You are here

Bartongate Surgery Good Also known as Drs Johnson, Nair, Karunaratne & Harris

Inspection Summary

Overall summary & rating


Updated 15 May 2018

This practice is rated as Good overall. (Previous inspection: January 2015 – Good and January 2014- The provider met all the standards where they were inspected)

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 Bartongate Surgery on 4 April 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.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients reported that they were able to access care when they needed it urgently. However, there were longer waiting times for routine appointments.
  • The practice worked with a local organisation to provide medical support for patients who were refugees from Syria.
  • There was a focus on continuous learning and improvement at all levels of the organisation.

We saw one area of outstanding practice:

The practice recognised the needs of its local population with regards to their culture and background and proactively found ways to support them to maintain their health. They had organised a learning event to support patients of the Muslim faith so that patients could obtain useful information on how to better manage their long term condition during the fasting period.

The areas where the provider should make improvements are:

  • Implement a schedule for regular fire drills to be undertaken.
  • Record the temperature of the internal thermometer when the external thermometer of vaccine fridges shows reading outside of the normal range.
  • Implement actions to improve the identification of carers.
  • Review the current appointment systems to improve patient experience.
  • Record all incidents, near misses and significant events so that trends can be analysed and actions implemented can be reviewed.

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

Inspection areas



Updated 15 May 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. Reports and learning from safeguarding incidents were available to staff. Staff who acted as chaperones were trained for their role and had received a Disclosure and Barring Service (DBS) check. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.)
  • Staff took steps, including working with other agencies, to protect patients from abuse, neglect, 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. All staff were required to complete a self-declaration document annually to demonstrate that their circumstances have not changed.
  • 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.
  • 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. The practice was also in discussion with a training provider to arrange for non-clinical staff to receive training in sepsis. Until this had been undertaken, we were told that they planned for GPs at the practice to give all non-clinical staff information on this topic during one of the practice’s training event in a few weeks’ time.
  • 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. We saw that the practice had taken actions when one of the vaccine fridges had operated outside of the normal range. For example, they had arranged for the fridge to be investigated and serviced by an engineer. They also identified that there were times where the temperature of the room where the fridge was kept increased and therefore, had installed an air-conditioning unit to keep the room cool. They had also installed a second internal thermometer to monitor the temperature of the fridge in line with best practice. The practice was able to demonstrate that appropriate actions had been taken to ensure the safety and efficacy of vaccines held in stock. However, when the maximum temperature of one of the vaccine fridges indicated that it was outside of the normal range, staff had not recorded the temperature of the internal thermometer.
  • 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 stewardship 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. There was a pharmacist attached to the practice who supported the GPs with medicine reviews.

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. However, we noted that a fire drill had not been undertaken since 2015. The practice sent us information following the inspection to demonstrate a fire drill had been undertaken on the 5 April 2018 and a regular schedule had been put in place to ensure fire drills are undertaken regularly.

Lessons learned and improvements made

The practice learned and made improvements when things went wrong.

  • Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The practice learned and shared lessons, identified themes and took action to improve safety in the practice. However, we noted that the practice had a low number of significant events in the last 12 months and we discussed these with the management team. They gave us examples where issues were resolved immediately and a change in process was implemented. For example, when a text reminder about the flu clinic was sent to the wrong patient, the practice identified that some patients had changed their phone numbers and not informed the practice about their updated contact details. The practice asked staff to check patient contact details when they call the practice and to update these where needed. They also identified that the text messaging service would send a notification to the practice when text messages could not be delivered. The practice used this as a prompt to contact the relevant patient to check their contact details. However, these actions had not been recorded.
  • 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 15 May 2018

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


(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.
  • The practice used their clinical systems to identify patients on specific treatment and to check whether those patients received care in line with best practice guidance.
  • 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. The pharmacist and practice nurse also undertook home visits to review medicines and health needs of patients who were housebound.
  • 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.
  • 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.
  • GPs followed up patients who had received treatment in hospital or through out of hours services for an acute exacerbation of asthma.
  • The practice had arrangements for adults with newly diagnosed cardiovascular disease including the offer of high‑intensity statins for secondary prevention, people 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 they identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension. The practice recognised that they had a number of patients who were at risk of developing diabetes and offered those patients a blood test if they presented with any signs and symptoms which was linked to diabetes. We saw evidence where patients had been diagnosed with diabetes following presentation with mild symptoms of diabetes. This has led to effective treatment being delivered for those patients before their symptoms worsened.
  • The percentage of patients with diabetes, on the register, in whom the last average blood glucose was 64 mmol/mol or less in the preceding 12 months (01/04/2016 to 31/03/2017) was 64% compared to the clinical commissioning group (CCG) of 82% and national average of 80%. We discussed the lower than average performance with the practice and they identified that this was due to many patient not complying with their treatment plan. Some patients were also diagnosed with much higher blood glucose levels and in those cases, treatment to bring patients’ average blood glucose within a safe range took longer to be effective.

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 below the target percentage of 90% or above. For example, the percentage of children aged two years old who had received all the recommended vaccines ranged between 88% and 89%. However, the percentage of children aged one with completed primary course of vaccine was 90%. The practice identified that they had a higher number of transient population which led to young children not having their vaccine records from their home country. We saw the practice had implemented a system where parents were encouraged to obtain their child’s immunisation records and when this was obtained, the practice nurse updated their records and followed up those children who required immunisation.
  • 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.

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

  • The practice’s uptake for cervical screening was 61%, which was in line with the CCG average of 76% and national average of 72%. The practice was working on hosting a “ladies evening” at a local café to raise awareness of the importance of cervical screening.
  • The practice also encouraged its patients to attend national screening programmes for bowel and breast cancer screening. The patient uptake for this service in the last two and a half years was 41%, compared to the CCG average of 62% and national average of 55%. The practice also encouraged eligible female patients to attend for breast cancer screening. The rate of uptake of this screening programme in the last three years was 61%, compared to the CCG average of 75% and national average of 70%.
  • The practice had systems to inform eligible patients to have the meningitis vaccine, for example before attending university for the first time.
  • Patients had access to appropriate health assessments and checks including NHS checks for patients aged 40-74. There was appropriate follow-up on the outcome of health assessments and checks where abnormalities or risk factors were identified.

People whose circumstances make them vulnerable:

  • End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.
  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers, refugees and those with a learning disability. Homeless people were referred to a local organisation for homeless people for further support. The practice also worked with a local organisation to provide medical support for patients who were refugees from Syria.
  • The practice had a system for vaccinating patients with an underlying medical condition according to the recommended schedule.

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

  • The practice assessed and monitored the physical health of people with mental illness, severe mental illness, and personality disorder by providing access to health checks, interventions for physical activity, obesity, diabetes, heart disease, cancer and access to ‘stop smoking’ services.
  • 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 CCG average of 87% and national average of 84%.
  • 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 CCG average of 94% and national average of 90%.
  • The practice specifically considered the physical health needs of patients with poor mental health and those living with dementia. For example, 94% of patients experiencing poor mental health had received discussion and advice about alcohol consumption. This was comparable to the CCG average of 93% and national average of 91%.
  • 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. For example, a number of clinical audits were undertaken where improvements were identified and implements. We reviewed one completed cycle audit where the practice had identified improvement. For example, a search was undertaken for patients who were on a class of medicines that prevented the loss of bone density. This was undertaken to ensure patients who had been on this medicine for five years or more had received a “drug holiday”. The audit identified that nine out of 54 patients needed a “drug holiday”. The practice contacted those patients to inform them that they should stop taking this medicine and to contact the practice in two years’ time for a review or sooner if they sustain a fracture. The practice identified best practice guidelines in relation to the prescribing of these medicines and shared this with all clinicians at the practice. A further audit showed that one patient (who was not part of the initial audit) had been on this medicine for five years or more, and had not received a treatment break. However, the patient had been reviewed by a consultant in secondary care who had recommended that the patient continue with this medicine.

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 practice ensured the competence of staff employed in advanced roles by audit of their clinical decision making, including non-medical prescribing.
  • 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 care home residents. They 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, 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 15 May 2018

We rated the practice as good for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients on the day of the inspection was positive about the way staff treat people. One comment cards however, contained mixed comments which related to the attitude of reception staff.
  • Staff understood patients’ personal, cultural, social and religious needs.
  • The practice gave patients timely support and information.

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, 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 identified carers and supported them. Six monthly health checks were offered to patients who were also identified as carers. However, the practice had only identified 59 patients as carers. This represented approximately 0.7% of the practice patient population.

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 15 May 2018

We rated the practice, and all of the population groups, as good for providing responsive services except for patient with long term conditions which we rated as outstanding


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 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 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 nursing home.
  • 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.

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.
  • The practice recognised the needs of its local population with regards to their culture and background and proactively found ways to support them to maintain their health. They had identified that there was an increase in patients suffering from fatigue, urine infections and sore throats during the period of Ramadan (Ramadan is the ninth month of the Islamic calendar, and a time when Muslims across the world will fast during the hours of daylight.). Following attendance at a training event, one of the practice nurses obtained information on how patients could keep well during fasting. The practice had therefore planned for a learning event to take place at the practice on the 2 May 2018 (approximately two weeks before the beginning of Ramadan) where patients of the Muslim faith would be invited to attend to learn hints and tips on how they can manage their long term conditions during that time. They had worked with a representative of the local mosque to share this information among the local Muslim community. Men and women of Muslim faith would be invited separately to accommodate the needs of this community. We were told that patients were sent letters in previous years to advise them to stop certain medicines during Ramadan to avoid any complications and manage their long term conditions better.
  • 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 participated in the winter resilience programme between December and March. Additional appointments were provided primarily for patients diagnosed with chronic obstructive pulmonary disease to avoid unnecessary hospital admissions.

Families, children and young people:

  • We found there were systems to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of accident and emergency (A&E) attendances.
  • All parents or guardians calling with concerns about a child under the age of 18 were offered a same day appointment when necessary. Patients we spoke with on the day of the inspection confirmed this.
  • The practice worked with families who were refugees to provide immunisation for their children.

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 offered on Tuesdays between 6.30pm and 8m. Additional Saturday appointments were offered between 9am and 1pm one Saturday a month between December and March.

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances including refugees and those with a learning disability.
  • The practice worked with a local organisation to provide medical support for patients who were refugees from Syria.

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.
  • The practice held GP led dedicated monthly mental health and dementia clinics. Patients who failed to attend were proactively followed up by a phone call from a GP.

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.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported that the appointment system was easy to use. However, they also reported that there were delays for routine appointments.

Results from the national GP patient survey showed that patient’s satisfaction with how they could access care and treatment was below local and national averages.

  • 67% of patients were able to get an appointment to see or speak to someone the last time they tried compared to the CCG average of 85% and national average of 76%.
  • 64% of patients responded positively to the overall experience of making an appointment compared to the CCG average of 80% and national average of 73%.

The practice had plans for two of the practice nurses to complete a triage course, which would enable more time to be available for GPs in the longer term.

Listening and learning from concerns and complaints

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

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The complaint policy and procedures were in line with recognised guidance. The practice learned lessons from individual concerns and complaints and also from analysis of trends. It acted as a result to improve the quality of care.

Please refer to the Evidence Tables for further information.



Updated 15 May 2018

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

Leadership capacity and capability

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

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

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 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. 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 around 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 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 arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

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

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

Continuous improvement and innovation

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

  • There was a focus on continuous learning and improvement. For example, the practice was successful in bidding for funds to improve some areas of the practice.
  • 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. However, not all incidents or significant events had been recorded.
  • 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