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Clerkenwell Medical Practice Good

Inspection Summary

Overall summary & rating


Updated 20 July 2018

This practice is rated as Good overall. (Previous report rating 05/2016 – 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

This service was previously inspected in December 2015 and given a rating of good for the key questions of safe, effective, caring, and well led care and a rating of outstanding for responsive. The overall rating was good.

We carried out an announced comprehensive re-inspection at Clerkenwell Medical Practice on 17 May 2018, as part of our inspection programme.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • The service responded to patient needs and specifically tailored and focused the way it provided care according to those needs. Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

  • Review the systems around the calibration of clinical equipment and the testing of electronic equipment (Portable Appliance Testing) to ensure that equipment is safe to use.
  • The practice should review how information is provided to patients who do not speak English as a first language, for instance, information about chaperoning services and health screening programmes.
  • Continue to review processes in place to further increase the uptake of cervical screening and childhood immunisations.
  • Continue to review high exception reporting with a view to ensuring that it remains appropriate and in line with local and national averages.
  • Review how patients with learning difficulties are supported.
  • Review and improve how patients with caring responsibilities are identified and recorded on the clinical system to ensure that information, advice and support is made available to them.

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 20 July 2018

We rated the practice as good for providing safe services.

Safety systems and processes

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

  • The practice carried out safety risk assessments and had a range of safety policies, which were stored on a shared drive on the computer system, and staff were all aware of how to gain access.
  • 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. Policies were regularly reviewed and were accessible to all staff. They outlined clearly who to go to for further guidance and staff we spoke with were all aware of the safeguarding lead GP and what to do if they had safeguarding concerns.
  • The practice had appropriate systems to safeguard children and vulnerable adults from abuse.
  • Staff at all levels knew how to identify and report safeguarding 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 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.
  • We saw that all notices were written in English, despite the practice having a large proportion of patient’s with English not as their first language.
  • We saw evidence of how 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. Staff attended regular safeguarding networking meetings and undertook case audits and pathways reviews. There was a specific slot for safeguarding in the weekly clinical meetings and learning points were shared with staff at the practice.
  • 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 (IPC). The lead nurse was the IPC lead. They had received appropriate training to enable the role to be carried out effectively. Audits had been undertaken and actions identified as a result had been implemented.
  • On the day of the inspection, we noted that Portable Appliance Testing (PAT) and calibration of clinical equipment had not been undertaken since 2016, which was not in line with best practice. On the day after day after the inspection, we received evidence demonstrating that PAT testing and calibration of clinical equipment had been carried out.
  • 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 had implemented a buddy system to cover for any periods of absences, to ensure patient care and safety was not compromised.
  • 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 information needed to deliver safe care and treatment was available to staff.
  • There was a documented approach to managing test results and we saw results were dealt with in a timely way.
  • The practice had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • Clinicians made timely referrals in line with protocols.

Appropriate and safe use of medicines

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

  • The systems for managing and storing medicines, including vaccines, medical gases, emergency medicines and equipment, minimised risks.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with current national guidance. The practice had reviewed its antibiotic prescribing and taken action to support good antimicrobial stewardship in line with local and national guidance. We saw evidence the practice had reduced antibiotic prescribing in the last 12 months.
  • The Patient Group Directions in place were adequate and kept under review by senior clinicians.
  • 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 took action to improve safety in the practice.
  • There was an effective a system for receiving and acting on safety alerts. The practice learned from external safety events as well as patient and medicine safety alerts. Processes had been updated to ensure actions were completed and documented and there was evidence that these processes were fully embedded. We saw from meeting minutes that relevant alerts were also shared with the wider team.

Please refer to the Evidence Table for further information.



Updated 20 July 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.

  • 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 over 65 were also asked if they had carer or were a carer, and if so they were put on a specific register.
  • Clinicians actively screen older patients for new cases of Atrial Fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate) and concerns regarding memory and depression.
  • 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.
  • Adults with newly diagnosed cardiovascular disease were offered 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 it identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (lung conditions that cause breathing difficulties), atrial fibrillation and hypertension (high blood pressure)
  • The practice’s performance on quality indicators for long-term conditions was in line and in some cases slightly above local and national averages.

Families, children and young people:

  • Childhood immunisation uptake rates for children aged 1 were in line with the 90%target set by the World Health Organisation (WHO).
  • Immunisation rates for children aged 2 were below the 90% minimum target set by WHO. The practice informed us that they were aware of the low uptake of childhood immunisation in 2016/2017 and had identified staff shortages as a significant contributor to this. The practice also told us that they had experienced cultural resistance to some childhood immunisations, and that they had taken steps to increase awareness of the benefits of childhood immunisations.
  • We reviewed the procedures that were followed to encourage the uptake of childhood immunisation, and noted that the steps included written invitations to parents inviting their child for immunisation, followed up by a letter from the nurse and a telephone call, where appropriate.
  • The practice showed us unverified data, which indicated a small percentage of improvement in 2017/2018.
  • The practice told us that to further increase the uptake of childhood immunisations, it had an action plan in place which included:
  • The recruitment of an additional nurse;
  • The recruitment of a secondary care nurse who was currently converting her qualifications for general practice;
  • The practice amended the patient alert system on their computer to identify any children who were overdue immunisations; and
  • The practice reached out to neighbourhood practices with similar demographics to see what their processes were for increasing the uptake of immunisations.
  • The uptake of cervical screening at the practice was slightly lower than CCG average and significantly lower than the England average. The practice explained that the patient population included a large cohort of university students who were patients at the practice only for the duration of their studies and accessed certain services from their family GP. The practice told us that this had affected the cervical screening uptake rate.
  • The practice also informed us that it had also experienced cultural barriers with some population groups who expressed reluctance to engage with the cervical screening programme.
  • The practice told us that they had responded to the low uptake rate of cervical screening and had carried out the following:
  • Writing to eligible patients explaining the benefits of the cervical screening programme;
  • Supplying the local university with information posters promoting the benefits of the cervical screening programme;
  • Engaging with the university nurse to encourage students to participate with the programme;
  • Recruiting an additional nurse who was trained to carry out cervical screening;
  • Ensuring that three GP’s were trained in cervical screening which meant that screening could be carried out opportunistically.
  • We reviewed unvalidated data for 2017/2018 which indicated that the cervical screening uptake rate had increased to 77% compared to the 58% uptake in 2016/2017.
  • The practice’s uptake for breast and bowel cancer screening was in line with the CCG average but below the national average. The practice demonstrated how it was addressing this area.
  • 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:

  • 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.

  • End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.
  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
  • The practice had a system for vaccinating patients with an underlying medical condition according to the recommended schedule.

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.
  • 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.
  • Patients were referred to the practice based mental health team (iCope) and there was an onsite psychiatrist who would see the practice’s patients.
  • 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 effectiveness and appropriateness of the care provided. Where appropriate, clinicians took part in local and national improvement initiatives.

  • Child immunisations for children aged 2 and cervical screening uptake was below local averages. The practice demonstrated that they were addressing these concerns by employing a new practice nurse and increasing communication in order to increase awareness within both patient groups. The practice also showed us unverified data which indicated that both these areas had improved in 2017/2018.
  • The QOF scheme includes the concept of ‘exception reporting’ to ensure that practices are not penalised where, for example, patients do not attend for review, or where a medication cannot be prescribed due to a contraindication or side-effect. The practice was aware their exception reporting was high in comparison to the CCG average and national average for indicators for diabetes, dementia, depression and osteoporosis. We reviewed the process of exception reporting in these areas and found that it was in line with guidance. We looked at a sample of patients who had been exception reported and were satisfied that their exception reporting was justified.
  • The practice used information about care and treatment to make improvements.
  • The practice was actively involved in quality improvement activity. Where appropriate, clinicians took part in local and national improvement initiatives.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

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

Coordinating care and treatment

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

  • We saw records that showed that all appropriate staff, including those in different teams and organisations, were involved in assessing, planning and delivering care and treatment.
  • The practice shared clear and accurate information with relevant professionals when discussing care delivery for people with long-term conditions. 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

Staffs 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, carers and those who were recently bereaved.
  • Staff encouraged and supported patients to be involved in monitoring and managing their own health, for example through social prescribing schemes. They were signposted and referred to local services to help them manage their conditions, such as programmes for diabetic patients.
  • 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 20 July 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 took account of patient needs and preferences.

  • The practice understood the needs of its population and tailored services in response to those needs. For example the practice recognised that a large number of its patients did not have English as their first language and in response to this:
  • Clinical and non-clinical staff had access to a translation service.
  • The practice website included a feature which allowed it to be translated in over 90 languages.
  • The practice employed staff, including clinical staff with a wide range of community language skills, including Turkish, Chinese, Spanish, French and Portuguese.
  • Telephone and web GP consultations were available which supported patients who were unable to attend the practice during normal working hours.
  • The practice recently introduced an email address where patients can request information on non-urgent matters.
  • 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.
  • There is a house bound register, and those on this register received annual GP and Nurse home visit consultations.
  • Introduction of easier access for patients aged 75 and over as they have automatic same day appointments, if requested.
  • Older patients would be routinely screened during their annual health checks/flu jabs for Atrial Fibrillation.
  • Older patients have a dedicated slot on the weekly clinical meetings.

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 multiple disciplinary meetings to discuss and manage the needs of patients with complex medical issues.
  • The practice hired a pharmacist to assist its patients with managing medicines and help with the reduction of poly-pharmacy.
  • The practice had a high HIV prevalence and was recognised as being ‘HIV friendly’ practice. The practice had been approved by Islington Clinical Commissioning Group to provide shared care enhanced services for patients with HIV in conjunction with the patient’s named hospital. All GP’s at this practice were trained in dealing with HIV patients.
  • Patients suffering from diabetes had access to specialist diabetic nurse who ran a weekly clinic at the practice. In addition, a doctor was allocated for those with challenging HBA1C results and early referrals were made to a community group education provider ‘DESMOND’ that would assist patients in self-managing their diabetes.
  • The practice had a high patient COPD prevalence, and those identified had a dedicated named GP and access to a COPD clinic to help manage the condition. Appropriate referrals were made to pulmonary rehabilitation services and annual reviews and a flu jab were carried out within the same appointment.

Families, children and young people:

  • We found there were systems to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of accident and emergency (A&E) attendances. Records we looked at confirmed this.
  • All parents or guardians calling with concerns about a child under the age of 18 were offered a same day appointment when necessary.
  • The practice had links and regular meetings with health visitors who were practice based.
  • Joint child health clinic held weekly by GP partner and health visitor.
  • All new deliveries are called for a 6-week check to ensure both baby and maternal health needs are identified early.

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, appointments are offered during lunch hours and patients who do not live in the area but work in the area are encouraged to join the practice.
  • The practice acted as a one of the main GP surgeries for the local university students. It held a good relationship and linked in with the university nurse, and had shared access to patient information for registered students. It also worked together in ensuring the student population was being screen for cervical screening and immunised against meningitis.

People whose circumstances make them vulnerable:

  • The practice informed us that it was now recognised as a fully IRIS Accredited GP surgery on domestic violence and abuse.

  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
  • People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode.
  • The practice was unaware that 7% of their patients self-declared as having a learning difficulty. The practice told us that they would review this cohort and would put a plan in place to engage with, and provide appropriate support where additional needs were identified.

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

  • The practice was aware of its high prevalence of patient’s with mental health conditions. People experiencing poor mental health had a named GP. Staff interviewed had an understanding of how to support patients with mental health needs and those patients living with dementia.
  • The practice was instrumental in working with the local Clinical Commissioning Group (CCG) to secure a practice based mental health team (iCope), so that its patients could access the service on site.
  • The practice informed us that they held a good relationship with the student mental health services at the local university, and that this aided in identifying and supporting these patients.
  • The practice informed us that they had good links with the local memory service, and when patients were identified with concerns about memory and function, the practice used a standardised blood test form to aid prompt access to the memory clinic.
  • The practice hosted a clinical psychiatrist who undertook appointments at the location which meant that patients did not need to travel to other locations for these appointments.
  • The practice had ensured that clinicians and patients had access to the mental health provider ‘Crisis’, who specialised in acute mental health services.

Timely access to care and treatment

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

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported that the appointment system was easy to use.
  • The practices GP patient survey results were in line with 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. 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 20 July 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.
  • The practice had recently appointed an executive partner to provide sustained leadership and help drive forward the practice vison and goals.

Vision and strategy

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

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


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

  • Staff stated they felt respected, supported and valued. They were proud to work in the practice.
  • The practice focused on the needs of patients.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.

  • Staff we spoke with told us they were able to raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary.
  • 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.

Managing risks, issues and performance

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

  • There were processes to identify, understand, monitor and address current and future risks including risks to patient safety. However, the practice had not recently PAT tested or calibrated its equipment, although both tests were carried out the day after the inspection.
  • 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.

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.
  • The practice used information technology systems to monitor and improve the quality of care.
  • The practice submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

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

  • A full and diverse range of patients’, staff and external partners’ views and concerns were encouraged, heard and acted on to shape services and culture.
  • There was an active patient participation group and we saw evidence of how the practice sought and acted upon their views (for example regarding appointments access).
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

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

  • There was a focus on continuous learning and improvement.
  • The practice had created a ‘super-administrator’ role, who had received additional training to safely process correspondence, results and clinical information for the GP’s. The practice told us that this had had a positive impact on administrative support to doctors in highlighting urgent issues. Doctors spoke positively about how this new role had enabled them to focus more efficiently on the clinical side of their work. The role was introduced to the local CCG and rolled out to other practices in the neighbourhood.
  • 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