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Falmouth Road Group Practice Good

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating


Updated 15 June 2018

This practice is rated as Good overall. (Previous inspection 26 October 2017 – Requires Improvement). The practice was previously operated by another provider. This provider was placed in special measures and subsequently had their CQC registration cancelled. The current provider (AT Medics) began operating the site in January 2017. Special measures transferred to the current provider when they assumed responsibility for the practice. At our last inspection we found that the new provider had not made sufficient improvement to come out of special measures.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Falmouth Road Group Practice on 26 April 2018 to follow up on breaches of regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 identified at our last inspection completed on 26 October 2017.

Concerns at our last inspection related to the management of medicines, systems to manage infection control, safeguarding, safety alerts and significant events. We also found that some pathology results had not been actioned within a reasonable timeframe. Our previous report can be found at

At this inspection we found:

That the provider had addressed all of the concerns raised at our previous inspection. In addition the practice continued to work to improve the standard of care and patient satisfaction after taking over operating the service from the previous provider in January 2017.

In addition:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • 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 strong focus on continuous learning and improvement at all levels of the organisation.

We saw one area of outstanding practice:

  • All Pharmacists working for the organisation were required to undergo objective structured clinical examination (OSCE) provided through AT Medics. This involved eight stations covering various prescribing areas including depression, contraception and pre diabetes. Each station had an actor and an examiner. Following the exam all pharmacists received individual and collective feedback. If a pharmacist has scored particularly poorly in an area, they would undergo remedial training or focused observation to see if they are safe to continue in that particular area.

The areas where the provider should make improvements are:

  • Continue with work to improve the uptake of bowel and breast screening.

  • Advertise translation services in the reception area.

I am taking this service out of special measures as a result of the significant improvements that the provider has made.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Inspection areas



Updated 15 June 2018

At our previous inspection we rated the service as inadequate for providing safe services. We identified concerns related to the management of medicines. For example we found that vaccine fridge temperatures had gone out of range and no action had been taken to ensure the vaccines remained safe to use. There was a lack of clear learning from significant events and there was limited evidence of action taken in response to patient safety alerts. Practice policies for safeguarding did not contain the names the current leads. We found that risks associated with infection control had not all been addressed satisfactorily and that there were a number of pathology results which had not been actioned within a reasonable timeframe.

At this inspection we found that the provider had taken action to address all of these concerns. Consequently the provider is now rated as good for providing safe services.

Safety systems and processes

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

  • At the last inspection we found that the practice’s safeguarding policies did not contain correct information about the practice’s safeguarding leads. At this inspection we found that practice had appropriate systems to safeguard children and vulnerable adults from abuse. All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns and policies contained all appropriate information. Information about the identity of the safeguarding leads was posted on the walls in the practice and the current leads were noted within the policy. Reports and learning from safeguarding incidents were available to staff. Staff who acted as chaperones were trained for their role and had received a DBS check. (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.)
  • Staff took steps, including working with other agencies, to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect. The practice held meetings with the health visitor every eight weeks.
  • The practice carried out appropriate staff checks at the time of recruitment and on an ongoing basis.
  • At the last inspection we found that the premises were not cleaned in all areas to a satisfactory standard including in the patient toilets and some clinical areas and that some pieces of clinical equipment had expired. We found that there were now effective system to manage infection prevention and control. Though the practice still reported that there were occasional issues with their cleaning company, staff were in regular communication with the contractor to ensure than the premises were cleaned to an acceptable standard. Expiry dates of equipment were regularly checked.
  • The practice had arrangements to ensure that facilities and equipment were safe and in good working order.
  • Arrangements for managing waste and clinical specimens kept people safe.

Risks to patients

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

  • Arrangements were in place for planning and monitoring the number and mix of staff needed to meet patients’ needs, including planning for holidays, sickness, busy periods and epidemics.
  • There was an effective induction system for temporary staff tailored to their role. As part of the induction/probationary process for non-clinical staff the practice manager met with staff every month to review the staff member’s progress and identify any additional training needs or support.
  • The practice was equipped to deal with medical emergencies and staff were suitably trained in emergency procedures. The practice had carried out a simulated anaphylaxis event to test the responsiveness of staff.
  • Staff understood their responsibilities to manage emergencies on the premises and to recognise those in need of urgent medical attention. Clinicians knew how to identify and manage patients with severe infections including sepsis. All staff within the practice had been on a training course about sepsis.
  • When there were changes to services or staff the practice assessed and monitored the impact on safety.

Information to deliver safe care and treatment

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

  • At the previous inspection we found that not all pathology results had been reviewed and actioned within an appropriate timescale. We found on this inspection that there were no overdue pathology results requiring action. In addition records we saw showed that information needed to deliver safe care and treatment was available to staff.
  • The practice had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • Clinicians made timely referrals in line with protocols.

Appropriate and safe use of medicines

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

  • At the last inspection we found that the practice had not taken action when vaccine fridge temperatures had gone out of range. At this inspection we saw that the systems for managing and storing medicines, including vaccines, medical gases, emergency medicines and equipment, minimised risks.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with current national guidance. The practice had reviewed its antibiotic prescribing and taken action to support good antimicrobial stewardship in line with local and national guidance.
  • Patients’ health was monitored in relation to the use of medicines and followed up on appropriately. Patients were involved in regular reviews of their medicines.

Track record on safety

The practice had a good track record on safety.

  • There were comprehensive risk assessments in relation to safety issues.
  • The practice monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture of safety that led to safety improvements.

Lessons learned and improvements made

The practice learned and made improvements when things went wrong.

  • Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • At our last inspection we found that the systems for reviewing and investigating when things went wrong were lacking as there was not always clear evidence of learning from significant events and no event had been raised when vaccine fridge temperatures had gone out of range. We found at this inspection that systems for learning from significant events had improved and there was evidence that the practice learned and shared lessons, identified themes and took action to improve safety in the practice.
  • At the last inspection we found that the practice held a log of patient safety alerts and there was evidence that these had been cascaded to clinical staff but there was no evidence of action taken in response to relevant alerts. At this inspection we found evidence of action taken in response to patient and medicine safety alerts.

Please refer to the Evidence Tables for further information.



Updated 15 June 2018

At our last inspection we rated the practice as good for providing effective services. Evidence showed that the provider had continued to improve the quality of clinical care provided to patients. Consequently the provider remains rated good for all of the population groups in respect of providing effective services


(Please note: Any Quality Outcomes (QOF) data relates to 2016/17 and this predominantly relates to performance under the previous provider, although 27% of achievement relates to the time between the current provider starting to operate the service in January 2017 and the end of the QOF year on 31 March 2017. Any reference to 2017/18 data is data which has been supplied by the practice and has not been officially verified. QOF is a system intended to improve the quality of general practice and reward good practice.)

Effective needs assessment, care and treatment

The practice had systems to keep clinicians up to date with current evidence-based practice. We saw that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols.

  • Patients’ immediate and ongoing needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Staff used appropriate tools to assess the level of pain in patients.
  • Staff advised patients what to do if their condition got worse and where to seek further help and support.

Older people:

  • Older patients who are frail or may be vulnerable received a full assessment of their physical, mental and social needs. The practice used an appropriate tool to identify patients aged 65 and over who were living with moderate or severe frailty. Those identified as being frail had a clinical review including a review of their medicines. 78% of patients taking more than four medicines had been reviewed in the last 12 months.
  • Patients aged over 75 were invited for a health check. If necessary they were referred to other services such as voluntary services and supported by an appropriate care plan. Over a 12 month period the practice had undertaken 37 holistic health assessments for frail elderly patients.
  • Clinical queries about older patients with complex conditions could be submitted to a consultant geriatrician from a local hospital who would provide advice and support.
  • The practice followed up on older patients discharged from hospital. It ensured that their care plans and prescriptions were updated to reflect any extra or changed needs.
  • Staff had appropriate knowledge of treating older people including their psychological, mental and communication needs.
  • The practice had increased the percentage of patients over 65 who received a flu immunisation since taking over the service. Performance for 2016/17 was 51% and this had increased to 68% in 2017/18.

People with long-term conditions:

  • Patients with long-term conditions had a structured annual review to check their health and medicines needs were being met. For patients with the most complex needs, the GP worked with other health and care professionals to deliver a coordinated package of care.
  • Staff who were responsible for reviews of patients with long term conditions had received specific training.
  • GPs followed up patients who had received treatment in hospital or through out of hours services for an acute exacerbation of asthma.
  • The practice was able to demonstrate how they identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension)
  • The practice had worked hard to improve QOF performance and there was improvement between 2016/17 and 2017/18 in respect of overall performance and specific areas of long term condition management. For example the provider supplied unverified data for 2017/18 which showed of the 377 patients on the practice’s diabetic register 86% had all eight care processes completed compared to 60% in 2016/17 under the previous provider.

Families, children and young people:

  • Childhood immunisations were carried out in line with the national childhood vaccination programme. Currently published official data related to the time the service was operated by the previous provider and showed that uptake rates for the practice population were not in line with the 90% national target. The practice provided unverified data which showed that uptake rates for the vaccines given to children were now in line with the target percentage of 90% or above.
  • The practice had arrangements to identify and review the treatment of newly pregnant women on long-term medicines and with long term conditions like diabetes and epilepsy. These patients were provided with advice and post-natal support in accordance with best practice guidance.
  • The practice had arrangements for following up failed attendance of children’s appointments for secondary care or immunisation.

Working age people (including those recently retired and students):

  • The practice provided evidence that the uptake for cervical screening in 2017/18 was 80%, which is the coverage target for the national screening programme.
  • The practice’s uptake for breast and bowel cancer screening was below the national average. Published data related to the period of time the previous provider operated the service. However, in response to the below average uptake among practice patients in 2016/17 the practice informed us that they were now proactively read coding and contacting patients periodically who failed to return their bowel screening kit or did not attend their appointment by text message or letter. This had been operational for the previous six months but the practice did not have access to any data which would show if uptake had improved as this was not available.
  • Patients had access to appropriate health assessments and checks including NHS checks for patients aged 40-74. There was appropriate follow-up on the outcome of health assessments and checks where abnormalities or risk factors were identified.

People whose circumstances make them vulnerable:

  • End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.
  • The practice held a register of patients living in vulnerable circumstances including homeless people and those with a learning disability.
  • The practice had a system for vaccinating patients with an underlying medical condition according to the recommended schedule. Fifty two percent of eligible patients under 65 had received a flu immunisation in 2017/18 which was higher than in the previous year and higher than the London average of 45%.

People experiencing poor mental health (including people with dementia):

  • The practice assessed and monitored the physical health of people with mental illness, severe mental illness, and personality disorder by providing access to health checks, interventions for physical activity, obesity, diabetes, heart disease, cancer and advice on locally commissioned ‘stop smoking’ services. There was a system for following up patients who failed to attend for administration of long term medicines.
  • When patients were assessed to be at risk of suicide or self-harm the practice had arrangements in place to help them to remain safe.
  • 82% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the previous 12 months. This is comparable to the national average. The practice indicated that they had achieved 88% in 2017/18.
  • 91% of patients diagnosed with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive, agreed care plan documented in the previous 12 months. This is comparable to the national average. The practice indicated that they had achieved 88% in 2017/18.
  • The practice specifically considered the physical health needs of patients with poor mental health and those living with dementia. For example 90% of patients experiencing poor mental health had received discussion and advice about alcohol consumption in 2016/17. This is comparable to the national average.
  • Patients at risk of dementia were identified and offered an assessment to detect possible signs of dementia. When dementia was suspected there was an appropriate referral for diagnosis.

Monitoring care and treatment

The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided. For example the practice had undertaken audits of patients prescribed warfarin, cervical screening and prescribing of antibiotics for urinary tract infections. These were all two cycle audits which demonstrated improvement in the quality of care.

  • The practice had taken over operating the service from the previous provider in January 2017. Consequently QOF data for 2016/17 only reflected part of the current provider’s achievement. We were provided with data at our last inspection which indicated that although the provider had only been operating from the site for a period of three months they had managed to achieve 27% of the points obtained. The practice provided us with unverified data for 2017/18 which showed that performance had further improved in all areas. The service was now in line with local and national averages for all QOF targets. There were higher rates of exception reporting in a number of areas though evidence provided showed that in most cases exceptions were justifiable. Currently available Public Health England data, which related to the time the previous provider operated the location, showed that there was a below average uptake for both breast and bowel screening compared to the local and national average. The practice had implemented systems to follow up patients who did not attend for bowel screening and told us that they intended to implement a similar system for breast screening in the future.
  • The practice used information about care and treatment to make improvements.
  • The practice was actively involved in quality improvement activity. Where appropriate, clinicians took part in local and national improvement initiatives.

Effective staffing

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

  • Staff had appropriate knowledge for their role, for example, to carry out reviews for people with long term conditions, older people and people requiring contraceptive reviews. AT Medics provided staff with regular internal clinical update training. For example they offered a fortnightly consultant led web based training on specialist areas, quarterly faced to face training for nursing staff. In addition web based training was offered to enable administrative staff to develop their skills.
  • Staff whose role included immunisation and taking samples for the cervical screening programme had received specific training and could demonstrate how they stayed up to date.
  • The practice 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 practice provided staff with ongoing support. This included an induction process which included regular one to ones with the practice manager, appraisals, coaching and mentoring, clinical supervision and support for revalidation. The induction process for healthcare assistants included the requirements of the Care Certificate. The practice ensured the competence of staff employed in advanced roles by audit of their clinical decision making, including non-medical prescribing. The practice required pharmacists to undertake written exams as well as practical exams featuring mock clinical scenarios.
  • There was a clear approach for supporting and managing staff when their performance was poor or variable.

Coordinating care and treatment

Staff worked together and with other health and social care professionals to deliver effective care and treatment.

  • We saw records that showed that all appropriate staff, including those in different teams and organisations, were involved in assessing, planning and delivering care and treatment.
  • The practice shared clear and accurate information with relevant professionals when deciding care delivery for people with long term conditions. The shared information with, and liaised, with community services, social services and carers for housebound patients and with health visitors and community services for children who have relocated into the local area.
  • Patients received coordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from hospital. The practice worked with patients to develop personal care plans that were shared with relevant agencies.
  • The practice ensured that end of life care was delivered in a coordinated way which took into account the needs of different patients, including those who may be vulnerable because of their circumstances.

Helping patients to live healthier lives

Staff were consistent and proactive in helping patients to live healthier lives.

  • The practice identified patients who may be in need of extra support and directed them to relevant services. This included patients in the last 12 months of their lives, patients at risk of developing a long-term condition and carers.
  • Staff encouraged and supported patients to be involved in monitoring and managing their own health, for example through social prescribing schemes.
  • Staff discussed changes to care or treatment with patients and their carers as necessary.
  • The practice supported national priorities and initiatives to improve the population’s health, for example, increasing the uptake of flu and shingles immunisations, completing all eight care processes for patients with diabetes and tackling obesity.

Consent to care and treatment

The practice 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.
  • Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The practice monitored the process for seeking consent appropriately.

Please refer to the Evidence Tables for further information.



Updated 15 June 2018

At the previous inspection we rated the provider as requires improvement for caring as feedback from patients about satisfaction with the practice’s nursing service was below local and national averages. The practice had undertaken a subsequent survey which produced positive feedback in all areas. Consequently the provider is rated good for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat people.
  • Staff understood patients’ personal, cultural, social and religious needs.
  • The practice gave patients timely support and information.
  • National patient survey data was below local and national averages in a number of areas. The most recently published data was collected between January 2017 and March 2017 and is therefore not likely to reflect the service provided by the current provider. The provider undertook a survey prior to our last inspection. The feedback from this survey indicated that there was dissatisfaction amongst patients in respect of the nursing service. The practice had undertaken several surveys prior to this inspection. All feedback provided showed that patient satisfaction with the care provided had improved.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment. They were aware of the Accessible Information Standard (a requirement to make sure that patients and their carers can access and understand the information that they are given.)

  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available.
  • Staff helped patients and their carers find further information and access community and advocacy services. They helped them ask questions about their care and treatment.
  • The practice proactively identified carers and supported them. The practice had held three carers’ events. Carers who registered with the practice were provided with a carers pack from a local carer support service once they had identified themselves as a carer. The practice provided carers with annual healthchecks and offered flu immunisations.
  • Again the practice’s most recent independent internal survey data showed that feedback was positive in respect of patient involvement about decisions in their care and treatment.

Privacy and dignity

The practice respected patients’ privacy and dignity.

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

Please refer to the Evidence Tables for further information.



Updated 15 June 2018

We rated the practice, and all of the population groups, as good for providing responsive services at our last inspection. The practice remains rated good for responsive across all population groups.

Responding to and meeting people’s needs

The practice organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • The practice understood the needs of its population and tailored services in response to those needs.
  • The practice offered transaltion services though these were not advertised in the reception area.
  • Telephone consultations were available which supported patients who were unable to attend the practice during normal working hours.
  • The facilities and premises were appropriate for the services delivered.
  • The practice made reasonable adjustments when patients found it hard to access services.
  • The practice provided effective care coordination for patients who are more vulnerable or who have complex needs. They supported them to access services both within and outside the practice.
  • Care and treatment for patients with multiple long-term conditions and patients approaching the end of life was coordinated with other services.

Older people:

  • All patients had a named GP who supported them in whatever setting they lived.
  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs. The GP and practice nurse also accommodated home visits.
  • There was a medicines delivery service for housebound patients.

People with long-term conditions:

  • Patients with a long-term condition received an annual review to check their health and medicines needs were being appropriately met. The practice aimed to ensure that, where possible, multiple conditions were reviewed at one appointment, and consultation times were flexible to meet each patient’s specific needs.
  • The practice held meetings with the local district nursing team to discuss and manage the needs of patients with complex medical issues

Families, children and young people:

  • We found there were systems to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of accident and emergency (A&E) attendances.
  • All parents or guardians calling with concerns about a child under the age of 18 were offered a same day appointment when necessary.

Working age people (including those recently retired and students):

  • The needs of this population group had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care. For example, employing different types of clinical staff and offering early morning appointments.

People whose circumstances make them vulnerable:

  • Patients with learning disabilities were offered longer appointments. Carers were also invited to attend and offered annual healthchecks.
  • People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode.

People experiencing poor mental health (including people with dementia):

  • Staff interviewed had a good understanding of how to support patients with mental health needs and those patients living with dementia.
  • All patients the practice’s mental health and dementia patients were invited for physical health reviews and recall via phone, text message and letter where required due to difficulties in arranging appointments.

Timely access to care and treatment

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

  • 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.
  • Patients reported that the appointment system was easy to use.

The most recently published national GP survey data showed that score related to satisfaction with access to care and treatment was below local and national averages. However this is likely to be reflective of the previous provider. The new provider had undertaken their own independent patient survey which indicated that patients now felt that access was good.

Listening and learning from concerns and complaints

The practice took 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 complaint policy and procedures were in line with recognised guidance. The practice learned lessons from individual concerns and complaints and also from analysis of trends. It acted as a result to improve the quality of care. We were satisfied with how the complaints we reviewed had been handled. Patients had received timely responses, apologies where appropriate and information about action taken to ensure similar incidents didn’t reoccur in the future.

Please refer to the Evidence Tables for further information.



Updated 15 June 2018

At our previous inspection we rated the practice as requires improvement for providing a well-led service due to the deficiencies in governance that impacted on the provider’s ability to provide safe care. The provider had address all concerns and now is rated as good for providing a service that is well led.

Leadership capacity and capability

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

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The practice had effective processes to develop leadership capacity and skills.

Vision and strategy

The practice had a clear vision and credible strategy to deliver high quality, sustainable care.

  • There was a clear vision and set of values. The practice had a realistic strategy and supporting business plans to achieve priorities. The practice developed its vision, values and strategy jointly with patients and staff.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.
  • The strategy was in line with health and social priorities across the region. The practice planned its services to meet the needs of the practice population.
  • The practice monitored progress against delivery of the strategy.


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

  • Staff stated they felt respected, supported and valued. They were proud to work in the practice.
  • The practice 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.

  • Staff we spoke with told us they were able to raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • 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 considered valued members of the practice team. They were given protected time for professional development and evaluation of their clinical work.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The practice actively promoted equality and diversity. 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 were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control
  • Practice 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 practice had processes to manage current and future performance. Performance of employed clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Practice leaders had oversight of national and local 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 practice to improve quality.
  • The practice had plans in place and had trained staff for major incidents.
  • The practice 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 practice 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 relevant meetings where all staff had sufficient access to information.
  • The practice 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 practice used information technology systems to monitor and improve the quality of care.
  • The practice 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 practice involved patients, staff and external partners to support high-quality sustainable services.

  • A full and diverse range of patients’, staff and external partners’ views and concerns were encouraged, heard and acted on to shape services and culture. There was an active patient participation group.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

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

  • There was a focus on continuous learning and improvement.
  • Staff knew about improvement methods and had the skills to use them.
  • The practice 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.

Please refer to the Evidence Tables for further information.

Checks on specific services

People with long term conditions


Families, children and young people


Older people


Working age people (including those recently retired and students)


People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable