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Archived: Bexley Group Practice Good

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Inspection Summary

Overall summary & rating


Updated 24 July 2018

This practice is rated as Good overall. (Previous inspection November 2017 – Inadequate)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Bexley Group Practice on 15 May 2018 to check that the regulatory breaches in their previous inspection had been addressed, and to consider whether sufficient improvements had been made to bring the practice out of special measures. At this inspection we found significant improvements had been made. Overall the practice is now rated as good. I am taking this practice out of special measures.

At this inspection we found:

  • The provider had addressed all the issues that led to the breaches of regulations at their last inspection
  • The provider had moved its main practice location, and closed two of its three branch locations.
  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved patients in their treatment and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that there had been improvements in them being able to access care when they needed it. However, some patients still felt there were further improvements needed in accessing appointments and waiting for appointments.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.
  • The practice had greatly improved their identification and offer of support to people with caring responsibilities
  • The practice provided regular health promotion poster campaigns and talks to people in the local community, which has raised awareness and increased diagnosis of the diseases focussed on during their campaigns.

The areas where the provider should make improvements are:

  • Review arrangements for the audit of clinical decision making for non-medical prescribers.

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

Inspection areas



Updated 24 July 2018

We rated the practice as good for providing safe services.

At our last inspection, we rated the practice as inadequate for providing safe services as they did not have suitable arrangements for dealing with medical emergencies, and we found serious concerns with their medicines management arrangements which constituted regulatory breaches. After the inspection, the provider sent us an action plan of how they would address the areas the regulatory breaches. At this inspection, we found all the breaches had been addressed and the provider was 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. All staff had been updated on the latest local safeguarding training event in January 2018 regarding human trafficking and modern slavery, sexual exploitation, domestic abuse (Clare’s Law) and the GPs role in MARAC (a system providing a coordinated community response to cases of domestic abuse). The practice operated an Orange dot scheme, which allowed patients to discreetly make staff aware of, and ask for help for, cases of abuse in any form in adults and children.
  • 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 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. 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 acted 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 activity. This helped it to understand risks and gave a clear, accurate and current picture of safety that led to safety improvements.

Lessons learned and improvements made

The practice learned and made improvements when things went wrong.

  • Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The practice learned and shared lessons, identified themes and acted 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 24 July 2018

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

(Please note: Any Quality Outcomes (QOF) data relates to 2016/17. QOF is a system intended to improve the quality of general practice and reward good practice.)

Effective needs assessment, care and treatment

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

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

Older people:

  • Older patients who are frail or may be vulnerable received a full assessment of their physical, mental and social needs. The practice used an appropriate tool to identify patients aged 65 and over who were living with moderate or severe frailty. Those identified as being frail had a clinical review including a review of medication.
  • Patients aged over 75 were invited for an annual health check. If necessary they were referred to other services such as voluntary services and supported by an appropriate care plan.
  • The practice had recently introduced a health assessment service for patients over the age of 85. The clinic was run by their advanced nurse practitioner.
  • 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. The practice had a clinical care coordinator whose responsibilities included offering support for access and review to patients on their hospitals admissions avoidance list.
  • Staff had appropriate knowledge of treating older people including their psychological, mental and communication needs. The advanced nurse practitioner was a clinical fellow in elderly care and urgent care.
  • Patients over the age of 65 were offered flu vaccinations.
  • The practice held monthly multidisciplinary team (MDT) meetings, which were attended by the practice clinical staff, as well a range of local services dependent on the patients to be discussed at the meeting. Their MDT meetings included members from various teams including district nurses, child and adolescent mental health services (CAMHS), health visitors, social services and palliative nurses.
  • The practice held fortnightly internal clinical meetings
  • The practice offered additional support to patients at the end of life, including facilitating their access to Coordinate My Care an NHS clinical service sharing information between healthcare providers, coordinating care, and recording wishes of how patients would like to be cared for, highlighting on patient notes that they were at the end of life and working to the Gold Standards framework for end of life care.
  • The practice offered a range of additional services to complement and enhance the clinical care including social prescribing, in-house pharmacist for medicines reviews, phlebotomy service
  • Housebound patients had their clinical records appropriately highlighted, were provided home visits, and access to many additional services offered in the practice such as the phlebotomy service.

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 specific training and specialties. For example, the lead GP was the diabetes lead and the practice was a Tier 2 practice, so able to initiate insulin in diabetic patients. Other clinical specialities among the practice GPs and nurse included joint injections, dermatology and respiratory care.
  • GPs followed up patients who had received treatment in hospital or through out of hours services for an acute exacerbation of asthma.
  • The practice offered a range of in-house services for people with long term conditions, including: spirometry (for patients with certain respiratory conditions), doppler testing (checks blood supply in arteries and blood vessels), and phlebotomy (for patients who need regular blood tests to monitor their condition).
  • Patients with long term conditions were offered an annual review by the practice nurses, and the practice performance for the management of long term conditions was comparable with other practices.

Families, children and young people:

  • Childhood vaccinations were carried out in line with the national childhood vaccination programme. However, the latest published data showed uptake rates for the vaccines given were slightly below the target percentage of 90% for children aged two. The practice held a weekly childhood vaccinations clinic. The practice provided us with their most recent figures for childhood vaccinations (not validated from the quarter ending 31/03/18) which showed that percentage of children aged 2 who have received immunisation for measles, mumps and rubella (first dose of MMR) was 94% (with 137 out of 146 eligible patients vaccinated), the percentage of children aged 2 who have received their immunisation for Haemophilus influenza type b (Hib) and Meningitis C (MenC) was 95% (with 138 out of 146 eligible patients vaccinated) and the percentage children aged 2 who have received their booster immunisation for Pneumococcal infection was 93% (with 122 out of 131elgible patients vaccinated). In addition, the percentage of children aged 1 with completed primary course of 5:1 vaccine was 99% (with 141 out of 146 eligible patients vaccinated).
  • The practice followed up children who had not been vaccinated, and used health promotion education campaigns and events to encourage parents to bring their children to receive vaccinations. The practice had assigned a designated team consisting of the practice manager, designated administrator and a GP to improve child immunisation uptake. They found this has shown an improvement in the uptake of childhood immunisations, which was reflected in their latest childhood vaccinations figures.
  • 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.
  • The practice had arrangements for following up failed attendance of children’s appointments following an appointment in secondary care or for immunisation.
  • Preconception, antenatal and postnatal advice was available from the GPs and family planning services included the fitting of long-acting reversible contraceptives (LARC) such as intrauterine devices (IUDs) and subdermal contraceptive implants.

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

  • The practice’s uptake for cervical screening was 71%, which was comparable to other practices locally and nationally, but was below the 80% coverage target for the national screening programme.
  • The practice’s 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 40-74. There was appropriate follow-up on the outcome of health assessments and checks where abnormalities or risk factors were identified.
  • The practice carried out monthly themed health promotions campaigns using posters and display screens in their reception areas. Recent examples of the campaigns they had arranged have been cervical screening in February 2018, prostate cancer in March 2018, ovarian cancer April 2018 and bowel cancer May 2018.

People whose circumstances make them vulnerable:

  • End of life care was delivered in a coordinated way which considered the needs of those whose circumstances may make them vulnerable.
  • The practice held a register of patients living in vulnerable circumstances including housebound patients, people at the end of life, homeless people and those with a learning disability.
  • The practice had a system for vaccinating patients with an underlying medical condition according to the recommended schedule.
  • All 45 of the practice’s patients with learning disabilities had received an annual health check. The practice was flexible in meeting patients’ needs in delivering this service, and cited an example of carrying out the health check at a day centre, as the patient concerned felt more comfortable having the assessment done there.
  • Carers of patients with learning disabilities could meet with the GPs to discuss their and the patient’s needs.

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.
  • 80% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the previous 12 months. This was comparable to the local area and national averages.
  • 93% of patients diagnosed with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive, agreed care plan documented in the previous 12 months. This was comparable to the local area and national averages.
  • The practice specifically considered the physical health needs of patients with poor mental health and those living with dementia. For example, 100% of patients experiencing poor mental health had received discussion and advice about alcohol consumption. This is above the local area and national average.
  • Patients at risk of dementia were identified and offered an assessment to detect possible signs of dementia. When dementia was suspected there was an appropriate referral for diagnosis.

Monitoring care and treatment

The practice had a programme of quality improvement activity and reviewed the effectiveness and appropriateness of the care provided. The practice had carried out several clinical and CCG led audits and reviews. The practice had carried out an audit on management of patients prescribed methotrexate. The audit had two cycles, with the second cycle showing nine patients were soon due tests. These patients were followed up and have subsequently completed their reviews.

The practice had carried out an audit on co-prescribing of amlodipine and simvastatin. The audit was more like a medicines management survey than a clinical audit. They had been carrying out this audit annually since 2012.

The practice had carried out an audit on controlled drugs. The audit had two cycles. However, the second cycle was not comparable, as it was not completed the same time frame as the first cycle.

The practice had completed a cancer peer review audit, which consisted of the detailed review of seven cases. This had been completed as part of a CCG led review.

Where appropriate, clinicians took part in local and national improvement initiatives. For example, clinicians took part in continuous professional development and revalidation.

  • The practice QOF results were comparable to local area and national averages.

The practice’s overall exception reporting rate was comparable to local area and national averages. However, the exception reporting rates for many indicators were significantly higher than the CCG or national averages or were above 10%: atrial fibrillation, coronary heart disease, peripheral arterial disease, stroke and transient ischaemic attack, cancer, dementia, depression and mental health. The practice provided detailed explanations for these, which were acceptable. For example, some patients were excepted from certain treatments due to adverse effect it would have as they were having other treatments, or due to complexities in their own health conditions, or they had been newly diagnosed with their condition. Some patients were also documented as refusing certain treatments, for example the flu vaccination was frequently documented in the excepted patients as refused. The latest practice data as of 31/03/18 high exception reporting for flu vaccinations for people with long term conditions: 30.9% for diabetes, 36.55% for CHD and 16.59% for COPD. The practice could review their arrangements for offering this service to patients with long term conditions, as some patients were not getting the recommended care in line with NICE guidance for seasonal influenza CKS.

  • 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 and management of people with long term conditions including specialist care for diabetic patients, older people and providing family planning services.
  • 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 practice ensured the competence of staff employed in advanced roles. However, we did not see evidence of audit of clinical decision making for non-medical prescribers.
  • There was a clear approach for supporting and managing staff when their performance was poor or variable.

Coordinating care and treatment

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

  • We saw records that showed that all appropriate staff, including those in different teams and organisations, were involved in assessing, planning and delivering care and treatment.
  • The practice shared clear and accurate information with relevant professionals when deciding care delivery for people with long term conditions and when coordinating healthcare for vulnerable patients. 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 considered 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 need 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, they had used their health promotion campaigns to raise awareness of, and encourage attendance at, cancer screening services. Their campaigns had had the desired impact and led to higher numbers of patient enquiries for screening of all these conditions, increased uptake in cervical and bowel cancer screening, and new diagnoses of prostate cancer from patients who had attended screening after seeing the practice’s prostate cancer campaign.

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 24 July 2018

We rated the practice as good for caring.

At our last inspection, we rated the practice as requires improvement for providing caring services due to patient feedback through the national GP patient survey which rated the practice below local area and national averages in some aspects of nurse consultations. At this inspection, we found patient feedback about nurse consultations had improved.

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 practice’s results from the GP patient survey were comparable to other practices for respondents stating they were treated with care and concern by the GP, but lower for the practice respondents stating they were treated with care and concern by the nurse. The practice’s own survey carried out in January 2018 had found that 98% of respondents stated the nurse treated 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 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. We noted that the practice’s identified carers had increased from 43 in June 2017 to 177 (1.5% of the patient list) in May 2018.
  • The practice’s results from the GP patient survey was comparable to other practices for respondents stating GPs and nurses involved them in decisions about their care. The practice’s results from the GP patient survey was comparable to other practices for respondents stating the GP listened to them, but was lower for the practice respondents stating the nurse listened to them. The practice recognised these scores but had found that their own survey conducted in January 2018 had shown improvement in this area. They had had team discussions and explored ways to continue to improve patient experiences at clinical appointments.

Privacy and dignity

The practice respected patients’ privacy and dignity.

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

Please refer to the Evidence Tables for further information.



Updated 24 July 2018

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


At our last inspection, we rated the practice as requires improvement for providing responsive services due to most of their sites needing renovation and redecoration, and patient feedback indicating access to appointments could be improved. At this inspection, we found the practice had closed two of its branch sites, moved to new purpose-built premises and had renovated its one remaining branch site. Patient feedback also indicated access to appointments had improved.

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 practice also offered a walk-in service on Monday to Thursday mornings at its main and branch sites
  • The facilities and premises were appropriate for the services delivered.
  • The practice made reasonable adjustments when patients found it hard to access services.
  • The practice provided effective care coordination for patients who are more vulnerable or who have complex needs. They supported them to access services both within and outside the practice.
  • Care and treatment for patients with multiple long-term conditions and patients approaching the end of life was coordinated with other services.

Older people:

  • All patients had a named GP who supported them in whatever setting they lived, 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.

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 MDT meetings to discuss and manage the needs of patients with complex medical issues.

Families, children and young people:

  • We found there were systems to identify and follow up children living in disadvantaged circumstances and who were at risk. 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.

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 were available at their main site.

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances including homeless people, and those with a learning disability.
  • People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode

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

  • Staff interviewed had a good understanding of how to support patients with mental health needs and those patients living with dementia.

Timely access to care and treatment

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

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported that the appointment system was easy to use.
  • The practice’s results from the GP patient survey were comparable to other practices for respondents stating it was easy to get through to someone at the GP surgery on the phone
  • However, the practice’s results from the GP patient survey were lower than other practices for respondents stating they could get an appointment with a GP or nurse the last time they needed one, and being satisfied with the practice’s opening hours. In response to these results and similar findings from our last inspection, the practice had considered ways to improve patient satisfaction with access to appointments. We saw evidence of many initiatives they had introduced including a walk-in service, extended hours, and general access to additional GP and nurse appointments following recruitment of additional clinical staff.

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 from analysis of trends. It acted as a result to improve the quality of care. The practice had completed a review of the complaints received in the 2017 / 2018 year, and discussed them individually and collected with the staff team, and explored ways of improving the patient experience.

Please refer to the Evidence Tables for further information.



Updated 24 July 2018

We rated the practice and all the population groups as good for providing a well-led service.

At our last inspection we rated the practice as inadequate for providing a well-led service because some practice policies and procedures were not being implemented, there was a lack of management oversight in key areas of practice, particularly in relation to medicines management and the arrangements for dealing with medical emergencies, and the practice did not proactively seek staff and patient feedback. At this inspection, we found all these issues had been addressed.

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 monitored progress against delivery of the strategy.


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

  • Staff stated they felt respected, supported and valued. They were proud to work in the practice.
  • The practice focused on the needs of patients.
  • Leaders and managers encouraged staff behaviour and performance to be consistent with the practice 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 could raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary.
  • Clinical staff were considered valued members of the practice team. They were given protected time for professional development and evaluation of their clinical work.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The practice actively promoted equality and diversity. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care.
  • Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control
  • Practice leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The practice had processes to manage current and future performance. Performance of employed clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Practice leaders had oversight of national and local safety alerts, incidents, and complaints.
  • The practice had plans in place and had trained staff for major incidents.

Appropriate and accurate information

The practice acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The practice used performance information which was reported and monitored and management and staff were held to account.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The practice used information technology systems to monitor and improve the quality of care.
  • The practice submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The practice involved patients, staff and external partners to support high-quality sustainable services.

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

Continuous improvement and innovation

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

  • There was a focus on continuous learning and improvement.
  • Staff knew about improvement methods and had the skills to use them.
  • The practice made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.
  • The practice was in the process of recruiting a paramedic to add to their clinical staff team. They were seeking to use this resource in carrying out assessments for home visits and acute illnesses.

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