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 Good.

At this inspection, the rating has changed to Inadequate.

This is because the service did not:

• have a positive learning culture in which safety concerns were reported, investigated and acted on effectively
• share information and review patients to help protect them from abuse, avoidable harm and neglect
• make sure all staff were trained in identifying and responding to an unwell patient and could always access medicines and equipment in the event of a medical emergency
• effectively identify and manage or address risks in the care environment, including those to prevent or control the spread of infection
• make sure patients received safe care and treatment, including from staff with the required skills, knowledge, competency and authorisation.

The service was in breach of legal regulation in relation safe care and treatment. We have told the provider they must take actions to ensure people using the service receive safe care and treatment.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Although staff told us they would report concerns, safety incidents and near misses to the practice manager and, in some cases, to one of the practice’s doctors, staff did not know how the practice recorded these.

The practice had recorded 4 significant events in the year leading up to this inspection. However, the practice had not identified several other significant events.

The practice did not investigate significant events thoroughly to identify and act on all possible learning from them.

Various members of clinical and non-clinical staff told us learning from concerns, safety incidents, near misses and complaints was not shared with them. Staff could not tell us about examples affecting the practice.

The practice did not have an effective system for recording and acting on safety alerts received into the practice, such as those from the Medicines and Healthcare Products Regulatory Agency (MHRA). Clinical guidance, such as from safety alerts, was not embedded into routine practice.

For example, a search of the practice’s clinical records system showed the practice had not made sure they had taken actions to protect patients affected by a MHRA safety alert about prescribing Clopidogrel and Omeprazole or Esomeprazole at the same time. For some patients, the practice had not identified when this medicine combination had been prescribed and taken actions to protect the patients from avoidable harm. For other patients, the medicines had been changed to suitable alternatives before being changed back to this non-recommended medicine combination. There were no clearly documented reasons for this, or evidence the risks had been discussed with each patient.

Leaders told us urgent referrals were made on the same day and routine referrals were sent within 2 days. However, our search of the practice’s clinical records system showed the practice did not always send referrals to other services in line with these expectations.

Systems to identify and monitor delayed referrals needed strengthening.

Although all test results coming into the practice were reviewed by a GP, our search of the practice’s clinical records system showed the practice did not always process letters and test results coming into the practice in a timely way.

Some people who used the service told us about times when the practice had not contacted them to follow-up abnormal test results.

Staff knew who the lead for safeguarding was in the practice and where to find information about safeguarding, such as practice policies.

Limited information was displayed on noticeboards in some clinical rooms.

However, some clinical staff told us if they had a concern they would message a doctor, for the doctor to “deal with” it. These staff also told us that although they would raise the concern with the practice manager, the practice’s safeguarding lead or with the patient’s usual doctor, they may not record their concerns on the patient’s medical records.

The practice did not have effective systems to identify people who may be at risk of abuse or neglect, and arrangements to help protect the practice’s most vulnerable patients. For example, the practice did not review registers of these patients that had been generated by the clinical records system to make sure they were kept up-to-date. The provider did not show they monitored these patients, identified indicators of risk, and took actions to help protect them from harm.

The practice did not routinely discuss children and adults at risk of, or experiencing, abuse or neglect either within the practice or with other services. Safeguarding meetings had stopped due to the COVID-19 pandemic and had not restarted.

The practice did not provide evidence 6 of the 10 members of clinical staff employed by the practice had completed the required training in safeguarding children, nor that 5 of the 10 members of staff had completed appropriate training in safeguarding adults.

The practice did not have all recommended equipment for use in an emergency, including absorbent towelling, monitoring equipment, and a variety of equipment to support a person’s airway and breathing.

However, the practice held most appropriate emergency medicines.

The provider did not show they had completed a risk assessment that explained the reasons for not keeping these items of equipment and some medicines and how any risks would be managed, such as outlining alternative arrangements the practice may have had in place.

Whilst emergency medicines were ‘in date’, some consumable items had passed their expiry dates, for example masks to help deliver oxygen to a patient had expired in 2019.

Although the practice responded immediately to our feedback and replaced these items, the systems the practice had in place for ensuring all emergency medicines and equipment were always available and safe to use, including monitoring expiry dates, had not worked effectively to identify these items so they could be replaced.

Checks of the emergency medicines and equipment were not carried out in line with national guidance. Checks had been recorded on 8 occasions between January 2024 and 2025, with gaps of up to 11 weeks between checks. The practice did not record checks of the defibrillator.

In addition, the practice did not keep emergency medicines and equipment in a way that meant one could easily identify if someone had accessed them. These meant the practice could not be sure emergency medicines and equipment were always available and safe to use if needed.

The practice did not provide evidence 2 of the 15 members of non-clinical staff employed by the practice had completed training in basic life support. In addition, the practice did not provide evidence of up-to-date training for 1 of the 10 members of clinical staff.

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. Some staff told us they could not remember having any training about sepsis and were not aware of any aides to help them identify symptoms and take suitable actions. However, we saw posters about sepsis in the practice’s waiting areas and reception areas.

The most recent fire risk assessment the practice showed us for this inspection was dated November 2015. The practice had not acted on the recommendations in the risk assessment to reduce risks to staff, patients and people who visited the practice.

For example, records showed the practice had not recorded tests of the fire alarm system weekly, in line with the recommendation in the fire risk assessment. Records showed the system had been checked 29 times between January 2024 and February 2025, with several occasions of gaps of 2 or 3 weeks between tests.

The practice did not provide evidence of weekly checks of the emergency lighting system. Records showed a monthly check of the emergency lighting system had last been completed in October 2016 and the system last serviced in August 2022. During our site visit we told the provider about a possible problem with one of the emergency lights.

The practice had reviewed their Fire Safety Instructions, including the evacuation procedure, in November 2024. Although staff were aware of the procedure for emergency evacuation and knew who the fire warden was for the practice, the provider had not completed details for the Fire Assembly Point on signs around the building, a recommended action in the fire risk assessment.

There were fire extinguishers throughout the building, which had been serviced in June 2024.

The practice had completed fire drills in November and December 2024, and in January and February 2025, although the practice had not always identified how the evacuation processes could be improved.

During our visit to the practice, we saw emergency exits had been obstructed. The provider did not acknowledge the risk or inform staff and visitors what to do instead if there was an emergency.

The practice told us training in fire safety had been arranged for March 2025 for all staff. Staff who were fire wardens had not completed additional training to enable them to do the role safely.

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’s Health and Safety Risk Assessment relating to COSHH was dated January 2023. This document did not relate to a GP practice generally nor specifically to Houghton Regis Medical Centre. The practice provided a COSHH Risk Assessment Template, however this had not been filled in. Therefore, there was no clear guidance for staff about specific 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 did not store the liquid nitrogen in line with the safety information that came with the chemical, for example in a way that restricted access to it and helped to reduce the risk of accidental spillages.

Most electrical equipment had been tested for safety in September 2024 and medical equipment calibrated in October 2024. Calibration is important to ensure the equipment provides correct readings to ensure patients receive appropriate treatment.

Some staff, both clinical and non-clinical, told us they felt there were enough staff to provide appointments. However, others felt there were not enough clinical and non-clinical staff, particularly as the number of patients registered with the practice had continued to grow.

There were some arrangements in place to cover expected and unexpected staff absences and known busy periods, although these were not always effective. Staff told us generally they covered for each other. Staff told us there had been times when numbers of staff had been low and staff had worked excessive hours due to short-staffing. The practice had asked locum or agency nurses to support on occasions, such as to deliver flu jab clinics.

Recruitment checks help to protect people and systems by making sure people are suitable for the roles they are employed to do. The practice had not always completed all recruitment checks, in line with regulations, when new staff joined the practice. For example, the provider had not always sought a full employment history or satisfactory explanations for gaps in employment or obtained proof of the person’s identity, including a recent photograph.

The practice did not provide evidence 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. The provider did not show staff worked within their scope of competence, knowledge and skill.

The provider did not have oversight of the performance and competence of clinical and non-clinical staff. Apart from appraisals, there were no systems to enable the provider to know staff worked safely, effectively and in line with guidance.

The provider had completed appraisals with all staff in the last year. However, the provider did not provide evidence of more frequent supervision for staff. The sample of appraisal records we looked at did not address concerns the practice had been made aware of. Records of the member of staff’s performance and objectives for the future were brief.

Some staff described their induction programme when they began working at the practice. However, induction checklists had not been filled-in for some staff. For other new staff to the practice, there was no evidence they had had an induction.

Some registered clinical staff had qualifications that allowed them to prescribe certain medicines without needing to ask a doctor. However, there were no agreed scopes of prescribing that set out what medicines these staff should and should not prescribe. The provider did not monitor or review the prescribing practices and knowledge for these staff, in line with national guidance, to know the patients seen by them received safe and effective care and treatment that was in line with up-to-date guidance.

Most staff knew who the lead for infection prevention and control (IPC) was in the practice.

However, the practice did not have effective systems for managing IPC and had not done all it could to protect patients, staff and visitors to the practice from infection and the spread of infection.

The IPC lead had completed an IPC audit in February 2025. However, the audit had not effectively identified areas needing attention from the practice.

For example, the practice had stated in this audit clinical handwash basins did not have plugs or overflows. During our site visit, we found and asked the practice to remove a plug from a handwashing basin in a clinical room.

The audit stated there was documentary evidence staff had received training in IPC that included hand hygiene and the management of sharps. However, the practice did not provide evidence 7 of the 10 members of clinical staff and 9 of the 15 non-clinical members of staff had completed training in IPC, as set out in the practice’s IPC policy dated August 2024. Some staff had completed training in ‘healthcare waste management and disposal’, however, this training did not provide all that was required in line with the practice’s policy.

This meant staff may not have been aware of up-to-date IPC practice, such as immediately discarding gloves put on to handle samples brought into the practice, such as urine or faeces, into a suitable bin. We observed reception staff wore single-use disposable gloves for the duration of their shift working on reception without changing them. We saw staff handling samples and then visiting other areas of the practice, handling telephones and computers and taking deliveries whilst wearing the same pairs of gloves.

The practice had also recorded in this audit all sharps bins in use were labelled correctly. We saw bins used for the disposal of sharps, for example needles and injections, had not been labelled in line with national guidance.

The provider did not complete audits, such as sharps bin audits, as set out in the practice’s policy.

Staff told us they had not been involved in any IPC audits and had not been informed about any learning or changes made as a result of them.

The building was in need of maintenance and repair work and updating. For example, repairs were needed to holes in ceilings and water-damaged ceiling tiles, tiled walls in clinical areas could be replaced to help reduce the number of areas where organisms may grow and make cleaning easier, and handwash basins in clinical areas could be updated.

The practice did not make sure all staff had immunity against various infectious diseases in line with the practice’s policy and guidance from the UK Health Security Agency (UKHSA). This helps to protect staff, patients, visitors and the public from harm. Where information about a member of staff’s vaccination history was not available, the provider had not taken steps to establish the staff member’s immunity status or carried out risk assessments to show how any risks would be managed.

The practice did not ensure medicines were stored safely and securely with access restricted to authorised staff. For example, fridges used for storing medicines were not locked and emergency medicines were not kept securely.

There was no system in place for monitoring the use of blank prescription stationery and reducing the risks associated with their potential misuse, in line with national guidance.

Staff administering medicines did not always have 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. It is important to monitor the temperatures of the fridges and be able to identify if the temperatures fall outside the acceptable range so that actions can be taken to make sure people receive medicines that work effectively to reduce the risk of avoidable harm. The practice could not show these medicines had been stored within an acceptable temperature range. The practice had not recognised when fridge temperature readings were not within the acceptable range, nor taken actions to investigate and ensure the medicines remained safe and effective to use.

The practice did not always monitor the health of patients prescribed medicines where monitoring is required because of the risks associated with taking the medicine. Our searches of the practice’s clinical records system found patients prescribed high-risk medicines had not had the necessary monitoring to make sure it was safe to continue to prescribe the medicine and the dose prescribed for them was suitable. This included patients prescribed a medicine called Azathioprine, a medicine used to calm and control the body’s immune system, to stop or slow the disease process in inflammatory conditions, such as rheumatoid arthritis; and patients prescribed a medicine for high blood pressure where monitoring is recommended yearly or more frequently. Some of these patients had not had monitoring for over 5 years.