St James Medical Practice

We carried out an announced comprehensive at St James Medical Practice on 12 October 2023. Overall, the practice is rated as requires improvement.

Safe - requires improvement

Effective - requires improvement

Caring - good

Responsive - good

Well-led - requires improvement

Following our previous inspection on 27 January 2015, the practice was rated good overall and for all key questions. The full reports for previous inspections can be found by selecting the ‘all reports’ link for St James Medical Practice on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting clinical staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A short site visit.

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:

• Governance systems required strengthening to ensure risks were mitigated. This included the management of risk assessments and acting on action plans.
• Systems required strengthening to ensure learning from incidents, and complaints was shared amongst all staff.
• We found the premises were well maintained and appeared clean and tidy; however, the infection control audit was not effective as no actions had been taken to mitigate risks that had been identified.
• Recruitment processes required improvement to ensure all potential employees had the appropriate documentation and staff immunisation status was recorded to mitigate risks to both patients and staff.
• The way the practice was led and managed needed definition as there was no effective delegation in place to manage the practice and ensure staff were clear about their roles and responsibilities.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Patients could access care and treatment in a timely way.
• Patient feedback through the National Patient Survey was positive in relation to access and the provision of care.

We found breaches of regulations. The provider must:

• 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.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.

The provider should:

• Take steps to improve the uptake of childhood immunisations and cervical cancer screening.
• Implement a process to follow up on bereaved patients to offer them support and guidance.
• Take action to issue steroid cards to patients where needed.

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