We carried out an announced inspection at Jubilee Medical Group between 21 February and 25 February 2022. Overall, the practice is rated as requires improvement.
The key questions are rated as:
Safe - Requires improvement
Effective - Requires improvement
Caring - Good
Responsive - Good
Well-led - Good
At our previous inspection on 14 December 2016, 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 Jubilee Medical Group on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out an announced comprehensive inspection between 21 February and 2 March 2022 as part of our provider monitoring programme.
We undertook this inspection at the same time as CQC inspected a range of urgent and emergency care services in Kent and Medway. To understand the experience of GP Providers and people who use GP services, we asked a range of questions in relation to urgent and emergency care. The responses we received have been used to inform and support system wide feedback.
How we carried out the inspection
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included:
- Conducting staff interviews using video conferencing
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider
- Reviewing patient records to identify issues and clarify actions taken by the provider
- Requesting evidence from the provider
- A short site visit to both main and branch surgery
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 have rated this practice as Requires Improvement overall
We found that:
- Patients received effective care and treatment that met their needs.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
- There was insufficient monitoring of a small number of patients who were prescribed medicines.
- There was a lack of monitoring of staff immunisations and risk assessments had not been undertaken to mitigate risks associated with a lack of immunisation.
- The recording of the investigation and action taken as well as the wider learning for significant events, complaints and safety alerts needed to be improved.
- Although the provider did have a system in place to record and act on safety alerts, we identified one alert which had been issued in the past that had not been acted on.
- We found gaps in processes relating to the monitoring of vaccine fridge temperatures to ensure those medicines remained safe to use .
- Staff recruitment files did not contain all of the required information.
- Medicine reviews and non-urgent referrals were not always completed in the required time frames.
- There was a lack of formalised staff clinical supervision.
- Staff training was not up to date, including safeguarding, basic life support, infection prevention and control, and sepsis.
- We saw evidence that clinicians took part in multi-disciplinary team meetings to discuss patient care.
- The practice was innovative in the use of social media platforms to provide information to patients about various health initiatives. They also held a monthly clinic at the local village hall to help people with the NHS App.
We found breaches of regulations. The provider must:
- Ensure care and treatment is provided in a safe way to patients
- 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 the duties.
- Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed and ensure specified information is available regarding each person employed
The provider should:
- Review and continue to monitor cervical screening to meet the Public Health England screening rate target.
- Continue to plan and carry out staff appraisals.
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