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Inspection Summary

Overall summary & rating


Updated 27 November 2019

We carried out an announced comprehensive inspection at The Walcote Practice on 16 October 2019 as part of our inspection programme and to follow up on breaches of regulations.

The Care Quality Commission (CQC) inspected this service on 7 September 2018 and asked the service to make improvements regarding:

  • Formal staff training relating to safeguarding adults and children.
  • Systems and processes for checking patient identity and confirming parental authority of children who use the service.
  • Systems and processes relating to the checking of emergency medicines and equipment.

We checked these areas as part of this comprehensive inspection and found these issues to have been resolved.

The Walcote Practice provides private GP services to self-funded and privately insured patients who are also registered with an NHS GP. Services include but are not limited to wellness screening and health checks, sexual health checks, and diagnosis and treatment of long-term conditions. The service also provides minor surgery, the fitting of contraceptive implants, joint injections, travel services and vaccines, and mother and baby checks.

The service has a registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We received 39 CQC comment cards from patients about the service. All were positive regarding the service.

Our key findings were:

  • The service had addressed the shortfalls identified at its previous CQC inspection and had made improvements to its systems and processes appropriately in relation to checking emergency medicines and equipment, oversight of safety alerts and checking the identity of patients and parental authority of those that brought children to the service.
  • The service offered a range of health services with a GP, immunisations for children and travel purposes, corporate and individual healthcare.
  • The service had recruited new and experienced staff since our previous inspection to support the increasing demand it was experiencing as the service continued to grow.
  • The service understood the needs of patients and were proactive to ensure the service was accessible.
  • Staff completed expected training either by online training or through in-house refresher training sessions. All staff had received formal safeguarding training appropriate to their role following our previous inspection.
  • The provider made extensive use of patient feedback as a measure to monitor and improve services.
  • The website for the service was very clear and it contained appropriate information regarding treatments available and fees payable.

We saw the following outstanding practice:

  • Through the use of longer appointments, the service had since it began, issued approximately 1,422 immunisations to patients who had previously refused or not received immunisations relating to the NHS immunisation schedule. This ensured more patients, especially children, had achieved better immunity from serious diseases, not previously achieved via the NHS.

The areas where the provider should make improvements are:

  • Continue to receive and review national guidance to ensure all staff are trained to appropriate levels, particularly in relation to safeguarding.
  • Continue to share learning from significant events and complaints with employed and contracted staff as relevant.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas



Updated 27 November 2019

At our previous inspection in September 2018, we found that there were areas where the service was not compliant with the regulations set out by the Health and Social Care Act 2014. These issues included the recording of checks of emergency equipment and emergency medicines; a lack of evidence relating to appropriate safeguarding training for staff relevant to their role; a lack of evidence relating to the checking of patient identity and oversight of actions in response to safety alerts.

At this inspection in October 2019, the service was rated Good for providing safe services as we found:

  • The lead GP, who was the safeguarding lead for the service, had completed up to date safeguarding training in 2018, and the receptionists employed by an independent company to provide receptionist & administrative duties for the service had received formal safeguarding training.
  • The service had implemented an appropriate recording system to document its daily checks of its emergency medicines and equipment.
  • Reasonable adjustments to the service’s process for checking patient identity and ensuring appropriate parental authority for children who attended the service had been implemented.
  • The service had implemented a formal documentation process for the actioning of safety alerts from external organisations such as the Medicines and Healthcare products Regulatory Agency (MHRA).

Safety systems and processes

The service had clear systems to keep people safe and safeguarded from abuse.

  • The service had a suite of safety policies, including a combined vulnerable adults and children safeguarding policy. These were regularly reviewed and communicated to staff. They outlined clearly who to go to for further guidance, such as the overarching safeguarding lead for the service. Staff received safety information from the service as part of their induction and refresher training. The service had systems to safeguard children and vulnerable adults from abuse.
  • Following our previous inspection, the safeguarding lead had completed up to date safeguarding training relevant to their role and the receptionists employed by the independent company, who had previously received informal training from the service, had completed formal safeguarding training to the equivalent of Level 1.
  • However, since January 2019, the Intercollegiate Document stipulates GP practice receptionists should be trained to Level 2 in relation to safeguarding children and adults. We discussed this with the service, who assured us that the receptionists had received the equivalent of level 2 training informally. However, as an interim measure until all appropriate formal training had been completed, the service immediately devised a risk assessment which stipulated a member of staff already trained to Level 2 in safeguarding, such as the practice manager or the practice administrator, would always be present in the service’s waiting area as and when a child was present. The receptionist employed to cover Saturday morning clinics had completed Level 2 in another role and the service confirmed it was satisfied with this. Since inspection, the service has confirmed all receptionists, employed by the independent company, have completed a formal safeguarding module equivalent to Level 2. Reception staff we spoke to on the day of inspection comprehensively knew how to identify and report concerns.
  • Information in the consultation rooms and on the service’s website advised patients that staff were available to act as chaperones. Staff who acted as chaperones were trained for the role and had received a DBS check. The service was able to offer the option of a male chaperone if required. If the male chaperone was not available at the time of an appointment, the appointment was re-arranged at no extra cost to the patient.
  • The service worked with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).
  • Since our previous inspection, the service had taken reasonable steps to implement a new system for checking the identity of patients as well as ensuring the parental authority of those patients under the age of 16 years. We saw evidence of an appropriate policy and procedure relating to this. The service had also undertaken a comprehensive risk assessment relating to seeking the confirmation of patient’s identification or parental authority where applicable.
  • There was an effective system to manage infection prevention and control (IP&C) and reduce the risk and spread of infection. The service received an IPC audit from the local clinical commissioning group (CCG) on 12 September 2019. The service was found to be compliant with CCG’s criterion in relation to IP&C but further recommendations for improved practices were made. We saw that all of these had been addressed or were scheduled to be addressed, such as the ongoing recording of staff immunisation status which was only being recorded at point of initial employment, implementation of an appropriate stock rotation system, and the installation of National Early Warning Score 2 (NEWS2) and FeverPain scoring systems to the service’s clinical record software. (NEWS2 and FeverPain are nationally recognised scoring systems to support the quick identification and treatment of sepsis (NEWS2) and throat infections (FeverPain).
  • Systems were in place to monitor the water system, this included legionella risk assessments. (Legionella is a term for a bacterium which can contaminate water systems in buildings). We saw the service had undertaken regular checks of the water temperature, in accordance with its policy and procedure, to minimise the risk of infection.
  • The service ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.
  • The service carried out appropriate environmental risk assessments, which took into account the profile of people using the service and those who may be accompanying them.
  • General risk assessments were reviewed annually, and an identified risk register was reviewed each month and discussed at the business meeting. The monthly risk assessment record documented what action had been taken.
  • The independent company who owned the building premises in which the service was located managed all arrangements relating to fire safety of the building. No formal documentation was shared with the service, but a good working relationship was maintained, and the practice manager of the service was aware of when fire safety checks and fire alarms were taking place. The last fire drill took place on 3 October 2019.

Risks to patients

There were systems to assess, monitor and manage risks to patient safety.

  • We reviewed the personnel files of the three staff members who had been recruited since our previous inspection and found appropriate recruitment checks had been undertaken prior to employment. For example, proof of identification, evidence of satisfactory conduct in previous employment in the form of three references, evidence of qualifications and registration with professional bodies as applicable to their role and the appropriate checks through the Disclosure and Barring Service.
  • The service maintained a group medical indemnity policy and all clinical staff also chosen to maintain their own individual indemnity cover.
  • The service had an established policy in place which ensured specific members of staff or types of staff were not absent from the service at the same time. For example, the practice manager was not able to be away at the same time as the lead GP, the business director or the practice administrator, and at least two GPs were to be in attendance at the service every week. This ensured the service was appropriately staffed and all areas of the service would be covered in any event of absence.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example sepsis.
  • There were suitable medicines and equipment to deal with medical emergencies which were stored appropriately and, since our previous inspection, there was evidence to demonstrate that these were being checked and recorded daily when the service was open.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • Individual care records were written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • On 1 October 2019, the service had transferred to a new clinical record software system. Patient records continued to be stored electronically and were encrypted to ensure they were safe, secure and adhered to data protection legislation. The service had a system in place to retain medical records in line with Department of Health and Social Care (DHSC) guidance in the event that they cease trading.
  • Due to the nature of the service, if a referral was required the service would either refer a patient back to their NHS GP with an accompanying letter explaining its rationale for the referral or it would directly refer a patient for further private treatment. This decision was made with the patient as an additional cost would be incurred if further private treatment was sought.

Safe and appropriate use of medicines

The service had reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for managing medicines, including vaccines, controlled drugs, emergency medicines and equipment minimised risks. The formal recording for checking the emergency medicines and equipment had improved since our last inspection as there was now a system in place to record the daily checks that took place when the service was operating.
  • The service used private prescriptions which were printed and given to patients. All prescription stationery, including prescriptions awaiting collection, were stored securely.
  • The service carried out regular medicines audit to ensure prescribing was in line with best practice guidelines for safe prescribing.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. The service prescribed Schedule 2, 3 and 4 controlled drugs (medicines that have the highest level of control due to their risk of misuse and dependence). When prescribing such medicines, the clinicians were contacting the patient’s NHS GP to inform of them. The lead GP also maintained a centralised monitoring spreadsheet of all controlled drug prescriptions to ensure oversight and maintain appropriate prescribing within the service.

Track record on safety and incidents

The service had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues.
  • The service monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture that led to safety improvements.
  • There was a system for receiving, reviewing and actioning safety alerts from external organisations such as the Medicines and Healthcare products Regulatory Agency (MHRA). Since our last inspection the service had created a spreadsheet which was maintained by the lead GP to formalise its process and ensure oversight of all alerts. All alerts received were entered into the spreadsheet, all GPs were notified, and the lead GP ran appropriate searches for patients as indicated by each alert. The lead GP would then contact any identified patients and enter appropriate notes into the patient’s records. The alert spreadsheet was then updated to confirm the alerts had been actioned appropriately.

Lessons learned and improvements made

The service learned and made improvements when things went wrong.

  • There was a system for recording and acting on significant events. Staff, including the receptionists employed by the independent company, understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • Significant events or incidents were reviewed and investigated promptly. Since our previous inspection, the service had reported two significant events. The service learned and shared lessons with the relevant staff members, identified themes and took action to improve safety in the service. Where changes to service had been made, these were communicated to staff both verbally and via follow up emails. However, the receptionists employed by the independent company told us they did not receive formal feedback relating to a significant event that they had some involvement with. We raised this with the service who confirmed a verbal debrief had taken place but a formal feedback of learning stemming from the event had not been relayed. The service planned to revise this and provide the receptionists with learning from significant events as and when it related to the service they provided.
  • The provider was aware of and complied with the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. The service had systems in place for knowing about notifiable safety incidents. The service gave affected people reasonable support, truthful information and a verbal and written apology. They kept written records of verbal interactions as well as written correspondence.



Updated 27 November 2019

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance (relevant to their service)

  • The provider assessed needs and delivered care in line with relevant and current evidence based guidance and standards such as the National Institute for Health and Care Excellence (NICE) best practice guidelines.
  • Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing.
  • Clinicians had enough information to make or confirm a diagnosis, and advised patients what to do if their condition got worse and where to seek further help and support.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Staff assessed and managed patients’ pain where appropriate.

Monitoring care and treatment

The service was actively involved in quality improvement activity.

  • The service used information about care and treatment to make improvements.
  • The service made improvements through the use of completed audits. Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to resolve concerns and improve quality. For example, the service now had access to the South Central Antimicrobial Network guidelines for the most current and appropriate information on antibiotic prescribing.
  • The service had conducted a clinical records audit in April 2019 and September 2019. Of the ten patient records reviewed, the results showed the service had made improvements across most areas. For example, the recording of regular medications in patient consultation had improved by 55%, to be up to 80% of records reviewed; the recording of relevant past medical history had improved by 33%, to be up to 83% of records reviewed, and the correct recording of a patient’s allergies into an easily visible area had improved by 20%, to be up to 100% of records reviewed. The only area where the service had decreased by 2% from its initial audit was in the recording of a named NHS GP, where 10% of records had met the expected standard. The service explained that most patients were recording their NHS GP practice but not the specific GP, so the service were discussing whether or not a named NHS GP was required for the purpose of its own patient records.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff.
  • All medical professionals were registered with the General Medical Council (GMC) and were up to date with revalidation.
  • The service understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop. The reception and administrative staff provided by an independent company were included in all in-house refresher training sessions.
  • All staff, including those employed by the independent company, had training records and we saw evidence to demonstrate that all staff had completed training modules as required by the service, such as fire safety, basic life support, information governance and infection prevention and control.
  • Staff whose role included immunisation and reviews of patients with long term conditions had received specific training and could demonstrate how they stayed up to date.
  • Each staff member had an annual or bi-annual appraisal where training needs were identified, but staff said training needs could also be identified informally throughout the year as required.
  • The GPs at the service all completed additional work within the NHS system and the service supported the GPs in the completion of their annual appraisal process.

Coordinating patient care and information sharing

Staff worked together, and worked well with other organisations, to deliver effective care and treatment.

  • Patients received coordinated and person-centred care. This included when they moved between services and when they were referred for specialist care.
  • All patients were encouraged to keep an NHS GP for access to out of hours care, and the service communicated with a patient’s NHS GP with the patient’s consent. For example, if a patient required follow-up treatment via the NHS.
  • As the service provided the national programme of childhood immunisations for babies and children, a child’s NHS GP was notified if the service administered immunisations to avoid the risk of a child receiving the same immunisation twice.
  • Before providing treatment, doctors at the service ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history. We saw examples of patients being signposted to more suitable sources of treatment where this information was not available to ensure safe care and treatment.
  • The provider had risk assessed the treatments they offered. They had identified medicines that were not suitable for prescribing if the patient did not give their consent to share information with their GP, or they were not registered with a GP. For example, medicines liable to abuse or misuse, and those for the treatment of long-term conditions such as asthma. Where patients agreed to share their information, we saw evidence of letters sent to their registered GP in line with GMC guidance.
  • Patient information was shared appropriately (this included when patients moved to other professional services), and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way. There were clear and effective arrangements for following up on people who had been referred to other services.

Supporting patients to live healthier lives

Staff were consistent and proactive in empowering patients and supporting them to manage their own health and maximise their independence.

  • The service offered a range of medical assessments which included pathology tests and patients could be referred for diagnostic screening such as X-ray, ultrasound, CT scanning and MRI.
  • Health screening packages were available to all patients and included an assessment of lifestyle choices.
  • Patients were encouraged to undergo regular health screening such as mammograms and cervical screening. The service referred patients to other providers for mammograms, as, following the recruitment of a female GP, the service was now able to offer appointments for a cervical screen with a female clinician.
  • Staff encouraged and supported patients to be involved in monitoring and managing their own health.

Consent to care and treatment

The service obtained consent to care and treatment in line with legislation and guidance


  • Clinicians understood the requirements of legislation and guidance when considering consent and decision making, including the Mental Capacity Act 2005.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The service monitored the process for seeking consent appropriately. We saw consent was recorded in the patient’s electronic records, in line with legislation and relevant national guidance. The service had improved how it assured itself of parental authority of children who used the service.
  • Information about fees for the service provided by the service was transparent and available online prior to clients booking an appointment. For example, fees for additional blood tests were discussed prior to procedures being undertaken.



Updated 27 November 2019

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • The service sought feedback on the quality of clinical care patients received and used patient feedback to monitor and improve its services. This was done through the use of evaluation surveys, compliments, complaints, and results from online reviews.
  • Feedback from patients was positive about the way staff treat people. We received 39 comment cards from patients for this inspection and all 39 provided positive reports on how they were treated at the service.
  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service had a system to identify patients who were also carers. Those patients received priority booking for consultations or home visits were arranged.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment.

  • Staff told us interpreting and translation services could be made available for patients who did not have English as a first language, and for patients who were either deaf or had a hearing impairment. Service leaflets could also be made available in large print and Easy Read format, which makes information easier to access for patients with learning disabilities or visual impairments.
  • The service gave patients timely support and information. Information about the service, including consultation fees and healthcare package fees, were easily accessible on the service’s website. Information relating to fees was also included in a patient resources folder kept in the waiting area of the premises building. Information relating to healthplan fees was also included in an initial confirmation letter to the patient upon booking with the service.
  • Patients told us through comment cards, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.
  • For patients with learning disabilities or complex social needs family, carers or social workers were appropriately involved.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.
  • Staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.



Updated 27 November 2019

Responding to and meeting people’s needs

The service organised and delivered services to meet patients’ needs.

It took account of patient needs and preferences.

  • The provider understood the needs of their patients and improved services in response to those needs. For example, following media coverage in 2016 in relation to Meningitis B, the service was faced with an excessive increased demand and limited stock due to a nationwide shortage of the immunisation. In response, the service found new supplies, arranged specific Saturday morning immunisations clinics and issued a total of 634 Meningitis B immunisations, the equivalent to 315 children being immunised, between June 2016 and June 2017. On review, the service confirmed it had immunised a total of 485 children against Meningitis B since the service began in June 2015.
  • The service provided immunisations for travel purposes and those relating to the NHS immunisation schedule. The fees for each immunisation were clearly listed on the service’s website. The service told us they had administered an approximate 1,422 immunisations, since the service started in June 2015, to patients who had previously refused or had not received immunisations previously.
  • In response to identifying that many of its patients experienced poor mental health and the service was almost reaching clinical capacity to meet the need, the service had recruited a new clinical member of staff with a special interest in psychiatry. Since the start of their employment in October 2018, the new GP has seen approximately 60 patients who have presented with specific poor mental health issues in addition to other patients presenting with a wide variety of health conditions. The service identified this specific recruitment had reduced the workload on the other GPs at the service, increased overall clinical capacity and provided an extra source of support and advice for all at the service in relation to helping patients with poor mental health.
  • The service attended offices of companies with whom they had a contract to administer flu vaccines for employees so that they did not have to attend the service.
  • The service delivered prescriptions to patients who were not able to attend the service.
  • The facilities and premises were appropriate for the services delivered. The service was located in a Grade II listed building, which was shared with other services.
  • The service was not accessible for patients who used a wheelchair as the building had steps to the front entrance. Patient mobility was checked at point of booking and the premises building’s access was stated on the service’s website. Instead, GPs offered to visit patients who used a wheelchair at their homes.
  • The service had a range of information available to patients. The website for the service was very clear and easily understood. In addition, it contained valuable information regarding treatment and fees payable.
  • Reasonable adjustments had been made so that people in vulnerable circumstances could access and use services on an equal basis to others.

Timely access to the service

Patients were able to access care and treatment from the service within an appropriate timescale for their needs.

  • The service was open from 8am until 6.30pm Monday to Friday and 9am until 12.30pm every Saturday. Home visits and consultation appointments were available during those times. The service told us that GPs sometimes conducted home visits in the evenings, at an agreed time and convenience of patients.
  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised. The service told us that on most occasions they were able to see patients on the same day or within 48 hours of a request for a consultation. This was reflected in comments received via the CQC comment cards and the service’s own patient feedback.
  • Patients paid per home visit or per 20 minute or 30-minute consultation and the fees payable were discussed before a consultation was undertaken.
  • GPs provided patients who were at the end of their life with personal contact telephone numbers.
  • Patients were encouraged to remain registered with an NHS GP in order to access other forms of out of hours care as required.
  • Referrals and transfers to other private services were undertaken in a timely way, or patients were directed back to their NHS GP to seek NHS treatment.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The service had received two complaints since our previous inspection. We reviewed both complaints and found the service had investigated and responded to the complainants comprehensively and in a timely manner with appropriate explanations and an apology from the service.
  • The service informed patients of any further action that may be available to them should they not be satisfied with the response to their complaint.
  • The service had complaint policy and procedures in place. The service learned lessons from individual concerns, complaints and from analysis of trends. It acted as a result to improve the quality of care, such as sourcing up to date training for its clinicians in relation to contraceptive implant insertion.



Updated 27 November 2019

At our previous inspection in September 2018, we found that there were areas where the service was not compliant with the regulations set out by the Health and Social Care Act 2014. These issues were in relation to a lack of appropriate governance arrangements to ensure appropriate oversight was in place to reduce potential risks to patients.

At this inspection in October 2019, the service was rated Good for providing well-led services as we found the service had implemented and embedded new systems and processes to ensure oversight was comprehensive and risks to patient safety was reduced.

Leadership capacity and capability;

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders had the experience, capability and integrity to deliver the service’s strategy and address the risks to it. The service had recruited an experienced practice manager to join its management structure and support the established leadership that was already in place.
  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. understood the challenges and were addressing them. The service leaders maintained a risk register of identified risks and we saw evidence of monthly meetings to review the register to ensure actions to resolve the risks were progressing appropriately.
  • Leaders were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership. Staff we spoke to during the inspection told us they were well-supported by the service leaders and reported they all took the time to listen and support as required.
  • The service had effective processes to plan for the future leadership of the service.

Vision and strategy

The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.

  • There was a clear vision and set of values. The service had a realistic strategy and supporting business plans to achieve priorities.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them
  • The service had planned its services to meet the needs of their patients to provide affordable and timely access to healthcare. The service wished to compliment the services provided by the NHS rather than be in competition with it.
  • The service monitored progress against delivery of the strategy.


The service had a culture of high-quality sustainable care.

  • Staff felt respected, supported and valued. They were proud to work for the service.
  • The service focused on the needs of patients.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.

  • We saw the service had implemented positive changes to the care and treatment of patients following reviews of complaints and significant event analysis. Lessons learned had been shared with relevant staff on each occasion, but we found evidence to suggest the relay of relevant information to the receptionists employed by the independent company was not formally embedded.
  • Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed. The service had a whistleblowing policy in place.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary. Clinical staff were given protected time for professional time for professional development and evaluation of their clinical work.
  • There was a strong emphasis on the safety and well-being of all staff. For example, the service had a lone worker policy and procedure which covered any potential risks when staff visited patients in their own homes.
  • The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care.
  • Staff, including those employed by an independent company but provided reception and administrative duties for the service, were clear on their roles and accountabilities.
  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Leaders had oversight of safety alerts, incidents, and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change services to improve quality.
  • The service had plans in place and had trained staff for major incidents.
  • The service implemented service developments and where efficiency changes were made this was with input from clinicians to understand their impact on the quality of care.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in meetings where relevant staff had sufficient access to information.
  • The service used performance information which was reported and monitored, and management and staff were held to account
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The service submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The service involved patients, the public, staff and external partners to support high-quality sustainable services.

  • The service encouraged and heard views and concerns from the public, patients, staff and external partners and acted on them to shape services and culture. Patients were regularly invited to completed surveys about the service they had received and, in addition, patient feedback forms were always readily available in the patient folder in the reception waiting area. Feedback was constantly monitored, and action was taken if feedback indicated that the quality of the service could be improved.
  • The service also gathered feedback from staff through staff meetings, appraisals, and through formal and informal discussions.
  • Staff could describe to us the systems in place to give feedback, such as twice-yearly staff satisfaction surveys. The receptionists employed by the independent company were also included in the staff surveys. The most recent staff survey, completed in June 2019, demonstrated that 100% of staff were happy working at the practice, that they were able to approach management about concerns or problems and the service was a good employer. The only area indicated for improvement was around 50% staff feeling involved with the running of the service, such as ‘receiving communication about certain things ahead of time’. The service confirmed it was working on ways to improve communication with all staff, including those employed externally for the service.
  • The service documented all suggestions made by patients and external partners. There was an overview system for all suggestions made and actioned. For example, the service had created immunisation record cards so patients who received immunisations had a single record to refer back to following suggestions from patients.
  • The service was transparent, collaborative and open with stakeholders about performance.
  • The service told us it had attempted to introduce a patient participation group (PPG) to promote engagement with its patients regarding service developments and improvements but it had so far received little engagement from its patients about forming such a group formally. Instead, the service was now exploring the option of a virtual PPG.

Continuous improvement and innovation

There were systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement.
  • The service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.