive impact. Since the last inspection they had:

• signed up to various courses, such as in practice management
• worked with the Bedfordshire, Luton and Milton Keynes Integrated Care Board to gain knowledge, for example to improve infection prevention and control in the practice and to develop safeguarding procedures and support for people whose circumstances may make them vulnerable
• worked with an external Health and Social Care Consultant who had supported them to make effective changes to systems and processes in the practice, offered guidance and training for all members of staff, and provided mentorship for the practice manager to develop their skills and knowledge.

Although there were improvements in the leadership of the practice and the consultant told us they would support the practice for as long as it was needed, it was too soon to know if leaders had developed the skills and knowledge needed to be able to lead the practice effectively without this support and the systems and processes introduced would be sustained and become embedded into routine practise.

Staff told us although they did not have any concerns to raise, they felt they would be able to if they needed to.

Staff were aware of whistleblowing and Freedom to Speak Up.

Freedom to Speak Up Guardians offer support to staff to raise concerns, or speak up, when they feel they cannot in other ways. There was a Freedom to Speak Up Guardian within the practice and staff knew they could contact them if needed.

The practice’s Freedom to Speak Up Policy also included details for a Freedom to Speak Up service that worked outside the practice with whom staff could raise concerns if they felt they needed external support or advice.

A mixture of male and female clinical staff worked at the practice and staff members were from a variety of different nationalities and backgrounds.

Staff felt they were treated fairly and the provider supported them to attend training courses.

Staff told us leaders supported them to be able to work flexibly to help them balance work with their personal lives, such as caring responsibilities and to attend healthcare appointments.

We saw the provider had made reasonable adjustments for staff who had long-term conditions or who had returned to work following a significant amount of time off due to illness. For example, reduced working hours and longer or more frequent breaks to help them continue to work effectively.

The partners had approved an updated Business Continuity Plan, dated October 2025. This outlined what staff should consider and what actions to take if there was a major incident or disruption to the service, such as a loss of computer or telephone systems, utilities, flooding, a pandemic, staff incapacity or terrorist attack. The plan was specific to the practice and contained relevant contact details and completed risk assessments for a variety of situations.

The GP partners and practice manager met weekly to discuss matters relating to the running of the practice.

The provider had introduced monthly clinical governance meetings, which clinical staff were invited to attend. These provided an opportunity to share information about the practice and their patients, learning from significant events and complaints, and updates to evidence-based best practice guidance. Minutes of these meetings were taken using a standardised template and were shared with all practice staff. Non-clinical staff told us they were invited to monthly team meetings, however, we did not see minutes for these meetings.

Staff told us they had protected time for administrative tasks and training. However, at the time of our assessment, not all staff members had completed training relevant to their roles.

Staff with additional responsibilities, such as a fire warden role or recording temperatures of the medicines fridges, had had some additional training to help them understand how to do the tasks safely and effectively.

Since the last inspection, leaders had introduced systems to improve the oversight of the day-to-day running of the practice and be able to identify and respond to risks, such as around fire safety and the availability of emergency medicines and equipment.

However, some of these systems would benefit from further strengthening or becoming embedded into routine practise, for example around the security of prescription stationery and seeking assurances satisfactory recruitment checks had been carried out.

Although the practice had introduced supervision for some clinical staff, including nursing staff who were qualified to prescribe medicines, there were no similar arrangements for other staff, to enable the provider to know staff worked in line with the practice’s policies, national guidelines and within their competencies. Governance in relation to patients’ long-term conditions management and medicine reviews required further strengthening.

Leaders were aware of other areas where they did not yet have assurance systems in place to know the systems and processes introduced worked effectively and as intended or expected. For example, the IPC lead told us about their plan to introduce audits to make sure checklists completed for clinical rooms reflected the actual environment.

Leaders had identified what training they expected staff to complete. Leaders had introduced a system for monitoring the training completed by staff. However, not all training was recorded on this system, including training outlined in the practice’s ‘mandatory training’ document. Leaders explained their plans for improving oversight of training completed by staff.

The practice had a Patient Participation Group (PPG) that met 4 times a year.

The practice manager and at least 1 doctor from the practice attended meetings.

The PPG told us they felt meetings were helpful and the practice representatives listened to their feedback. They told us the practice provided updates about changes happening in the practice and feedback about complaints and significant events.

The next meeting was planned for January 2026 and there were plans to discuss patient feedback about the new ‘Total Triage’ appointment booking process.

The PPG told us they promoted the PPG at local health promotion events and several patients had asked about joining the PPG.

There was information about the PPG on the practice’s website and in the waiting area. However, this lacked detail about the PPG, the role of the group, how to join the group and how one could provide feedback to the PPG. The practice did not share with patients feedback and updates about work the PPG had done and was doing.

The practice monitored their performance against other similar practices, for example in the uptake of cervical screening and childhood immunisations.

Leaders reviewed responses to the NHS Friends and Family Test and patient feedback about the eConsult service, to help inform and make improvements. The practice was working through the actions they had identified in their action plan in response to the findings of the 2025 national GP Patient Survey, to help improve access to the service and people’s experiences of using the service.

Since the last inspection, the practice had started using a new ‘Total Triage’ appointment booking process, and had also started using a system for recording and sharing information within the practice.

However, evidence was not yet available to show the impact of the changes the practice had made.

Leaders had prioritised work to make sure people using the service were protected from potential avoidable harm, and so had focused on addressing immediate safety concerns.

Staff showed their commitment to improving the service. The provider acknowledged they were on an ‘improvement journey’ and there were some areas that would benefit from further work or needed to become embedded into routine practise.

CQC recognised the progress the practice had made since the inspection in February 2025 and has withdrawn the enforcement action proposed against the provider. To help the practice continue to prioritise the work needed to further improve the quality and safety of the service and to give reassurance the practice will continue on their ‘improvement journey’, we have asked the provider to send us an action plan in response to the breaches of regulation identified.