During an assessment under our new approach
Date of Assessment: 17 December 2025 (Remote clinical searches) and 18 December 2025 (Site visit).
We carried out this announced comprehensive assessment as part of our regulatory functions.
The Connaught Square Practice is a GP practice and delivers service to 11,420 patients under a contract held with NHS England. The National General Practice Profiles states that the ethnic make-up of the practice is 52% White, 21% Asian, 6% Black, 6% Mixed and 15% Other ethnic groups.
Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population groups as 7, on a scale of 1 to 10. The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
SAFE: Recruitment checks were not always carried out in accordance with regulations prior to employment. Disclosure and Barring Service (DBS) checks were not always undertaken appropriate to the role where required. We found concerns related to the monitoring of some high-risk medicines, some emergency medicines and monitoring of the prescription box for uncollected prescriptions. The practice did not make sure relevant fire and legionella risk assessments were carried out by a qualified person in a timely manner. The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed most risks. The facilities and equipment met the needs of people, were clean and well-maintained. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care.
EFFECTIVE: People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. However, our clinical records searches identified some gaps in medicine reviews for patients with asthma and patients prescribed bisphosphonates (which are used to treat and prevent bone-related conditions such as osteoporosis). Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people took decisions in people’s best interests where they did not have capacity.
CARING: People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. The service supported staff wellbeing.
RESPONSIVE: People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. We noted toilet facilities were located on the lower ground (basement) floor only and were not accessible to patients with mobility difficulties. The practice was situated in a Grade II listed building, which limited the extent to which structural alterations could be made to improve accessibility. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care.
WELL-LED: Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. However, we found there was a lack of good governance in some areas. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas. The practice was in the process of re-establishing the Patient Participation Group (PPG).
At this assessment, we found breaches of the following regulations:
- Regulation 12 (Safe care and treatment), and
- Regulation 19 (Fit and proper persons employed).
We have asked the provider for an action plan in response to the concerns found at this assessment.