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 Data from the 2018/19 QOF year provided by the practice which was unpublished at the time of our inspection, showed actions were having a positive impact on patient outcomes.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

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