St John's Medical Centre

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

This is the first inspection for this service since its registration with CQC. This key question has been rated as Good.

This service scored 67 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. Reception staff were aware of the needs of the local community. Reception staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments. Staff checked people’s health, care, and wellbeing needs during health reviews. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. The provider had effective systems to identify people with previously undiagnosed conditions. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The service did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them. Systems were not always in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical records we saw did not always demonstrate care was provided in line with current guidance.

Our remote clinical searches identified the practice had 555 patients with Asthma of which 43 (8%) had been prescribed 2 or more courses of rescue steroids. In some cases, the dose of prednisolone prescribed to treat an exacerbation had been lower than the recommended National institute for health and social care (NICE) exacerbation of asthma guidance. We reviewed 5 patient records and found that some consultations lacked details in the history to determine the severity of the illness. Examinations were not always thorough, for example they did not include respiratory rate, and there was no examination recorded for 1 patient. Safety netting was sometimes vague, and patients were not followed up within 48 hours as per NICE guidelines. However, on highlighting this to the surgery they have confirmed that appropriate action was taken immediately with the affected patients.

Our remote searches identified 15 patients were identified as having a potential missed diagnosis of diabetes. A review of 5 patient records was undertaken, which found that 2 required further clinical action. Following discussion with the provider, assurance was given that appropriate steps had been taken to review and follow up with all patients identified through our searches.

Our remote clinical searches identified that the surgery had 799 patients with diabetes of which 102 (13%) latest HbA1c was >75mmol/l. People were followed up after a result however repeat tests were not always done after the patient’s medication had been adjusted to ensure improved control. We reviewed 5 patients and found 2 patients were overdue checks to ensure improvement after having a raised HbA1c 7 months previously, 1 patient was overdue their annual diabetic and medication review, and 1 patient had not had a HbA1c check since November 2023, the surgery had tried to contact them. However, on highlighting this to the surgery they have confirmed that appropriate action was taken with the affected patients.

Our remote clinical searches identified the surgery had 442 patients with hypothyroidism of which 6 had not had a thyroid function test monitoring for over 18 months. We reviewed 5 patients records, 2 patients had not been tested since November 2023, although the practice had taken action to inform the patient and request blood tests. 1 patient had not had blood monitoring since 2020 but they had declined monitoring in the past and had been asked to come in for a blood test, the other 2 patients had left the surgery. On highlighting this to the surgery they have confirmed that appropriate action was taken with the affected patients.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

The service always supported people to manage their health and wellbeing to fully maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support. For example, for the last 7 months, Modality health had set up an online coaching lifestyle application (App) which patients could download to their phone which had a real live coach at the end which patients could use for obesity, weight management, blood pressure control, hypertension, sleep hygiene, and diabetes to give extra support. As an outcome of this, St John's medical centre had found a 10% reduction in HbA1c for patients using this app and also a drop in blood pressure and weight. The surgery had also offered group consultations for diabetes improvement.

Staff focussed on identifying risks to patients’ health, including those in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking.

The latest GP patient survey carried out, showed that 87% of respondents felt their needs had been met during their last general practice appointment which was in line with the local average and slightly below the national average of 90%.

The service routinely monitor people’s care and treatment to continuously improve it. The practice met national targets for child immunisations, However, did not meet national screening targets for cervical cancer in the age group 25 to 49 they met 74.7% and age group 50 to 64 they met 75.1% the expected target was 80% for the year April 2023 to March 2024. However, the practice have provided data for the year April 2024 to March 2025 stating for the year ending March 25, for age group 25 to 49 they met 83.1% and age group 50 to 64 they met 80.8% both above the national target, but this has not been verified.

The practice had an established programme of clinical and non-clinical audits and action plans aimed at driving continuous improvement in patient care and operational efficiencies.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.