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Greenfield Medical Centre Good

Inspection Summary

Overall summary & rating


Updated 25 September 2018

This practice is rated as Good overall. (Previous rating September 2015 – Good)

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 Greenfield Medical Centre on 26 July 2018, as part of our inspection programme.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved its processes.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
  • Feedback from patient interviews and CQC comment cards was positive about the way staff treated them.
  • 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 practice.

The areas where the provider should make improvements are:

  • Continue with efforts to improve the up-take of childhood immunisations.
  • Continue with efforts to improve the up-take of cervical screening.
  • To continue to review the gender mix of clinical staff so as to ensure that the needs of patients requesting a male clinician can be met.

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 25 September 2018

We rated the practice as good for providing safe services.

Safety systems and processes

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

  • The practice had a suite of safety policies which were regularly reviewed and communicated to staff. They outlined clearly who to go to for further guidance. Staff received safety information for the practice as part of their induction and refresher training. The practice had systems to safeguard children and vulnerable adults from abuse.
  • The practice worked with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • All staff received up-to-date safeguarding and safety training appropriate to their role – for example GP’s were trained to level 3, nurses level 2 and administrative staff level 1. Staff knew how to identify and report concerns.
  • The practice carried out staff checks, including checks of professional registration where relevant, on recruitment and on an ongoing basis. Disclosure and Barring Service (DBS) checks were undertaken where required. DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.
  • There were seven members of staff who acted as chaperones; they were trained for the role and had received a DBS check.
  • We saw evidence that regular infection prevention and control (IPC) audits were conducted, most recently in May 2018, with no significant issues identified. The practice maintained a log to confirm that medical equipment was cleaned regularly and maintained according to manufacturers’ instructions. The premises were clean and tidy; we saw cleaning was carried out in accordance with written schedules and logs were maintained. Staff received annual IPC refresher training. There were systems in place for safely managing healthcare and clinical waste.
  • The practice conducted a health and safety risk assessment in January 2018 and a fire risk assessment had been carried out in July 2018. The alarm was tested weekly and monthly walk around checks were carried out and logged. Electrical appliances and clinical equipment had been inspected, PAT tested and calibrated in July 2018.

Risks to patients

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

  • Arrangements were in place for planning and monitoring the number of staff needed to meet patients’ needs, including planning for holidays, sickness, busy periods and epidemics.
  • The practice had an induction process for new staff, who were subject to a probationary period. Locums were inducted by senior staff and provided with a comprehensive practice information pack.
  • Staff understood their responsibilities to manage emergencies on the premises and to recognise those in need of urgent medical attention. Emergency medical equipment and medicines, which included emergency oxygen and a defibrillator, were monitored and logged.
  • On the day of the inspection we noted that the practice did not stock the recommended emergency drugs; Glucagon, used in an emergency to treat patients with low blood sugar; Diazepam, used in an emergency to treat a patient suffering from an epileptic fit; and Chlorphenamine, an antihistamine used in an emergency to treat anaphylaxis and acute angio-oedema. After the inspection, the practice provided us with a delivery note confirming that it now stocked Chlorphenamine, and also provided us with risk assessments for not stocking Glucagon and Diazepam.
  • A GP partner at the practice had provided sepsis training for all staff at the practice, in accordance with guidelines issued by the National Institute for Health and Care Excellence (NICE). Staff we spoke with demonstrated an understanding of what sepsis was and what the associated ‘red flag’ symptoms were, for example high temperature, chest pains, shortness of breath, nausea, vomiting, chills and shivering.

Information to deliver safe care and treatment

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

  • Individual care records were written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • Referral letters included all of the necessary information.

Appropriate and safe use of medicines

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

  • There were systems for minimising risks in relation to managing medicines, including vaccines. The practice kept prescription stationery securely and monitored its use.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. Data showed that the practice’s antibacterial prescribing was low.
  • We reviewed care records for 18 patients who were prescribed with high risk medication (for example patients prescribed with warfarin, methotrexate, azathioprine and lithium). We found that the records were of a good standard and there was evidence of appropriate monitoring and clinical reviews.
  • The practice had a policy for monitoring uncollected prescriptions, which included a monthly check of the prescription collection box, and any prescriptions not collected for one month would be passed on to the prescriber for review or destruction.

Track record on safety

The practice had a good track record on safety.

  • There were comprehensive risk assessments in relation to safety issues.
  • The practice monitored and reviewed safety using information from a range of sources.

Lessons learned and improvements made

The practice learned and made improvements when things went wrong.

  • There was a system for recording and acting on significant events and incidents. There had been five significant events recorded in the last 12 months. Staff understood their duty to raise concerns and report incidents and near misses. Practice management supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The practice learned from incidents, lessons were shared, and action to improve safety was taken. We saw evidence that significant events were discussed at practice meetings, being a standing agenda item, and were reviewed on an annual basis. Minutes of discussions were emailed to all staff to share learning.
  • There were systems for receiving and acting on safety alerts. These were received from the NHS Central Alerting System. The practice manager and GP partners were responsible for reviewing the relevant alerts and, if appropriate, passed them on to staff by email. In the event that drugs alerts were received, records searches were carried out to check whether any patients were affected. If so, they were called in for review.

Please refer to the evidence tables for further information.



Updated 25 September 2018

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

Effective needs assessment, care and treatment

The practice had systems to keep clinicians up to date with current evidence-based practice. We saw that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols. The practice had access to guidance including that issued by the National Institute for Health and Care Excellence (NICE). Patients’ needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.

  • Staff advised patients what to do if their condition got worse and where to seek further help and support.
  • We saw no evidence of discrimination when making care and treatment decisions.

Older people:

This population group was rated good because:

  • Older patients who are frail or may be vulnerable received a full assessment of their physical, mental and social needs. Those identified as being frail had a clinical review including a review of medication.
  • There were 381 patients aged over 75, all of whom had a named GP. These were invited for a health check and if necessary they were referred to other services such as voluntary services and supported by an appropriate care plan.
  • The practice provided care for a local care home which had 34 residents. There was a named doctor who primarily provided care to the residents. We were told that the practice had recently provided sepsis training to the practice manager of the care home. We were advised that there was an incident at the care home and the practice manager recognised the patient was suffering from sepsis and had called the emergency services. The practice informed us that they planned to provide sepsis training for all staff working at the care home.
  • Personalised care plans were in place for the most frail and vulnerable patients. These patients were also provided with routine home visits.
  • The practice followed up on older patients discharged from hospital. It ensured that their care plans and prescriptions were updated to reflect any extra or changed needs.
  • Staff had appropriate knowledge of treating older people including their psychological, mental and communication needs.
  • We saw evidence of effective liaison with other healthcare professionals and staff attended monthly multi-disciplinary team meetings.

People with long-term conditions:

This population group was rated good because:

  • Patients with long-term conditions had a structured annual review to check their health and medicines needs were being met. For patients with the most complex needs, the GP worked with other health and care professionals to deliver a coordinated package of care.
  • Staff who were responsible for reviews of patients with long term conditions had received specific training, for example clinicians had received advanced diabetic training.
  • GPs followed up patients who had received treatment in hospital or through out of hours services for an acute exacerbation of asthma.
  • Adults with newly diagnosed cardiovascular disease were offered statins for secondary prevention. Patients with suspected hypertension were offered ambulatory blood pressure monitoring and patients with atrial fibrillation were assessed for stroke risk and treated as appropriate.
  • The practice was able to demonstrate how it identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension.
  • We saw from published performance data for 2016 / 2017 that the practice was not an outlier in relation to long term conditions, with its various indicators being comparable with or slightly above local and national averages.

Families, children and young people:

This population group was rated good because:

  • Childhood immunisations were carried out in line with the national childhood vaccination programme.
  • The most recent published data, for 2016 / 2017, showed that immunisation rates for children aged two were below the target rate of 90% or above. For example:

  • The percentage of children aged 2 who had received their booster immunisation for Pneumococcal infection (i.e. received Pneumococcal booster) (PCV booster) (01/04/2016 to 31/03/2017) was 78%
  • The percentage of children aged 2 who had received their immunisation for Haemophilus influenza type b (Hib) and Meningitis C (MenC) (i.e. received Hib/MenC booster) (01/04/2016 to 31/03/2017) was 81%.
  • The percentage of children aged 2 who had received immunisation for measles, mumps and rubella (first dose of MMR) (01/04/2016 to 31/03/2017) was 81%.

  • The practice informed us that they were aware of the low uptake of childhood immunisations for children aged two in 2016/2017. To address this, they had a weekly baby walk-in clinic for immunisations every Tuesday between 2pm-3pm, and they would also offer immunisations to children opportunistically.
  • The practice had arrangements for following up failed attendance of children’s appointments following an appointment in secondary care or for immunisation. They had a system in place to encourage parents to bring in their children for immunisations by phone call followed up by two letters.
  • The practice told us that their internal database indicated that performance in childhood immunisations for children aged two had improved in 2017/2018. However, this data was unverified and unpublished. The practice told us that they would make further efforts to improve childhood immunisations particularly for those aged two.
  • All mothers with new born babies were invited for post-natal checks.
  • The practice maintained a register of children on protection plans. Staff met regularly to review cases. The families discussed were coded as vulnerable families and care plans were added to patients’ records.

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

This population group was rated good because:

  • The national coverage target for cervical screening is 80%. The practice’s uptake was 65%, compared with the CCG average of 64% and the England average of 72%.
  • The practice informed us that some patients had cited cultural concerns as a reason for not engaging with the cervical screening programme. The practice told us they worked towards educating eligible patients about the benefits of the screening programme at face to face consultations and by providing information leaflets. The practice provided us with unverified data which indicated that for 2017/2018 the practice’s uptake for cervical screening tests had increased to 76%.
  • 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:

This population group was rated good because:

  • 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 offering vaccinations to patients with an underlying medical condition according to the recommended schedule.

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

This population group was rated good because:

  • The practice assessed and monitored the physical health of people with mental illness, by providing access to health checks, interventions for physical activity, obesity, diabetes, heart disease, cancer and access to ‘stop smoking’ services. There was a system for following up patients who failed to attend for administration of long term medication.
  • When patients were assessed to be at risk of suicide or self-harm the practice had arrangements in place to help them to remain safe.
  • All clinical staff had undertaken dementia training. Patients at risk of dementia were identified and offered a detection assessment. When dementia was suspected there was an appropriate referral for diagnosis.
  • The practice offered annual health checks to patients with a learning disability.
  • The practices performance on quality indicators for mental health was in line with local and national averages.

Monitoring care and treatment

  • The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided. For example by frequent clinical audit.
  • The practice participated in the Quality Outcome Framework (QOF), a system intended to improve the quality of general practice and reward good practice. The most recently published QOF results were those for 2016 / 17, which showed the practice achieved 99% of the total number of points available which is above the CCG and England average of 96%.
  • The overall exception reporting rate was 7% compared with the CCG average of 8% and the national average of 10%. Exception reporting is the removal of patients from QOF calculations where, for example, the patients decline or do not respond to invitations to attend a review of their condition or when a medicine is not appropriate.
  • The practice used information about care and treatment to make improvements. It had carried out 16 clinical audits in the past two years, two of which we reviewed were repeat or completed cycle audits. We saw evidence of improvements from repeat audits, as set out in the evidence table.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles. For example, staff whose role included immunisation and taking samples for the cervical screening programme had received specific training and could demonstrate how they stayed up to date.

  • Staff had appropriate knowledge for their role, for example, to carry out reviews for people with long term conditions, older people and people requiring contraceptive reviews.
  • The practice understood the learning needs of staff and provided protected time and training to meet them. Up to date records of qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • The practice provided staff with ongoing support. There was an induction programme for new staff. This included one to one meetings, appraisals, coaching and mentoring, clinical supervision and revalidation.
  • There was a clear approach for supporting and managing staff when their performance was poor or variable.

Coordinating care and treatment

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

  • We saw records that showed that all appropriate staff, including those in different teams and organisations, were involved in assessing, planning and delivering care and treatment.
  • The practice shared clear and accurate information with relevant professionals when discussing care delivery for people with long term conditions and when coordinating healthcare for care home residents. It also shared information and liaised with community services, social services and carers for housebound patients, and with health visitors and community services for children who 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, 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 25 September 2018

We rated the practice as good for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • We received 66 CQC comments from patients which were all was positive about the way staff treated them.
  • Staff understood patients’ personal, cultural, social and religious needs.
  • The practice gave patients timely support and information.
  • The practice’s GP patient survey results for 2017 were in line or above local and national averages for questions relating to kindness, respect and compassion.
  • Patients we spoke with during the inspection and comment cards we received, stated that the clinicians were good at treating them with care and concern.

Involvement in decisions about care and treatment

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

  • Staff communicated with people in a way that they could understand. For example, communication aids and easy read materials were available.
  • Staff helped patients and their carers find further information and access community and advocacy services. They helped them ask questions about their care and treatment.
  • The practice was working to identify all patients who were carers. Its computer system alerted GPs if a patient was also a carer. The practice had identified 79 patients as carers (1% of the patient list). The practice told us that it had recently hosted a coffee morning for carers with representative from the organisation Age UK. The practice planned on hosting regular coffee mornings for carers.
  • The practice’s GP patient survey results for 2017 were in line with or above local and national averages for questions relating to involvement in decisions about care and treatment.
  • Patients we interviewed and comment cards we received stated that the clinicians were good at involving them in decisions about their care.

Privacy and dignity

The practice respected respect patients’ privacy and dignity.

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

Please refer to the evidence tables for further information.



Updated 25 September 2018

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


Responding to and meeting people’s needs

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

  • The practice understood the needs of its population and tailored services in response to them. The practice was aware that all of the clinicians working at the practice were female. The practice told us that if a patient did wish to see a male clinician, then they would assist the patient in booking an appointment with a male GP or nurse at one of the extended hours hub locations.
  • Telephone consultations were available which supported patients who were unable to attend the practice during normal working hours.
  • The facilities and premises were appropriate for the services delivered.
  • The practice made reasonable adjustments when patients found it hard to access services, for example offering home visits.
  • The practice provided effective care coordination for patients who are more vulnerable or who had complex needs. They supported them to access services both within and outside the practice.
  • Care and treatment for patients with multiple long-term conditions and patients approaching the end of life was coordinated with other services.

Older people:

This population group was rated good because:

  • All patients over the age of 75 had a named GP who supported them in whatever setting they lived, whether it was at home or in a care home or supported living scheme.
  • The practice was responsive to the needs of older patients, offering home visits and urgent appointments for those with enhanced needs. The GPs accommodated home visits for those who had difficulties getting to the practice.
  • Where appropriate the practice made referrals to the local Rapid Response Team which was able to visit and treat patients reducing unnecessary hospital admissions.
  • Staff told us that any repeat prescription requests made by members of this population group were completed as soon as possible (and at times there and then) to avoid multiple unnecessary visits to the practice.

People with long-term conditions:

This population group was rated good because:

  • Patients with a long-term condition received an annual review to check their health and medicines needs were being appropriately met. Multiple conditions were reviewed at one appointment, and consultation times were flexible to meet each patient’s specific needs.
  • The practice held regular meetings with the local district nursing team to discuss and manage the needs of patients with complex medical issues.
  • The practice hosted a diabetes prevention clinic, which provided patients with lifestyle and healthcare advice aimed at preventing and/or controlling diabetes.
  • We were told all specialist clinicians would meet with the principle GP at the end of their respective clinics to discuss the care of the patients that were seen and inform them of changes in medication or treatment.

Families, children and young people:

This population group was rated good because:

  • We found there were systems to identify and follow up children living in disadvantaged circumstances and who were at risk. For example, children and young people who had a high number of accident and emergency (A&E) attendances.
  • All parents or guardians calling with concerns about a child were offered a same day appointment when necessary.
  • All newly registered patients under the age of three were seen by a GP to ensure that they were safe and healthy. We were told that this was in response to a lack of health visiting support in the local area.
  • Safeguarding was a standing item on the weekly team meeting agenda.
  • The practice offered antenatal and postnatal care in conjunction with the services provided by the local hospital.

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

This population group was rated good because:

  • 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 was aware that 68% of its patients were working age. The practice had reviewed its appointment system to give this cohort of patients more access to its services. For less serious matters patients were offered appointments with the prescribing pharmacist and nurse. Telephone consultations were available which supported patients who were unable to attend the practice during normal working hours. The practice also offered online appointments and prescription requests.
  • An extended hours Hub operated from the practice every Monday and Wednesday between 6.30 pm and 9.00 pm and every Saturday 9.00 am to 1.00 pm.
  • The practice informed us that it recently hosted a health stall at a local over 50’s event. It provided free health checks and advice to those in attendance.

People whose circumstances make them vulnerable:

This population group was rated good because:

  • The practice held a register of patients living in vulnerable circumstances including homeless people and those with a learning disability.
  • Longer standard appointments with GPs and nurses were available for this patient group.
  • The practice informed us that its staff had recently carried out Identification and Referral to Improve Safety (IRIS) training in domestic violence, and was recognised as an IRIS accredited GP surgery on domestic violence and abuse. We were told that within weeks of undertaking this training the practice had made two referrals to this organisation.

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

This population group was rated good because:

  • Staff interviewed had a good understanding of how to support patients with mental health needs and patients living with dementia.
  • The practice provided access to various local organisations that provided mental health support services.
  • Regular multi-disciplinary team meetings were held with mental health care professionals from the local hospitals.

Timely access to care and treatment

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

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported that the appointment system was easy to use.
  • The practices GP patient survey results were in line or above local and national averages for questions relating to access to care and treatment.

Listening and learning from concerns and complaints

The practice took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

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

Please refer to the evidence tables for further information.



Updated 25 September 2018

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

Leadership capacity and capability

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

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

Vision and strategy

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

  • The practice had a realistic strategy to achieve priorities.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.
  • The strategy was in line with health and social care priorities across the region. The practice planned its services to meet the needs of the practice population.
  • The practice monitored progress against delivery of the strategy.


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

  • Staff stated they felt respected, supported and valued.
  • The practice focused on the needs of patients.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff we spoke with told us they were able to raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisals, protected time for professional development, and career development conversations. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The practice actively promoted equality and diversity. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

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

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

Managing risks, issues and performance

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

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The practice had processes to manage current and future performance. Practice leaders had oversight of safety alerts, incidents, and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change practice to improve quality.
  • The practice had plans in place and had trained staff for major incidents.
  • The practice considered and understood the impact on the quality of care of service changes or developments.

Appropriate and accurate information

The practice acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. The practice manager was responsible for reviewing ongoing QOF data and reporting to the team on a monthly basis. Performance information was combined with the views of patients, from suggestions and comments received.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The practice used performance information which was reported and monitored and management and staff were held to account.
  • The information used to monitor performance and the delivery of quality care was accurate and useful.
  • The practice 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.

  • There was an active patient participation group (PPG). Members of the PPG gave us positive feedback regarding its engagement with the practice. The PPG met quarterly and told us that the practice recently supported the formation of a gardening club, which was used as a platform for patients to socialise at their local practice.
  • The practice monitored and responded to patients’ reviews left on the NHS Choices website and carried out its own annual patient surveys.
  • The practice was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

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

  • 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