The Care Quality Commission
  • Doctor
  • GP practice

Jubilee Health Centre

Overall: Good read more about inspection ratings

1 Upper Russell Street, Wednesbury, West Midlands, WS10 7AR (0121) 556 4615

Provided and run by:
Dr Samares Bhaumik & Dr Syed Ayaz Ahmed

Important: The partners registered to provide this service have changed. See old profile

All Inspections

24 January 2024

During an inspection looking at part of the service

We carried out an announced focused assessment of the responsive key question at Jubilee Health Centre at on 24 January 2024. The rating for the responsive key question is Requires Improvement. As the other domains were not reviewed during this assessment, the rating of good will be carried forward from the previous inspection and the overall rating of the service will remain Good.

Safe - Good

Effective - Good

Caring - Good

Responsive – Requires Improvement

Well-led – Good.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Jubilee Health Centre on our website at www.cqc.org.uk

Why we carried out this inspection.

We carried out this inspection to undertake a targeted assessment of the key question of responsive.

We recognise the work that GP practices have been engaged in to continue to provide safe, quality care to the people they serve. We know colleagues are doing this while demand for general practice remains exceptionally high, with more appointments being provided than ever. In this challenging context, access to general practice remains a concern for people. Our strategy makes a commitment to deliver regulation driven by people’s needs and experiences of care. These assessments of the responsive key question include looking at what practices are doing innovatively to improve patient access to primary care and sharing this information to drive improvement.

How we carried out the inspection

This inspection was carried out remotely.

This included:

  • Conducting staff interviews using video conferencing.
  • Requesting evidence from the provider.

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We found that:

  • The practice understood the needs of its local population and tailored services to meet those needs.
  • The practice worked effectively with local partners to improve access to services for the wider patient population.
  • During the assessment process, the provider highlighted the efforts they are making or are planning to make to improve the responsiveness of the service for their patient population. The effect of these efforts are not yet reflected in patient feedback. Patient feedback was that they could not always access care and treatment in a timely way.

Whilst we found no breaches of regulations, the provider should:

  • Continue with efforts to improve patient satisfaction in relation to access.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

15 April 2019

During a routine inspection

We carried out an announced comprehensive inspection at Jubilee Health Centre on 15 April 2019 as part of our inspection programme.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We carried out an announced comprehensive inspection, at Jubilee Health Centre in September 2018 as part of our inspection programme where the service was rated as requires improvement overall. As a result, we issued requirement notices and a warning notice as legal requirements were not being met and asked the provider to send us a report of the actions they were going to take to meet legal requirements. We then carried out a focused inspection, in February 2019 to follow up on the warning notice. The full comprehensive report of our previous inspection can be found by selecting the ‘all reports’ link for Jubilee Health Centre on our website at

This inspection was an announced comprehensive inspection carried out on 15 April 2019 to check whether the providers had taken action to meet the legal requirement’s’ as set out in the requirement notices and warning notice. The report covers our findings in relation to all five key questions and related population groups.

We have rated this practice as good overall and good for all population groups.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm. There were clear systems for managing risks so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • Since our September 2018 inspection, the practice had reviewed their governance arrangements in a number of areas. For example, processes for the management of medicines had been reviewed and changes made to ensure patients received safe care and treatment that met their needs.
  • There were areas where the practice 2017/18 Quality Outcomes Framework (QOF) performance was below local and national averages. The practice demonstrated awareness of this and were taking action to improve the management of clinical indicators. Data from the 2018/19 QOF year provided by the practice which was unpublished at the time of our inspection, showed actions were having a positive impact on patient outcomes.
  • The practice continued carrying out quality improvement activities in line with their clinical audit plan. Data provided by the practice showed actions taken as a result of audit findings demonstrated quality improvements.
  • Staff we spoke with demonstrated how they ensured patients were dealt with kindness and respect and involved them in decisions about their care. Survey results and feedback form various sources showed mixed views regarding patients’ satisfaction. However, the practice was aware of areas where patients were less satisfied, and actions were being taken to improve patient satisfaction.
  • The national survey results showed as well as feedback received from other sources patients were not consistently positive regarding accessing care and treatment in a timely way. The practice was aware of patients views and had an action plan which enabled the practice to organise and deliver services to meet patients’ needs.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care. For example, following our previous inspection, the practice embraced our findings and demonstrated maturity in regard to implementing a number of changes to their governance structure to support the delivery of safe and effective care. The practice made positive steps to ensure oversight of clinical governance arrangements were operating effectively.

Whilst we found no breaches of regulations, the provider should:

  • Continue reviewing patient feedback and taking action to improve areas where survey results and feedback shows low patient satisfaction.
  • Continue carrying out actions to improve the uptake of national screening programmes as well as childhood immunisations.
  • Continue carrying out quality improvement activities and using information about patients care and treatment to make improvements.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

18 February 2019

During an inspection looking at part of the service

We carried out an announced focused inspection at Jubilee Health Centre on 18 February 2019 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the warning notice we issued on 19 October 2018. This report only covers our findings in relation to those requirements.

At the last inspection in September 2018 we rated the practice as inadequate for providing safe services and requires improvement for providing effective and well-led services. Breaches of legal requirements were found and after our comprehensive inspection we issued the following warning notices:

  • A warning notice informing the practice that they were failing to comply with relevant requirements of the Health and Social Care Act 2008. As a result, the practice were required to become compliant with specific areas of Regulation 12: safe care and treatment HSCA (RA) Regulations 2014, by 12 December 2018.

The full comprehensive report on the September 2018 inspection can be found by selecting the ‘all reports’ link for Jubilee Health Centre on our website at .

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and

We found that:

  • The practice was able to demonstrate they had taken some steps to improve the monitoring of test results prior to issuing a repeat prescription. We saw evidence of ongoing actions being taken to address the areas identified during our previous inspection. A random sample of records we viewed demonstrated that medicines were mostly being prescribed within recommended guidelines.
  • The practice was unable to provide assurance that appropriate monitoring and review of unusual prescribing quantities of controlled drugs was being carried out. Following our inspection, we asked the provider to review controlled drug prescribing and provide a report of their findings. The report showed prescribing was outside national controlled drug prescribing guidelines.
  • We notified Sandwell and West Birmingham Clinical Commissioning Group and the Controlled Drug accountable officer (CDAO) of our findings.
  • We found gaps in the management of patients diagnosed with asthma. Although we saw some evidence of actions that had been taken to improve the management of patients with asthma, these were ongoing and not yet complete.

It was evident that actions had been taken to address and improve some areas of medicines management within the practice. However, we found that some required actions were ongoing and not yet fully embedded or completed. As a result, the areas where the provider must make improvement are:

  • Ensure that care and treatment is provided in a safe way.

The practice is due to be inspected again within six months of publication of the September 2018 comprehensive inspection report. When we re-inspect, we will also look at whether further progress has been made to enable compliance with Regulation 12: safe care and treatment HSCA (RA) Regulations 2014; including specific areas for improvement such as medicines management.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

During a routine inspection

This practice is rated as requires improvement overall. (Previous inspections carried out under the previous providers in January 2017 and September 2017. The practice was rated as Inadequate)

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Requires improvement

We carried out an announced comprehensive inspection at Jubilee Health Centre under the previous provider in January 2017 and September 2017. The practice was rated overall inadequate. As a result, we carried out enforcement actions as legal requirements were not being met and placed the practice into special measures.

We received a registration application from a new partnership and the new legal entity was successfully registered with Care Quality Commission (CQC) in July 2018. The new partnership is formed of two GPs, one of which was a partner in the previous partnership. This inspection, of the new registration, was an announced comprehensive inspection carried out on 11 September 2018 the report covers our findings in relation to all five key questions and six population groups.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • Systems for appropriate and safe monitoring of medicines were not always effective. For example, we saw examples where high-risk medicines were monitored appropriately; however, other medicines were not reviewed or checked in line with guidance to keep patients safe.
  • The practice had a system in place for receiving and acting on drug safety alerts and medicine recalls but not for patient safety alerts. As a result, patient safety alerts which required action had not been acted on. The practice addressed the issues identified during our inspection.
  • Clinical audits showed that the practice was in the first stages of their audit cycle. However, the practice did not have an effective plan to review the effectiveness and appropriateness of the care it provided. The practice was unable to demonstrate actions taken as a result of findings from their data collection exercises.
  • The 2016/17 Quality Outcome Framework related to the previous provider. Data showed that performance for the practice was below local and national averages in several areas. The practice was aware of this and taking some action to improve the monitoring of patients’ treatment.
  • Staff involved and treated patients with compassion, kindness, dignity and respect. Although the 2018 national GP patient survey results which related to the previous partnership indicated positive changes in patient satisfaction with how patients were treated and involved in their care and treatment the results were still below local and national averages.
  • Completed Care Quality Commission (CQC) comment cards showed that patients were positive about the care they received but did not always find the appointment system easy to use and were not always able to access care when they needed it.
  • The practice was aware of patients views and had an active patient participation group who they worked jointly with to improve patient satisfaction. Actions to improve patient satisfaction formed part of the practice business plan.
  • There was a focus on continuous learning and improvement following incidents, complaints and patient satisfaction surveys at all levels of the organisation.
  • The practice was making positive steps towards improving the delivery of the service. For example; since the new partnership formed the practice had developed a clear vision and strategy. The practice were actively strengthening the governance framework; however, improvement plans were ongoing and we found that oversight of clinical governance arrangements were not entirely operating effectively.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Continue reviewing systems to ensure all relevant safety alerts are received and appropriate actions taken to keep patients safe.
  • Establish a system to validate the practice carers list to ensure accurate identification of carers.
  • Continue reviewing patient feedback and taking action to improve areas where survey results and feedback shows low patient satisfaction.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice