- GP practice
Archived: JS Medical Practice
All Inspections
12 Dec 2018
During an inspection looking at part of the service
We carried out an announced focussed inspection at JS Medical Practice on 13 December 2018 to follow up on issues we found at our last inspection in June 2018. A copy of our pervious inspection report can be found by going to and selecting the Reports tab.
In addition to the areas which were identified for improvement under the key questions of providing effective and well-led services relating to that inspection, we also said the practice should make improvements in the following area:
- Review how to improve the security of waste storage bins outside of the three practice locations.
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, its staff, patients, the public and other organisations.
We have rated this practice as good overall and good for all population groups.
We found that:
- The practice had made improvements to the security of waste bins outside the three practice locations. At the Philip Lane and Westbury Avenue locations the clinical waste bin was secured to a fixed point with a chain and lock. At the Park Lane location, the clinical waste bin was stored in a secure area behind the practice.
- Patients with long-term conditions had a structured annual review to check their health and medicines needs were being met.
- Patients received effective care and treatment that met their needs.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
- Staff who were responsible for reviews of patients with long-term conditions had received specific training.
- Staff used data to adjust and improve performance.
- Leaders demonstrated that they understood the challenges to quality and sustainability.
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
07 June 2018
During a routine inspection
This practice is rated as Requires Improvement overall. (Previous inspection September 2015 – Good)
The key questions are rated as:
Are services safe? – Good
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 JS Medical Practice on 7 June 2018. We carried out this inspection as part of our inspection programme.
At this inspection we found:
- The practice’s QOF achievement (Quality and Outcomes Framework) was below local and national averages in a number of areas including for patients with diabetes, long-term conditions and those with mental health issues.
- The practices performance for cervical screening and screening for breast and bowel cancer were below local and national averages.
- There was no standard procedure for recording QOF (Quality and Outcomes Framework) and screening programme information across the practice’s three branches. This had resulted in its QOF achievement being, in some areas, significantly below CCG and national averages. Its performance for screening for breast and bowel cancer was below CCG and national averages. In addition, its performance for childhood immunisations was below World Health Organisation targets.
- The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
- There was a positive and open culture and staff felt supported by the practice leaders.
- There was a strong focus on continuous learning and improvement at all levels of the organisation.
- Staff who acted as chaperones received training for this role.
- All staff of the practice received DBS (Disclosure and Barring Service) checks.
- The practice had systems to manage risk so that safety incidents were less likely to happen.
The areas where the provider must make improvements are:
- Ensure the care and treatment of patients is appropriate, meets their needs and reflects their preferences.
- 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:
- Review how to improve the security of waste storage bins outside of the three practice sites.
Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice
15 September 2015
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at JS Medical Practice on 15 September 2015. Overall the practice is rated as good.
Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.
Our key findings across all the areas we inspected were as follows:
- Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
- Risks to patients were assessed and well managed.
- Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
- Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
- Information about services and how to complain was available and easy to understand.
- Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
- There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
However, there were areas of practice where the provider needs to make improvements.
The provider should:
- Develop a full business continuity plan.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice