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Stockwell Road Surgery Outstanding

Inspection Summary

Overall summary & rating


Updated 3 July 2018

This practice is rated as Outstanding overall. (Previous inspection September 2015 – Outstanding)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Outstanding

Are services responsive? – Outstanding

Are services well-led? - Outstanding

We carried out an announced comprehensive inspection at Stockwell Road Surgery on 9 May 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 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.
  • There was evidence of safe prescribing with reviews undertaken with those patients who were prescribed high risk medicines.
  • Patients’ comments were positive regarding access to appointments and the service they received form practice staff.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • There was evidence of a cohesive practice team. Support and respect was shown by all members of staff towards one another.
  • 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.
  • There was a range of inclusive meetings to ensure all staff were engaged and kept up to date.
  • GP national survey results were consistently above local and national averages in all areas.
  • The practice reviewed appointment availability throughout the day to ensure that same day appointments were available.

We saw three areas of outstanding practice:

  • The practice availability of appointments was intensively monitored constantly to ensure same day appointments were always available. Patients reported they could always access same day appointments as a result of the appointment system.
  • The practice had a comprehensive audit programme across a range of service areas to monitor and improve patients care. The programme was managed so that two or more cycles were evident in more than 10 audit areas enabling better management of risk.
  • The practice engaged with academic institutions and participated in significant research programmes for the benefit of its own patients and the wider population. Their contribution to clinical care was recognised by the local medical school.

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

Inspection areas



Updated 3 July 2018

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 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 these were discussed and at staff meetings and lessons learnt were recorded.
  • 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 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, regularly maintained 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. We saw there was forward planning which allowed GP’s to cover for one another minimising the need for locum cover.
  • 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.
  • There was a system in place to manage patient alerts. These were cascaded to staff as appropriate and discussed at staff meetings. We saw where action had been taken as a result of alerts.

Information to deliver safe care and treatment

Staff had 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. There was a documented approach to managing test results.
  • 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, 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 management 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 were encouraged and supported to raise any areas of concern. They 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 3 July 2018

We rated the practice, and all of the population groups, 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 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.
  • Clinical templates were used, where appropriate, to support decision making and ensure best practice guidance was followed.
  • 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 medication.
  • 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.
  • Patients aged 65 years and older were offered vaccinations for the prevention of influenza, pneumococcal and shingles.

  • 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.

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.
  • 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)

Families, children and young people:

  • Childhood immunisations were carried out in line with the national childhood vaccination programme. Uptake rates for the vaccines given were 97% which was above the target percentage of 90%.
  • The practice had arrangements to identify and review the treatment of newly pregnant women on long-term medicines. These patients were provided with advice and post-natal support in accordance with best practice guidance.
  • Antenatal and postnatal care was provided in conjunction with a midwife from the local hospital.
  • There was regular liaison with the health visitor to support children and families.
  • The practice had arrangements for following up failed attendance of children’s appointments following an appointment in secondary care or for immunisation

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

  • The practice’s uptake for cervical screening was 80%, which met the national target of 80% was better than the CCG average of 76% and national average of 72%.
  • The practices’ uptake for breast and bowel cancer screening was in line the national average.

  • 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 to 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, travellers and those with a learning disability.
  • The practice had a system for vaccinating patients with an underlying medical condition according to the recommended schedule.
  • Annual health checks were offered to patients who had a learning disability. These patients were signposted to other services for additional support.
  • Staff had received training to identify signs of abuse in patients and those who may be at risk of radicalisation.

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.
  • All patients with poor mental health had access to health checks and supportive interventions relating to improving their physical and mental wellbeing. These included access to crisis intervention, substance misuse services and local support groups.
  • The practice specifically considered the physical health needs of patients with poor mental health and those living with dementia.
  • 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.
  • The practice offered annual health checks to patients with a learning disability.

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.

  • The QOF results showed the practice was performing generally above CQC and national averages. The practice achieved 100% of the quality targets with a lower than CCG and national average of exceptions (patients excluded from the targets due to exceptional circumstances).
  • 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 conducted audits and regularly took part in research.

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. This included an induction process, one-to-one meetings, 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
  • There was a clear approach for supporting and managing staff when their performance was poor or variable.

Coordinating care and treatment

Staff worked work 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 and when coordinating healthcare for care home residents. 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, 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 3 July 2018

We rated the practice as outstanding for providing caring services.

The practice was rated as outstanding for providing caring services because:

People are truly respected and valued as individuals and are empowered as partners in their care, practically and emotionally, by an exceptional and distinctive service. The practice was highly rated by patients and was consistently rated higher than CCG and national averages in all areas of the National GP patient survey. Comments we received from patients on the day confirmed the caring nature of the practice, with patients telling us they would consider the practice catchment area when moving house, and feeling lucky to be with such a good practice. The results of the practice’s own patient survey in 2018 corroborated this further, with 97% of the 72 respondents rating the standard of care received over the last 12 months as good or excellent. We found that all staff were prepared to go the extra mile for patients by providing one to one tuition in using the online services, ensuring housebound and vulnerable patients received their medication and used social prescribing to ensure a holistic approach was taken to individuals. Care was particularly evident with the vulnerable and at the beginning and end of life as clinicians shared the life experiences of their patients.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • There is a strong, visible person-centred culture. Staff are highly motivated and inspired to offer care that is kind and promotes people’s dignity. Relationships between people who use the service, those close to them and staff are strong, caring, respectful and supportive. These relationships are highly valued by staff and promoted by leaders.
  • Feedback from people who use the service, those who are close to them and stakeholders is continually positive about the way staff treat people. People think that staff go the extra mile and their care and support exceeds their expectations.
  • Staff recognise and respect the totality of people’s needs. They always take people’s personal, cultural social and religious needs into account and find innovative ways to meet them.
  • People’s emotional and social needs are seen as being as important as their physical needs.
  • The practice gave patients timely support and information.
  • The results of the latest National GP survey demonstrated that the practice were rated higher than CCG and National averages for treating patients with respect and compassion.
  • The percentage of patients in the GP patient survey who said the GP was good at listening to them was 97% compared to a CCG average of 95% and a national average of 89%.
  • The percentage of patients in the GP patient survey who said they would recommend the GP surgery to someone who had moved into the area was 99% compared to a CCG average of 89% and a national average of 79%. The practice’s own patient survey completed in 2018 corroborated this, with 100% of the 72 respondents saying they would recommend the practice to friends and family.
  • The percentage of patients in the GP patient survey who said the GP was good at treating them with care and concern was 97% compared to a CCG average of 91% and a national average of 86%.
  • We were told of GPs who sent congratulation messages to patients who had fertility problems when they achieved a pregnancy.
  • The surgery hosted a range of additional services from other providers such as Living Well, mental health organisations and bereavement organisations.

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.
  • People who use the service and those close to them are active partners in their care. Staff are fully committed to working in partnership with people and making this a reality for each person.
  • Staff always empowered people who use the service to have a voice and to realise their potential. They showed determination and creativity to overcome obstacles to delivering care. People’s individual preferences and needs were always reflected in how care was delivered.
  • The results of the latest National GP survey demonstrated that the practice better than CCG and National averages for patient involvement.
  • The percentage of patients in the GP patient survey who said the GP was good at involving them in decisions about their care was 96% compared to a CCG average of 89% and a national average of 82%.

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.
  • People were always treated with dignity by all those involved in their care, treatment and support. Consideration of people’s privacy and dignity was constantly embedded in everything that staff do, including awareness of any specific needs and these were recorded and communicated.
  • People felt really cared for and that they mattered.
  • Staff are exceptional in enabling people to remain independent.
  • People valued their relationship with staff team and felt that they often go ‘the extra mile’ for them when providing care.
  • Staff found innovative ways to enable people to manage their own health and care when they could and to maintain independence as much as possible

Please refer to the Evidence Tables for further information.



Updated 3 July 2018

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

The practice was rated as outstanding for providing responsive services because:

The practice provided services that were tailored to meet the needs of individual people and are delivered in a way to ensure flexibility, choice and continuity of care. They responded to patients views constantly and ensured that same day appointments were always available and that there were a wide range of clinicians available to support patient choice. The practice worked as a cohesive team that were flexible throughout the day. Suggestions made by the PPG were acted upon to improve services and access. The practice visited two large care homes on a weekly basis, but were also responsive to acute requests for attendance in between. The practice was rated consistently higher than CCG and national averages for access in the GP national survey. The practice used technology to communicate with patients in line with patient choice.

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.
  • Telephone 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 made reasonable adjustments when patients found it hard to access services.
  • The practice provided effective care coordination for patients who were 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.
  • The availability of appointments was being constantly monitored by the practice manager to ensure appointments were available throughout the day and that individual clinicians had availability to ensure patients had choice.
  • The practice used a range of communication methods including text messaging and emails as per the patient’s preferences.

Older people:

  • All patients 75 years and older 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 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 for those who had difficulties getting to the practice due to limited local public transport availability.
  • The practice had organised a medicines delivery service for housebound patients.
  • The practice had close working links with a range of community based services to support the provision of care for older people.
  • The practice visited two of the large care homes locally to provide weekly consultation availability to patient’s resident there. They tried to ensure the same GP attended the same care home for continuity. They also provided urgent home visits to the care homes as required.
  • Do Not Attempt Resuscitation declarations were reviewed in the care homes on a regular basis.

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.
  • Patients with long term conditions were proactively invited for influenza, pneumococcal and shingles immunisations.
  • Clinical leads regularly reviewed the disease specific registers to ensure patients were receiving the correct level of care.

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. Records we looked at confirmed this.
  • All parents or guardians calling with concerns about a child under the age of 18 were offered a same day appointment when necessary.
  • Appointments were communicated by text for teenage patients who preferred this method of communication.
  • A local phone number was provided for teenagers who required services.
  • GPs supported patients undergoing fertility treatment and recognised the achievement when successful and treated patients compassionately when unsuccessful.

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 offered extended opening hours appointments on Wednesday evenings and through the local federation of GP practices.
  • The practice encouraged use of the online services and provided individual tuition to support this.
  • Patients could receive text communication for appointments and results.
  • Telephone and email consultations were available. Consent was sought from the patient in advance of any email contact and this was noted on their record.

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
  • People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode.
  • Longer appointments were available for those patients who had complex needs or needing translation services.
  • Patients with learning difficulties were personally invited for health checks resulting in an exceptionally high uptake of this service.
  • Prescriptions on repeat for vulnerable patients were organised in conjunction with a local chemist.
  • Appointments were flexible where needed.
  • Reception recognised the vulnerable patients and accommodated them according to their needs.

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.
  • Clinicians had access to a local mental health service where they could refer patients.
  • Carer’s health checks were offered.
  • Patients were referred to local mental health support services.

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.

Patients were encouraged and supported to use the on line services to access appointments and request repeat prescriptions.

  • The results of the latest National GP survey demonstrated that the practice was rated better than CCG and National averages by their patients for accessing care.
  • The percentage of respondents to the GP national survey who found the telephone access to the surgery easy was 100% compared to a CCG average of 86% and a national average of 71%
  • The percentage of respondents to the GP national survey who said they were able to get an appointment were 93%, compared to a CCG average of 85% and a national average of 76%.
  • The percentage of patients who made positive responses to the overall experience of making an appointment was 93%, compared to CCG average of 82% and a national average of 73%.

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. For example, following patient complaint the practice manager advised receptionist them to put calls with patients on hold when seeking advice from colleagues.

Please refer to the Evidence Tables for further information.



Updated 3 July 2018

We rated the practice as outstanding for providing a well-led service. This was because:

The leadership, management and governance of the organisation assured the delivery of high-quality and person-centred care, supported learning and innovation, and promoted an open and honest culture. There was compassionate, inclusive and effective leadership at all levels. There were high levels of staff satisfaction throughout the organisation and staff told us they were proud to work at the practice and felt truly valued and appreciated. Patient feedback showed they held the practice and staff who worked there in high regard and they told us they felt lucky to be a patient there. The systems and processes in place to support the ongoing review of the practice’s appointment system demonstrated strong collaboration and team working for the benefit of their patients. There was a fully embedded and systematic approach to continuous improvement which made use of recognised improvement methodology. The practice was also a member of the Yorkshire Research Network and was highly regarded by trainees and the medical school.

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.

  • 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, staff and external partners.
  • 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 had a culture of being open and delivering 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 evidence of a cohesive team and positive relationships between all the staff.

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.
  • There were a range of inclusive meetings where good governance was high on the agenda and ensured that all staff were up to date.

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 monitor and improve practice performance.
  • 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.

  • The service was transparent, collaborative and open with stakeholders about performance.
  • 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.
  • The practice was involved in a range of research aligned to local universities supporting improvements in patient care. The practice was part of the Yorkshire Research Network.
  • The practice had received an award form Leeds University Medical School in 2017 in the outstanding clinical team category.

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