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Somers Town Medical Centre Good

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating


Updated 14 November 2018

This practice is rated as Good overall. (not previously rated under the current provider)

The key questions at this inspection 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 Somers Town Medical Centre on 11 September 2018 as part of our inspection programme.

At this inspection we found:

  • 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 its 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.
  • Feedback from patient interviews and CQC comment cards was positive about the way staff treated them.
  • Patient feedback indicated that people sometimes found it difficult to gain access to the practice by telephone, although they were usually able to get an appointment when they did get through.
  • The provider’s patient list included a large cohort of Bengali patients and in response full time Bengali interpreters were based at the practice.
  • There was visible leadership and a strong focus on continuous learning and improvement at all levels of the practice.

The areas where the provider should make improvements are:

  • Continue with the action plan to improve and address the low scores in the GP patient survey, particularly for questions relating to listening to patients; treating patients with care and concern; telephone access and appointment bookings.
  • Continue with efforts to improve the up-take of childhood immunisations.
  • Continue with efforts to improve the up-take of cervical screening.
  • Review providing all reception staff with sepsis training.

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

Please refer to the detailed report and the evidence tables for further information.

Inspection areas



Updated 14 November 2018

We rated the practice as good for providing safe services.

Safety systems and processes

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

  • The practice had a suite of safety policies which were regularly reviewed and communicated to staff. They outlined clearly who to go to for further guidance. Staff received safety information for the practice as part of their induction and refresher training. The practice had appropriate systems to safeguard children and vulnerable adults from abuse.
  • The practice 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.
  • All staff received up-to-date safeguarding and safety training appropriate to their role – for example all clinicians were trained to level 3 and administrative staff were trained to level 2. Staff knew how to identify and report concerns.
  • The practice carried out appropriate staff checks, including checks of professional registration where relevant, on recruitment and on an ongoing basis. 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.
  • The nursing and non-clinical staff acted as chaperones; they were trained for the role and had received a DBS check.
  • There was an effective system to manage infection prevention and control.
  • There were systems in place for safely managing clinical specimens and healthcare and clinical waste, which kept people safe.
  • The practice had arrangements to ensure that facilities and equipment were safe and in good working order.

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 of staff needed to meet patients’ needs, including planning for holidays, sickness, busy periods and epidemics.
  • The practice had an induction process for new staff, who were subject to a probationary period. Locums were inducted by senior staff and provided with a comprehensive practice information pack.
  • Staff understood their responsibilities to manage emergencies on the premises and to recognise those in need of urgent medical attention. Emergency medical equipment and medicines, which included emergency oxygen and a defibrillator, were monitored and logged.
  • 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. Reception staff were competent in identifying an acutely unwell or deteriorating patient, but had received no formal sepsis training.
  • 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.

  • Individual care records were written and managed in a way that kept patients safe.
  • 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.

  • The systems for managing and storing medicines, including vaccines, medical gases, emergency medicines and equipment, minimised risks.
  • The practice kept prescription stationery securely and monitored its use.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. Data showed that the practice’s antibacterial prescribing was low.
  • We reviewed care records for 13 patients who were prescribed with high risk medicine We found that the records were of a good standard and there was evidence of appropriate monitoring and clinical reviews.
  • The practice had a policy for monitoring uncollected prescriptions, which included a monthly check of the prescription collection box, and any prescriptions not collected for one month would be passed on to the prescriber for review or destruction.

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 safety using information from a range of sources.

Lessons learned and improvements made

The practice learned and made improvements when things went wrong.

  • There was a system for recording and acting on significant events and incidents. Staff understood their duty to raise concerns and report incidents and near misses. Practice management supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The practice learned from incidents, lessons were shared, and action to improve safety was taken. We saw evidence that significant events were discussed at practice meetings, being a standing agenda item, and were reviewed on an annual basis. Minutes of discussions were emailed to all staff to share learning.
  • There were systems for receiving and acting on safety alerts. These were received from the NHS Central Alerting System. The practice manager and GP partners were responsible for reviewing the relevant alerts and, if appropriate, passed them on to staff by email. In the event that drugs alerts were received, records searches were carried out to check whether any patients were affected. If so, they were called in for review.

Please refer to the evidence tables for further information.



Updated 14 November 2018

We rated the practice and all of the population groups as good for providing effective services overall.

Somers Town Medical Centre registered in its current location in July 2017. This means that Quality Outcomes (QOF) data for 2016/17 relates to performance under the previous registration. On the day of the inspection, we reviewed unverified and unpublished QOF data provided by the practice for the period between 01/04/2017 to 31/03/2018. Comparisons with local and national averages were not available for this data at the time of the inspection. However, we did not identify any significant concerns with QOF performance in the data available.

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. The practice had access to guidance including that issued by the National Institute for Health and Care Excellence (NICE).

  • Patients’ needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.
  • Staff 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.

Older people:

  • Older patients who are frail or may be vulnerable received a full assessment of their physical, mental and social needs. Those identified as being frail had a clinical review including a review of medication.
  • Patients aged over 75 had a named GP. These were invited for a health check and if necessary they were referred to other services such as voluntary services and supported by an appropriate care plan.
  • Personalised care plans were in place for the most frail and vulnerable patients. These patients were also provided with home visits, when requested.
  • 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.
  • We saw evidence of effective liaison with other healthcare professionals and staff attended monthly multi-disciplinary team meetings.

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, for example clinicians had received advanced diabetic training.
  • The practice told us that they had a high prevalence of diabetes patients. To help improve patient outcomes the practice put in place a diabetes improvement project. The project had achieved positive results and improved patient outcomes. Further information can be found in the evidence tables.
  • GPs followed up patients who had received treatment in hospital or through out of hours services for an acute exacerbation of asthma.
  • Adults with newly diagnosed cardiovascular disease were offered statins for secondary prevention. Patients with suspected hypertension were offered ambulatory blood pressure monitoring and patients with atrial fibrillation were assessed for stroke risk and treated as appropriate.
  • The practice was able to demonstrate how it identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension.
  • The practice was aware of the low QOF score under its previous registration for 2016/2017 for the indicator relating to atrial fibrillation. We reviewed the unverified and unpublished QOF scores which indicated that the current provider at the practice had made a small improvement and this score had increased from 66.7% to 70%.

Families, children and young people:

  • The practice informed us that they were aware that under its previous registration the uptake for childhood immunisation was below the 90% target for the national immunisation programme in some indicators.
  • The practice showed us unverified and unpublished data which indicated that in 2017/2018 the uptake for childhood immunisation for children aged one was 88% and the uptake for childhood immunisations for the three indicators relating to children aged two was between 83%-85%.
  • We were provided with evidence demonstrating that the practice had an effective process in place to help increase the uptake of childhood immunisations, please see evidence table for more details.

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

  • The national coverage target for cervical screening is 80%. The practice provided us with unverified and unpublished data which indicated that for 2017/2018 the practice’s uptake for cervical screening tests was 62% for women aged 25-49 and 74% for women aged 50-64. This was an improvement from when the practice was registered previously; please see evidence table for more details.
  • The practice informed us that it had experienced cultural barriers with some population groups who expressed reluctance to engage with the cervical screening programme. The practice provided us with evidence which demonstrated that an effective process was in place to call and recall patients to have a cervical screening test. Educational leaflets were also provided to patients which explained the benefits of the cervical screening programme.
  • The practice had systems to inform eligible patients to have the meningitis vaccine, for example before attending university for the first time.
  • 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 offering vaccinations to patients with an underlying medical condition according to the recommended schedule.

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

  • The practice assessed and monitored the physical health of people with mental illness, by providing access to health checks, interventions for physical activity, obesity, diabetes, heart disease, cancer and access to ‘stop smoking’ services. There was a system for following up patients who failed to attend for administration of long term medication.
  • 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.
  • The practice offered annual health checks to patients with a learning disability.
  • The practice was aware of the low QOF score under its previous registration for the indicator relating to patients with schizophrenia, bipolar affective disorder and other psychoses whose alcohol consumption has been recorded in the preceding 12 months. We reviewed the unverified and unpublished QOF scores which indicated that the practice had made a significant improvement and this score had increased from 62% to 100%.

Monitoring care and treatment

  • The practice participated in the Quality Outcome Framework (QOF), a system intended to improve the quality of general practice and reward good practice. We reviewed unpublished and unverified data for 2017/18, which indicated that the practice had achieved 100% of the total number of points available.
  • Unpublished and unverified data indicated that the practice had an exception rate of 6%. Exception reporting is the removal of patients from QOF calculations where, for example, the patients decline or do not respond to invitations to attend a review of their condition or when a medicine is not appropriate.
  • 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.
  • The practice used information about care and treatment to make improvements. It had carried out clinical audits in the past 12 months, two of which we reviewed were repeat or completed cycle audits. We saw evidence of improvements from completed 2-cycle audits in relation to diabetes monitoring and stroke monitoring.

Effective staffing

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

  • 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.
  • The practice understood the learning needs of staff and provided protected time and training to meet them. Up to date records of qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • The practice provided staff with ongoing support. There was an induction programme for new staff. This included one to one meetings, appraisals, coaching and mentoring, clinical supervision and revalidation.
  • 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 discussing care delivery for people with long term conditions and when coordinating healthcare for care home residents. It also shared information and liaised with community services, social services and carers for housebound patients, and with health visitors and community services for children who had 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. For example elderly patients were signposted to a local Age Concern representative and Bengali patients were also signposted to a local counselling service specially set-up for the Bengali community.
  • 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, stop smoking campaigns 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 14 November 2018

We rated the practice as good for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Patients we spoke with during the inspection and comment cards we received, stated that the clinicians were good at treating them with care and concern.
  • Staff understood patients’ personal, cultural, social and religious needs.
  • The practice gave patients timely support and information.
  • The 2018 GP patient survey results indicated that the practice had achieved lower than average scores for questions relating to patients being listened to and being treated with care and concern (please see evidence table for further details).
  • The practice told us that it had received the results for the 2018 GP patient survey a couple of weeks prior to the inspection date. The practice said that having reviewed the results it was concerned about some of the low scores, so to address this they conducted an internal patient survey covering the same questions as the GP patient survey. This survey was carried out face to face at the practice with 72 patients, which was the same number of patients who returned the GP patient survey. The practice informed us that as 70% of its patients were from Bengali backgrounds and did not have English as their first language, patients were interviewed with the aid of an independent Bengali interpreter.
  • The practice showed us the findings for the internal survey (please see evidence table), which demonstrated more positive results in comparison to the GP patient survey. The practice told us that despite the findings of the internal survey, it had put in place an action plan to improve the GP patient survey results.
  • To address the low scores for the questions relating to care and concern and listening to patients, the practice’s action plan indicated that all clinicians would receive online customer service training and also carry out in-house role play exercises where staff would feedback on each other’s customer care skills, which included level of empathy, engagement, listening, interacting and communication skills. Please see evidence table for more details.

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 was working to identify all patients who were carers. Its computer system alerted GPs if a patient was also a carer. The practice had identified 55 patients as carers (1.5% of the patient list).
  • The practice’s GP patient survey results for 2018 were in line with or above local and national averages for questions relating to involvement in decisions about care and treatment.
  • Patients we interviewed and comment cards we received stated that the clinicians were good at involving them in decisions about their care.

Privacy and dignity

The practice respected respect patients’ privacy and dignity.

  • When patients wanted to discuss sensitive issues or appeared distressed reception staff offered them a private room to discuss their needs.
  • Staff recognised the importance of people’s dignity and respect.

Please refer to the evidence tables for further information.



Updated 14 November 2018

We rated the practice, and all of the population groups, as good for providing responsive services


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 them. In response to 70% of the practice patient list coming from Bengali backgrounds, the practice had Bengali interpreters present during practice opening hours. The practice told us that between its staff it could communicate in 12 foreign languages.
  • 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, for example offering home visits.
  • The practice provided effective care coordination for patients who are more vulnerable or who had complex needs. They supported them to access services both within and outside the practice.

Older people:

  • All patients over the age of 75 had a named GP who supported them in whatever setting they lived, whether it was at home or in a care home or supported living scheme.
  • The practice told us that 2017/2018 the practice administered the influenza vaccine to 77% of its patients that were over the age of 65.
  • The practice was responsive to the needs of older patients, offering home visits and urgent appointments for those with enhanced needs. The GPs accommodated home visits for those who had difficulties getting to the practice.
  • Staff told us that any repeat prescription requests made by members of this population group were completed as soon as possible (and at times there and then) to avoid multiple unnecessary visits to the practice.

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. Multiple conditions were reviewed at one appointment, and consultation times were flexible to meet each patient’s specific needs.
  • The practice held regular meetings with the local district nursing team to discuss and manage the needs of patients with complex medical issues.
  • The practice hosted a diabetes prevention and management clinic hosted by Camden Diabetes Integrated Practice Unit, which provided patients with lifestyle and healthcare advice aimed at preventing and/or controlling diabetes.

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 were offered a same day appointment when necessary.
  • Safeguarding was a standing item on the two-weekly team meeting agenda.
  • The practice offered antenatal and postnatal care in conjunction with the services provided by the local hospital.
  • The practice told us that their approach to mothers and babies was to offer them consecutive appointments where a mother and child are seen on the same day.
  • The practice had established good links with the local health visiting team for child protection issues.
  • The practice referred patients aged up to 18 years of age to NHS's Child and Adolescent Mental Health Services (CAMHS) for psychological therapies.

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.
  • The practice had reviewed its appointment system to give working age patients more access to its services. For less serious matters patients were offered appointments with the prescribing pharmacist and physician associate. Telephone consultations were available which supported patients who were unable to attend the practice during normal working hours.
  • The practice also offered online appointments and prescription requests.
  • An extended hours Hub operated from the practice every week day between 6.30pm and 9pm and every weekend 8am to 8pm.

People whose circumstances make them vulnerable:

  • Homeless people could register at the practice using the practice address.
  • Longer standard appointments with clinicians were available for this patient group.
  • Home visits were offered to this group of patients.
  • Regular multi-disciplinary meetings were held for patients identified with multiple and complex conditions, child protection concerns and those requiring palliative care.

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 patients living with dementia.
  • The practice provided access to various local organisations that provided mental health support services.
  • Regular multi-disciplinary team meetings were held with mental health care professionals from the local hospitals.

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 we spoke with reported that the appointment system was easy to use.
  • The practices GP patient survey results were below local and national averages for questions relating to access to care and treatment. The practice carried out an internal survey which showed more positive results. The practice also put in place an action plan to address these issues. Please see the evidence table for more details.

Listening and learning from concerns and complaints

The practice 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 in the reception area and on the practice website. Staff treated patients who made complaints compassionately.
  • The complaint policy and procedures were in line with recognised guidance. We saw evidence that complaints were reviewed at practice meetings so that learning points could be identified and shared. Complaints were handled by the practice manager.
  • There had been five complaints received in the last year, which we saw had been satisfactorily handled in a timely way.

Please refer to the evidence tables for further information.



Updated 14 November 2018

We rated the practice as good for providing a well-led service.

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, including planning for the future leadership of the practice.

Vision and strategy

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

  • The practice had a realistic strategy to achieve priorities.
  • 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 care 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.
  • 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 appraisals, protected time for professional development, 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.
  • 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 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 policies, procedures and activities to ensure safety and assured themselves that they were operating as intended. Policies were regularly reviewed and staff were given protected learning time to acquaint themselves with any changes.

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. Practice 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 practice to improve quality.
  • The practice had plans in place and had trained staff for major incidents.
  • The practice considered and understood the impact on the quality of care of service changes or developments.

Appropriate and accurate information

The practice acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. The practice manager was responsible for reviewing ongoing QOF data and reporting to the practice team on a monthly basis. Performance information was combined with the views of patients, from suggestions and comments received.
  • 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.
  • 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, the public, staff and external partners to support high-quality sustainable services.

  • There was an active patient participation group (PPG). Members of the PPG gave us positive feedback regarding its engagement with the practice.
  • The practice monitored and responded to patients’ reviews left on the NHS Choices website and carried out its own annual patient surveys.
  • The practice was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There were evidence of systems and processes for learning and continuous 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


Updated 14 November 2018

Families, children and young people


Updated 14 November 2018

Older people


Updated 14 November 2018

Working age people (including those recently retired and students)


Updated 14 November 2018

People experiencing poor mental health (including people with dementia)


Updated 14 November 2018

People whose circumstances may make them vulnerable


Updated 14 November 2018