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 Good.

At this inspection, the rating has changed to Inadequate.

This is because there was a lack of strategic leadership and the service did not have a shared vision, strategy and culture that was inclusive of and responsive to the needs of patients and the community.

Although leaders were visible and approachable, staff felt they were not included in the planning for the future of the practice or that their ideas and concerns were listened to and acted on.

Arrangements to support staff to speak up required strengthening.

Staff told us they felt there was inequity in the way leaders and managers supported them to balance their health, well-being and other commitments with their work.

Leaders did not have the skills and knowledge to lead effectively, and did not always do so with openness and transparency.

There was ineffective oversight of the day-to-day running of the practice. The practice did not have effective governance and assurance systems in place. This meant risks were not identified and managed or addressed.

Relationships with others could be strengthened and information used more effectively to help generate new ideas and develop a culture where improvement and innovation was encouraged and used to develop the service.

The service was in breach of legal regulation in relation to good governance of the service. We have told the provider they must take actions to establish effective systems and processes and operate them effectively to ensure the service provided a consistently safe and effective service.

This service scored 32 (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 told us they were currently developing a business plan and strategy and therefore could not share with us their vision and plans for the future of the practice.

Clinical and non-clinical staff told us they had not been involved in the planning or development of the vision and plans for the future of the practice. Some staff told us they did not feel there was a clear vision for the future of the practice.

Whilst staff shared a common aim to do the best they could for patients, not all staff were aware of the practice’s values.

The provider shared with us a succession planning template, however, this had not been filled in.

Staff and leaders were aware of some challenges affecting the service, including the limited space available, more patients registering with the service, maintaining and making improvements and repairs to the building, access to some types of appointments, and the availability of other services to help protect patients at risk of, or experiencing, abuse or harm. However, the provider had not always taken steps to address them safely and effectively.

There was a lack of strategic leadership and ineffective oversight of the day-to-day running of the practice. This meant risks affecting the service were not identified and managed, for example gaps in checks to make sure emergency medicines and equipment were always available and safe to use, gaps in checks of fire safety systems to help reduce the risk of harm in the event of an emergency, or checks of fridge temperatures to make sure medicines stored in the fridges had been kept in a way that meant they would be safe and effective to use.

Leaders did not always have the skills and knowledge to lead effectively. Leaders did not always identify concerns and did not know when and how to seek advice from other organisations. This meant leaders did not always have the ability to address issues effectively, such as those relating to infection prevention and control.

Leaders had not carried out their statutory responsibilities to notify other organisations about certain situations or events affecting the practice. These included informing CQC about an incident involving the Police.

Although staff told us leaders and managers were visible and approachable, not all staff felt leaders and managers were open and transparent.

Staff told us they felt able to make suggestions about the running of the practice. However, although some staff said they felt leaders and managers welcomed their feedback, other staff felt leaders and managers did not listen to their feedback and ideas.

Some staff told us they felt the provider did not act on staff feedback, with some saying they felt suggestions were viewed as complaints or they felt they were penalised if they raised a concern.

Staff who provided feedback for this inspection did not give examples of changes that had been made in the practice as a result of feedback from staff.

Staff who provided feedback for this inspection told us they knew what Whistleblowing was. However, not all staff were aware of the practice’s policy.

Staff could approach a specific member of practice staff for support, including to raise concerns with the practice’s leaders and managers anonymously. However, not all staff were aware of this resource, which we were told had not been used much.

The majority of staff did not know they could contact a Freedom to Speak Up Guardian if needed.

Freedom to Speak Up Guardians offer support to staff to raise concerns, or speak up, when they feel they cannot in other ways.

The practice did not have arrangements with someone from outside the practice for staff to 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.

Although staff felt they were treated fairly, not all staff felt the practice offered opportunities for career progression and professional development.

Some staff told us the practice manager had discretely supported them with personal matters and that the provider had supported their return to work following illness or injury, for example by allowing them to wear comfortable clothing or providing equipment. However, other staff told us the provider could have been more understanding and supportive in helping them to continue to work effectively with a long-term condition.

Staff told us they could work flexibly and that the provider was understanding towards helping them balance work with caring responsibilities.

We did not see evidence of personalised support for staff, for example personal emergency evacuation plans for staff who may benefit from additional assistance.

Although staff knew where to find policies and guidance and told us they knew who they could speak to if they had a question or concern, some of the documents we saw needed updating, were not specific to the practice, or gave conflicting or had missing information.

For example, the provider shared with us 2 different Business Continuity Plans. These plans 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 such as gas, electricity and water, flooding, a pandemic, staff incapacity or terrorist attack. One of these had been reviewed in October 2023. However, the provider had not inserted information to make the plan relevant to the practice. The practice had reviewed the other plan in January 2024. However, this plan needed updating and specific details adding to inform staff how to respond to events affecting the practice. Actions leaders told us they would take were not always the same as the processes outlined in the plan, for example the procedure for informing staff. It was not clear which plan staff should use. Not all staff were aware the practice had these business continuity plans.

The provider did not have checks in place to know their systems for identifying issues that needed to be acted on and to provide quality assurance worked effectively and as expected. For example, to check recommendations in fire risk assessments, and in safeguarding and IPC audits were acted on effectively, and fire drills were effective, recorded accurately and any learning from them identified and shared.

The provider did not make sure staff worked in line with the practice’s policies, national guidelines and within their competencies, such as through clinical supervision or running audits or searches on the clinical records system.

The provider had not identified when there were gaps in recruitment checks or knowledge of staffs’ immunity to certain infectious diseases, so that any risks to patients and staff could be managed effectively.

The provider was not clear about training staff were required to complete, and did not have an effective system to monitor training completed by staff. This meant the provider was unable to know what training staff had completed, what training staff needed to do, and when refresher training was needed. For example, the provider was unable to tell us which staff had completed up-to-date training in sepsis awareness, the Mental Capacity Act or chaperoning.

The GP partners and practice manager met weekly to discuss matters relating to the running of the practice. However, there were no regular meetings attended by other practice staff, for example to share information about the practice and to keep up-to-date with evidence-based best practice. Staff told us they were not invited to and did not attend staff meetings.

Staff told us information was sometimes shared with them during protected learning time, but it was more usual for the practice manager to visit each room in the practice when they needed to share information. Immediate communication with other practice staff was through the use of ‘instant messages’.

Clinical and non-clinical staff told us they did not have protected time to carry out specific tasks given to them, for example to check medicines and equipment, or to carry out tests of systems such as fire alarm testing.

Some staff told us they had not had additional training to understand how to do these tasks safely and effectively.

The practice had a Patient Participation Group (PPG). However, there was little information on the practice’s website and in the practice’s waiting areas about how the PPG supported the practice or how patients could join the group.

Staff told us patient feedback was collected through the PPG. Staff told us the practice manager interacted with the PPG and that they were not involved.

The practice manager told us they had recently attended a meeting with members of the PPG. However, meetings were infrequent and no records of meetings were available.

The practice told us during this meeting they answered queries about the practice that the PPG asked, however, did not share other information about the practice with the PPG.

The PCN had recently set up social media pages for the PPG.

Leaders told us they attended monthly meetings with the other practices in the PCN. However, leaders did not demonstrate they always shared information about the practice and learning with others in an honest and meaningful way.

The practice did not have a focus on continuous learning, innovation and improvement, and there was no embedded quality improvement programme.

For example, the practice had not carried out their own patient surveys or created audits and clinical searches to identify areas for improvement.

The practice shared with us information collected for the PCN that showed only a slight imbalance between the demand for appointments and the appointments offered by the practice between October 2023 and October 2024. Practice leaders also told us they monitored queues on the practice’s telephone lines and acted when queues got too long. However, leaders did not show they had used these pieces of information, or that they were aware of other information available such as telephone and appointment data, the findings of the GP Patient Survey or responses to the NHS Friends and Family Test, to help inform and make improvements.

The practice did not benchmark their performance with other GP practices to identify areas for improvement, for example in the uptake of cervical screening.

The practice did not show they used information requested by the commissioners of the service, for example about the numbers of patient reviews carried out, management of long-term conditions or about the prescribing of certain medicines, to help make improvements for people using the service.

Staff who provided feedback for this inspection did not know of changes that had been made in the practice as a result of patient or staff feedback. Neither did staff share with us examples of how the service had developed nor of things they felt the practice did particularly well.