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King's College London NHS Health Centre Good

This service was previously registered at a different address - see old profile

Inspection Summary

Overall summary & rating


Updated 17 January 2019

This practice is rated as Good overall.

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 Kings College NHS Health Centre on 8 November 2018. This inspection was undertaken as part of our inspection programme.

The previously registered and inspected service at this location, also known as Kings College NHS Health Centre, ceased providing services in February 2018.

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 their processes.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • There was a clear management structure in place and staff had lead roles in practice service delivery. The practice team worked well together and practice governance processes were comprehensive.
  • Patients found the appointment system easy to use and reported 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.
  • There was a clear vision and leaders were able to describe a set of guiding principles around which it structured its services. The practice had a realistic strategy and supporting business plans to achieve priorities.

The areas where the provider should make improvements are:

  • Continue to monitor the health of patients diagnosed with diabetes with a view to bringing about further improvements to clinical outcomes.
  • Continue to encourage eligible patients to participate in public health screening programmes, including cervical screening with a view to improving uptake rates.
  • Continue to review the system for the identification of carers to ensure all carers have been identified and provided with support.

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 17 January 2019

We rated the practice as good for providing safe services.

Safety systems and processes

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

  • The practice did not register children as patients, but had appropriate systems to safeguard 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. Learning from safeguarding incidents was available to staff. Staff who acted as chaperones were trained for their role and had received a Disclosure and Barring Service (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, discrimination and breaches of their dignity and respect.
  • The practice carried out appropriate staff checks at the time of recruitment and on an ongoing basis.
  • There was an effective system to manage infection prevention and control.
  • 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.
  • The practice was equipped to deal with medical emergencies and staff were suitably trained in emergency procedures.
  • 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.
  • 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.

  • The care 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.

  • The systems for managing and storing medicines, including vaccines, medical gases, emergency medicines and equipment, minimised risks.
  • Staff prescribed and 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.
  • There were effective protocols for verifying the identity of patients during remote or online consultations.
  • 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 safety using information from a range of sources.

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.
  • There were adequate systems for reviewing and investigating when things went wrong. The practice learned and shared lessons, identified themes and took action to improve safety in the practice.
  • The practice acted on and learned from external safety events as well as patient and medicine safety alerts.

Please refer to the evidence tables for further information.



Updated 17 January 2019

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

Effective needs assessment, care and treatment

The practice had systems to keep clinicians up to date with current evidence-based practice. We saw 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 advised patients what to do if their condition got worse and where to seek further help and support.

Older people:

  • The practice had a very small population of older people relative to the total list size. There were only 12 patients, less than 1% of the practice population, above 66 years of age.
  • The practice had systems in place to ensure older patients who were 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 medication.
  • The practice followed up on older patients discharged from hospital. It ensured 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.

People with long-term conditions:

  • Data from 2017/2018 showed that outcomes around certain clinical indicators for patients diagnosed with diabetes were in line with averages for most indicators, for instance, 88% had well controlled blood pressure compared to the CCG average of 76% and the national average of 78%. However, outcomes around the management of blood sugar levels were lower than average. Specifically, 67% of patients with diabetes had well controlled blood sugar levels compared to the CCG and national averages which were both 79%. The practice told us the majority of patients on the diabetic register were young people with Type 1 diabetes whose conditions were more difficult to manage. The practice explained this atypical profile was significant when compared to practices with a majority of Type 2 diagnoses. The practice also told us that young people taking responsibility for their own health for the first time often experienced initial difficulties adjusting to independent living which could impact on the management of their diabetes. The practice told us they had a process in place to invite diabetic patients to regular reviews and provided advice and information about the condition, including the potential consequences of failing to manage the condition properly.
  • The practice had implemented an action plan to bring about further improvements to outcomes for diabetic patients. This included the development of a monthly, multidisciplinary clinic attended by a consultant endocrinologist, specialist diabetes nurse and a dietician. These clinics provided patients with Type 1 diabetes with access to additional support to help them manage their condition. The practice was able to show us evidence in the form of an NHS Diabetes Dashboard which showed the practice this clinic was having a positive impact on outcomes for diabetic patients.
  • The practice population was predominantly aged between 19 and 44 years which meant the practice did not have a high prevalence of conditions sometimes associated with older people, for instance, hypertension and dementia. The practice’s performance on quality indicators for other long-term conditions was in line with local and national averages.
  • 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 it identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension.

Families, children and young people:

  • The practice did not register children as patients. Members of the university community who wished to register their children as patients with a practice locally were given advice about other GP practices in the area.

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

  • The practice’s uptake for cervical screening was 38%, which was below the 80% coverage target for the national screening programme. The practice was aware of their uptake rate and had reviewed how it supported this programme to ensure eligible patients were aware of the programme and how to participate if they wished to do so. We saw evidence that the practice had actively participated in the national ‘Don’t fear the smear’ publicity programme by giving the campaign literature a prominent place on the practice website and in social media channels. The practice had trained female sample takers to be available and had arrangements in place for patients who required appointments outside of normal opening hours. The practice contacted eligible patients by letter and by telephone until the patient attended or expressly stated they did not wish to participate in the programme. We were told a significant percentage of patients eligible for cervical screening were registered at the practice for a year or less, whilst others were foreign students who had participated or were intending to participate in screening programmes in other countries.
  • The practice had reviewed the needs of it significant student demographic and had ensured it employed clinicians who were trained to offer enhanced sexual health screening as well as a GP who could fit contraceptive implants and intrauterine contraception.
  • We saw the practice encouraged its patients to attend national screening programmes for breast and bowel cancer screening. However, uptake rates for breast and bowel cancer screening for the practice were unavailable as the practice had too few eligible patients registered to record statistically reliable data.
  • The practice encouraged patients, most of whom were university students, to have the meningitis vaccine, and had highlighted this service to students attending welcome events at the start of the academic year.
  • 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:

  • The significant majority of the practice population were university students, many of whom were living some considerable distance from family and traditional support. The practice had developed relationships with other stakeholders to provide that support and was mindful of the potential vulnerability of its patients.
  • 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 had a system for vaccinating 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, severe mental illness, and personality disorder 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 had arranged for two clinicians from the Improving Access to Psychological Therapies (IAPT) service to hold clinics at the practice on two days each week, providing in-house mental health support for both students and members of the university staff.
  • The practice hosted a mental health nurse who provided specialist support for patients with complex mental health needs.
  • The practice liaised closely with the university’s own student counselling service and worked with them to provide enhanced care for students experiencing mental health difficulties.
  • The practice population was significantly younger than average which meant the practice had fewer patients at risk of dementia on the register. However, systems were in place to identify patients who were at risk and to offer 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 review the effectiveness and appropriateness of the care provided. Where appropriate, clinicians took part in local and national improvement initiatives.

  • 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.
  • 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. 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.
  • 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 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.
  • That practice was aware many students arriving at University had not completed recommended vaccination programmes whilst a significant cohort also arrived from abroad without having received vaccinations during childhood in the UK. The practice carried out on-going promotional activity to encourage those with outstanding vaccinations, teenage booster doses and the HPV vaccine to make appointments.
  • The practice had made arrangements with Haven and Insight, two drug and alcohol advisory services to provide training for clinicians around the early detection of symptoms of substance misuse and had made links with outreach organisations to which patients could be referred for further support.
  • 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, 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 17 January 2019

We rated the practice as 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.
  • The practices GP patient survey results were below local and national averages, however, we noted that of 418 survey forms sent out, only 24 had been returned which was a response rate of less than six percent and represented less than 0.2% of the practice population. This meant it was difficult to draw meaningful conclusions from the survey.
  • The practice carried out its own patient survey consisting of 24 questions including questions around how well a clinician listened and showed care and concern during appointments. We reviewed results from the most recently completed and analysed survey which was undertaken in 2017. This had received 386 responses, more than 16 times greater than the national survey. When asked how well the clinician had listened to them at their most recent appointment, 95% had responded as very good or excellent whilst 92% of respondents said their clinician was very good or excellent at treating them with care and concern.

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 they are given.)

  • The practice had a significant cohort of patients who were new to living in the United Kingdom and unfamiliar with the local health care system. The practice had systems in place to advise newly registering patients about the services available in NHS GP practices, for instance public health screening.
  • The practice also liaised closely with the university student services team who told us the practice proactively engaged with students by providing a visible presence at induction events. We were told the practice had taken time to orient these students about the NHS and had provided literature and guidance about local prescribing guidelines and how to access emergency care.
  • Staff communicated with people in a way 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 had a process in place to identify and support carers. However, due to the demographics of the population where the overwhelming majority of patients were university students without caring responsibilities the practice did not have any carers in the register at the time of the inspection.

Privacy and dignity

The practice respected 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. They challenged behaviour that fell short of this.

Please refer to the evidence tables for further information.



Updated 17 January 2019

We rated the practice, and all of the population groups as good for providing responsive services except working age people which was rated outstanding.

Responding to and meeting people’s needs

The practice organised and delivered care 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.
  • Telephone and web GP 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 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 end of life was coordinated with other services.

Older people:

  • The practice register included just 12 patients aged over 66 years. This meant older patients were able to receive highly personalised care.

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 majority of patients on the diabetic register had been diagnosed with Type 1 diabetes which required a higher level of support. The practice held a dedicated diabetic clinic where patients could access longer appointments.

Families, children and young people:

  • The practice only registered students and staff who were enrolled at, or employed by, King’s College London. Although spouses could also register, the practice did not register patients aged under 16 years.

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, extended opening hours during term time.
  • A significant percentage of the practice population were young adults, many of whom were transitioning to living independently with full responsibility for their own health for the first time. The practice told us they had identified a pattern in which self-management of existing health conditions could deteriorate during this period whilst other conditions, for example, some mental health conditions, including eating disorders, were diagnosed for the first time. The practice also told us they were also conscious of links between poor mental health and poor physical health. The practice was in the process of implementing a plan to create a Young Peoples Hub, where patients could have access to GPs with special interests as well as in-house access to specialist clinicians who normally worked in secondary care locations. As part of this plan, the practice had recruited GPs with specialist training in dermatology, gynaecology and diabetes, whilst two of the practice nurses had undertaken specialist training in sexual health. Two GPs at the practice were also trained to fit contraceptive devices. In addition , the practice hosted twice weekly sexual health clinics which were provided by a specialist nurse, twice weekly clinics with psychological therapists and hosted substance misuse clinicians at the practice.
  • The practice was able to demonstrate that rates of referral to secondary care were significantly lower than other practices for gynaecology and dermatology, whilst the rate of attendance at urgent or emergency care providers was consistently amongst the lowest in the CCG area.
  • The practice had carried out surveys to identify how patients preferred to communicate with the practice and this had identified that most patients preferred online communication, As a result of this research, the practice had made arrangements to allow online registration with suitable processes in place to confirm patient identity.
  • The practice had developed social media channels to communicate with patients and had created special sub-groups for people interested in particular conditions. For instance we saw a social media group dedicated to providing support for people affected by irritable bowel syndrome.
  • The practice had promoted its online services during welcome events for new and returning students and had analysed contact transactions to help plan further technology opportunities. The practice told us that during the start to the current academic year, it had been named in over 72,000 searches for GP services which led to over 30,000 visits to the practice website and 658 internet calls placed directly through the practice website.
  • The practice made reasonable adjustments when patients found it hard to access services.
  • The practice provided first aid training to nominated student ambassadors who were able to use these skills in halls of residence and other university facilities.
  • The practice hosted free Yoga sessions to promote well-being.
  • The practice waiting area had been designed to include furniture which allowed patients to work on laptops whilst they waited for appointments.

People whose circumstances make them vulnerable:

  • The practice had arrangements in place to provide specialist support to patients identified as being at risk of misusing alcohol or drugs.
  • The practice had considered the needs of LGBTQ+ patients and had ensured the premises included gender neutral toilet facilities.
  • 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 we spoke with had a good understanding of how to support patients with mental health needs and those patients living with dementia.
  • The practice held GP led dedicated weekly mental health clinics. Patients who failed to attend were proactively followed up by a phone call from a GP.
  • The practice had arranged for psychological therapy clinics to be held at the practice on two days each week.
  • The practice worked closely with a psychiatrist employed by the university and carried out joint consultations when this was helpful.

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 the appointment system was easy to use.
  • The practice’s own patient survey had asked patients about their experience of getting through to the practice by telephone and 78% of those who said they had tried this said they had been able to do so. Ninety percent of respondents had said they were satisfied with the practice opening hours whilst 62% said they were seen at their booked appointment time.

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. 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.

Please refer to the evidence tables for further information.



Updated 17 January 2019

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.
  • The Principal GP had a significant role in developing the tri-borough Joint Strategic needs Assessment (JSNA) for the boroughs of Westminster, Hammersmith and Fulham and Kensington and Chelsea. They had led a team which carried out complex research around the needs of, and services available to, students and young adults aged between 18 and 25 years. This work was used to provide an evidence base which could be used to assess future needs and develop strategies for early interventions which could prevent the development of long-term conditions. The Joint Strategic Needs Assessment is a process by which local authorities and Clinical Commissioning Groups assess the current and future health, care and wellbeing needs of the local community to inform local decision making.

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.
  • 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. They were proud to work in the practice. We were told the practice organised yearly away days and social events for staff.
  • 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 these would be addressed. The practice held daily briefings where staff could talk about or seek support to deal with emerging issues
  • 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.
  • 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.
  • The practice took a role in community initiatives which benefitted public health. For instance, we saw evidence the practice had played a high profile role in a campaign to increase the number of people from black and ethnic minority backgrounds registering to become stem cell donors.

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 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. 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. 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, the public, 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.
  • The practice explored different ways of engaging with patients, for instance we saw the practice had collaborated with art students on an interactive installation which was used to collect patient comments.

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