St John's 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

We looked for evidence that people were protected from abuse and avoidable harm.

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

This service scored 72 (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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. However, date of actions completed as an outcome of significant events had not been recorded on the significant event register. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way.

The service looked after 2 care homes for patients with complex needs, which patients sometimes only stayed at for a few days, the service had a dedicated GP for 3 sessions a week along with an advanced clinical practitioner. The clinical pharmacy team dedicated sessions to review these patients.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people who were appropriately coded and safeguarding alerts were placed on both individual and household family members. The surgery acted on concerns working in partnership with other organisations.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. Staff had completed basic life support training within the past 12 months, ensuring they were prepared to respond as appropriate in an emergency.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Health and safety protocols, including fire safety measures, were in place across the practice. Staff had received training in Health and Safety topics such as fire procedures and infection control. Risk assessments for the premises had been reviewed and had highlighted some concerns around overloading extension leads with plugs, gaps in doors where they had dropped (leaving room for fire/smoke to escape) and sealant and strips around the door being painted over which was a fire hazard. The practice assured us that appropriate workman had been instructed to complete these tasks prior to the end of August 2025. Clear signage was present throughout the building to support safe evacuation procedures in case of an emergency.

There was a business continuity plan in place which was monitored and reviewed.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were a range of clinical and non-clinical roles within the practice, including clinical pharmacists, an advanced clinical practitioner, healthcare assistants and 2 paramedics. The service had a lead nurse who worked across 8 Modality run services in Walsall, supporting the practice nurses with continuous internal training or appropriate external training to meet the needs of the surgery. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Safe recruitment practices were followed.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. As part of our remote clinical record searches, we reviewed how the practice monitored patients prescribed high-risk medicines. Of the 26 patients identified as being prescribed methotrexate (a medicine to treat autoimmune conditions) 2 patients were overdue monitoring in line with national guidance, 1 of them did not have the day of the week specified on their methotrexate prescription, in line with Medicines and healthcare products regulatory agency (MHRA) guidance, and the other lacked an alert they were on a Disease-modifying antirheumatic drug (DMARD). Following our findings, the practice confirmed that appropriate action had been taken.

Clinical searches related to patients prescribed Direct Oral Anticoagulants (DOACs) revealed that recommended monitoring was not consistently carried out at the required frequency for frail individuals and those aged over 75. We found 34 patients were overdue monitoring, and following discussion with the provider, assurance was given that action would be taken to address monitoring frequency for this specific cohort.

Staff did not always involve people in reviews of their medicines and help them understand how to manage their medicines safely. Our remote searches identified 31 patients had been prescribed 12 or more Short-acting beta agonist (SABA) inhalers in the last 12 months. We reviewed 5 patient records and found 2 patients had not had an effective asthma review, as information from a questionnaire suggesting suboptimal asthma control had not been appropriately managed. However, on highlighting this to the surgery they confirmed that appropriate action was taken immediately with the affected patients.

Our remote clinical searches showed that 1952 patients had a medicine review in the last 3 months. A review of 5 patient records showed that reviews did not always cover every prescribed medicine. The practice has reviewed this and agreed to improve the process.

Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely. Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Waste medicines were recorded and disposed of appropriately. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring.