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Inspection Summary

Overall summary & rating


Updated 27 December 2018

This practice is rated as Good overall. (Previous inspection January 2015 – Requires Improvement. Follow up inspection October 2015 - Good)

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 Bottreaux Surgery, including the dispensary on 1 November 2018. We visited the branch surgery at Tintagel and inspected the dispensary there. The inspection was a routine inspection as part of our inspection schedule.

At this inspection we found:

  • Despite national recruitment challenges for the primary medical services sector, the practice had successfully attracted a new GP partner to join Bottreaux Surgery practice.
  • The practice was focussed on safety and had clear systems to manage risk across the practice so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved processes.
  • Audit was an area for improvement for practice to routinely review the effectiveness and appropriateness of the care it provided.
  • Care and treatment was always delivered according to evidence-based guidelines.
  • All the feedback from 10 patients at the inspection was positive about staff treating them with compassion, kindness, dignity and respect.
  • Patient feedback about the appointment system had been listened to. The practice had increased patient access to appointments employing a varied skill mix of staff and increasing the number of appointments available with the GP and nursing team.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation. Proactive succession planning based on staff development and training of future GPs, doctors and practice nurses was evident at this training practice.
  • There was a proactive approach to preventing development of long term health conditions. For example, 226 patients within the pre-diabetic range received support and advice and were reviewed annually.

Areas where the provider should make improvements are:

  • Review the security of blank prescriptions within the dispensaries so that it is in line with national guidance.

  • Review infection prevention and control arrangements to promote patient and staff safety.

  • Develop an overall quality improvement programme with regular audits carried out across all staff groups and services.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas



Updated 27 December 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 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.
  • We reviewed two files and the locum GP files and found the practice carried out appropriate staff checks at the time of recruitment and on an ongoing basis.
  • There was a system to manage infection prevention and control. However, gaps were seen in a number of areas which had already been identified by the practice and actions taken to address this.
  • The practice had arrangements to ensure that facilities and equipment were safe and in good working order.
  • Arrangements for managing waste and clinical specimens kept people safe.

Risks to patients

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

  • Arrangements were in place for planning and monitoring the number and mix of staff needed to meet patients’ needs, including planning for holidays, sickness, busy periods and epidemics.
  • There was an effective induction system for temporary staff tailored to their role. This included a structured induction and an induction pack should any locum staff work at the practice.
  • The practice was equipped to deal with adult and paediatric 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. Assessment tools were seen to be displayed in all clinical areas and information in the waiting room was available for patients about early symptoms of 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 practice used a risk management system, which enabled patient records to be analysed to produce risk profiles to target audit activity, health screening and ongoing monitoring of 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 medicines, including vaccines, medical gases, and emergency medicines and equipment minimised risks. The practice kept prescription stationery securely and monitored its use. However, external cleaning staff had access to the dispensary out of hours where blank prescription forms were accessible.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. The practice had audited antimicrobial prescribing. There was evidence of actions taken to support good antimicrobial stewardship.
  • Patients’ health was monitored to ensure medicines were being used safely and followed up on appropriately. The practice involved patients in regular reviews of their medicines.
  • Arrangements for dispensing medicines at the practice kept patients safe.

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.
  • Policies and procedures had been updated and staff given a new handbook outlining these.

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.
  • The practice acted on and learned from external safety events as well as patient and medicine safety alerts. An audit was undertaken on receipt of a medicines safety alert in 2017 about the risks of sodium valproate (a medicine for epilepsy). This demonstrated the practice had identified all childbearing female patients who were prescribed sodium valproate, reviewed and altered the prescription where appropriate and advised them of the associated risks during pregnancy. A recent equipment alert regarding a device delivering emergency medicine used to treat patients who experiencing early anaphylactic shock (an emergency situation) had also been appropriately dealt with.

Please refer to the Evidence Tables for further information.



Updated 27 December 2018

We rated the practice as good for all of the population groups and 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.
  • The practice had near patient blood testing for any patients on anticoagulant medicines (warfarin). This enabled patients to receive the result and guidance about dosing before leaving the practice.
  • Staff advised patients what to do if their condition got worse and where to seek further help and support.

Older people:

  • Older patients who were 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 regular clinical reviews including a review of medicines. The practice had a monthly meeting to discuss all patients on the frailty register with the multidisciplinary team.
  • The practice followed up on older patients discharged from hospital. They 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:

  • The practice’s performance on quality indicators for long term conditions was in line with local and national averages with some being exceeded. Performance was above average for quality indicators covering respiratory conditions – asthma and chronic pulmonary disease.
  • Patients at risk of developing a long-term condition, for example those classed as being pre-diabetic, were closely monitored with regular blood checks and access to support to promote healthy living.

We also found that:

  • 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 and clinical pharmacist worked with other health and care professionals to deliver a coordinated package of care.
  • Practice nurses were responsible for reviews of patients with long term conditions had received specific training. The nurses held diploma qualifications covering the management of patients with diabetes and respiratory conditions such as asthma and chronic pulmonary disease.
  • 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 they identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension. Standardised templates were used to assess patients to identify any risks, which prompted specific follow up actions.

Families, children and young people:

  • Childhood immunisation uptake rates were above the world health organisation target percentage of 95%. All the four indicators were above this target ranging from 95.7% for under one’s and 95.1% for over 2s immunisations. Parents were actively encouraged to engage in the childhood immunisation programme which had resulted in the higher levels of immunisation.
  • The practice had arrangements for following up failed attendance of children’s appointments following an appointment in secondary care or for immunisation.
  • Practice nurses held advanced family planning qualifications and in addition to GPs were able to offer appointments for female patients to have contraceptive implants.

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

  • The practice’s uptake for cervical screening was 75%, which was below the 80% coverage target for the national screening programme. The practice uptake was in line with the local (75%) and above the national (72%) averages. Staff verified every contact with eligible women was used to encourage and support them to have cervical screening.
  • The practice’s uptake for breast and bowel cancer screening was in line with the national average.
  • The practice had systems to inform eligible patients to have the meningitis vaccine, for example before attending university for the first time.
  • Patients had access to appropriate health assessments and checks including NHS checks for patients aged 40-74 at least every five years. There was appropriate follow-up on the outcome of health assessments and checks where abnormalities or risk factors were identified.

People whose circumstances make them vulnerable:

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

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

  • The practice was a positive outlier for the assessment and monitoring of 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. The practice performance was positive with 100% of patients on this register having been reviewed compared to the national average of 90%. 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 patient or carer contacts from patients in crisis were treated as urgent and referred immediately to the GP.
  • 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.
  • 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. Where appropriate, clinicians took part in local and national improvement initiatives.

  • Data for 2016/17 demonstrated the practice was achieving comparable results compared with local and national practices.
  • We looked at the exception reporting rates, for example for patients on the asthma and mental health registers which were higher than the locality and national averages. When we inspected QOF data for 2017/18 had not been published. Overall exception rates (6.3%) were lower than the CCG figure (6.8%) and above the National figure (5.7%). However, the practice demonstrated monthly QOF performance was closely monitored. Exception reporting (exclusion of a patient for review) was only done at the end of the financial year when all opportunities encouraging eligible patients to attend for a review of their long-term condition had been explored. Clinicians made the decision as to whether to exception report for two reasons, patient dissent or not appropriate due to clinical reasons. The practice used information about care and treatment to make improvements.

Effective staff

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 management team had oversight of all mandatory and specific training via an online system and were able to demonstrate staff had updated or were due to later in the year.
  • 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. The practice had a competency framework, which staff were familiar with setting out values and behaviours expected of them and used an external human resources specialist for advice about any issues.

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. 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.
  • There was a proactive approach to preventing development of long term health conditions. For example, 226 patients within the pre-diabetic range received support and advice and were reviewed annually.
  • Staff encouraged and supported patients to be involved in monitoring and managing their own health, for example through social prescribing schemes.
  • Staff discussed changes to care or treatment with patients and their carers as necessary.
  • The practice supported national priorities and initiatives to improve the population’s health, for example, stop smoking campaigns and tackling obesity.

Consent to care and treatment

The practice obtained consent to care and treatment in line with legislation and guidance.

  • Clinicians understood the requirements of legislation and guidance when considering consent and decision making.
  • Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The practice monitored the process for seeking consent appropriately.

Please refer to the evidence tables for further information.



Updated 27 December 2018

We rated the practice as good for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from 10 patients was positive about the way staff treat people.
  • Staff understood patients’ personal, cultural, social and religious needs.
  • The practice gave patients timely support and information.
  • The practice’s GP patient survey results were in line or above local and national averages for questions relating to kindness, respect and compassion..

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 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 identified carers and supported them, with over 2% of patients including young carers known to be in this position.
  • The practices GP patient survey results were in line local and national averages for questions relating to involvement in decisions about care and treatment. The percentage of respondents to the GP patient survey who answered positively about whether they had confidence in their GP was 97% which was above local and national averages.

Privacy and dignity

The practice respected 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. They challenged behaviour that fell short of this.

Please refer to the evidence tables for further information.



Updated 27 December 2018

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

Responding to and meeting people’s needs

  • The coastal areas of Boscastle and Tintagel receive significant numbers of visitors each year, peaking during the summer months some needing primary medical services.
  • The practice understood the needs of its population and tailored services in response to those needs. Patients reported improved access to appointments following a challenging period for the practice over the summer months. Increased staffing resources followed a review of patient needs, including: appointment of new practice nurse (due to start after the inspection); recruitment of a new GP partner and increased phlebotomy hours.
  • Telephone consultations were available which supported patients who were unable to attend the practice during normal working hours.
  • All the practice nurses held the independent prescribing qualification and were able to assess, diagnose and treat patients with minor illness.
  • The practice provided online services. Repeat prescriptions could be ordered on line and could be sent to the patient choice of pharmacy or for those eligible from either of the two practice dispensaries.
  • The facilities and premises were appropriate for the services delivered. There was a planned refurbishment schedule in place for the practice following patient feedback.
  • The practice made reasonable adjustments when patients found it hard to access services. GPs reported the practice had a much lower home visiting rate compared with other practices.
  • The practice provided effective care coordination for patients who are more vulnerable or who have complex needs. Staff had received signposting training and links were made with the ‘community maker’ (link person with knowledge of support, events and activities available for people in the community) to help patients 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.
  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs.
  • Arrangements were in place for the practice dispensaries at Boscastle and Tintagel to provide a delivery service of medicines prescribed for housebound patients.

People with long-term conditions:

  • Patients with a long-term condition received an annual review to check their health and medicines needs were being appropriately met. Multiple conditions were reviewed at one appointment, and consultation times were flexible to meet each patient’s specific needs.
  • The practice held regular meetings with the local district nursing team and social care representatives to discuss and manage the needs of patients with complex medical issues.
  • The practice hosted a number of clinics by visiting healthcare professionals. This included a weekly physiotherapy clinic for patients recovering from injuries or needing rehabilitation following hospitalisation.

Families, children and young people:

  • After school and early morning appointments were available to avoid disturbing school attendance.
  • 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 a well-established recall system with named staff monitoring the childhood immunisation register. On receipt of the hospital discharge letter the practice sent out an appointment for the baby and parent/s to see the GP and practice nurse at the same time. Staff told us they saw this as an important opportunity to engage with parents to explain childhood health, support available and services at the practice.

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, flu vaccination clinics throughout the autumn and winter months; text reminders; And online access to book appointments in advance and request repeat prescriptions.
  • The practice provided NHS and non NHS travel vaccination service, which included yellow fever. Information about the costs of non NHS vaccines was accessible on the practice website.
  • Information about Kernow wide improved access services was available for patients on the practice website. The locality had commissioned seven hub centres to provide extended hours access for patients across Cornwall meaning patients could gain out of hours appointments at one of the local HUB practices even when their own practice was closed.

People whose circumstances make them vulnerable:

  • Systems were in place for early identification and support of suspected victims of abuse.
  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
  • Patient records included details about specific needs such as accessible information requirements.
  • People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode. Staff explained the remoteness of the practice meant that they were rarely approached by people of no fixed abode wishing to register there but had the facility to provide this if required.

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. Data showed the practice achieved 84% performance with reviews and support of patients with dementia, which was in line with the national average.
  • Patients in mental health crisis were dealt with as a medical emergency and flagged as urgent to their named or duty GP. Review meetings were held at Bottreaux Surgery with the community mental health team.
  • Named clinical staff visited patients living in a care home in Tintagel, carrying out regular visits to do medicines and frailty reviews.
  • The practice had staff or were able to access support from staff who were skilled mental health and dementia practitioners. Patients who failed to attend were proactively followed up by a phone call from staff who knew them.
  • The practice sign posted patients to the local depression and anxiety service.

Timely access to care and treatment

All patients who provided feedback reported improved access to care and treatment from the practice, since the last GP survey results were published in 2018.

  • The practice had listened to patient feedback and was improving access to appointments within its remit. However, patients told us about the challenges they now faced with the countywide changes to a hub model to increase patient access to appointments. The nearest hub was at Bodmin, which was 20 miles away and limited transport links. Patients told us staff at Bottreaux Surgery were supportive and tried to accommodate their needs where ever possible and provided up to date information about where extended access appointments were being provided every weekday and weekend.
  • 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. Working patients told us they tended to use the online services.
  • The practices GP patient survey results were comparable 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 appropriately to improve the quality of care.

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

Please refer to the evidence tables for further information.



Updated 27 December 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 in line with the practice business strategy. For example, in recognition of national and local challenges recruiting GPs the practice had focussed on skill mix and diversified roles. The productive general practice programme was being used to review work streams to improve outcomes for patients. There was a whole team approach to reviewing and implementation of changes.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The practice had effective processes to develop leadership capacity and skills, including planning for the future leadership of the practice.

Vision and strategy

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

  • There was a clear vision and set of values based on quality patient care based on: respecting others, working as a team, embracing change, being an effective business, having effective leadership and patient focussed. The practice had a realistic strategy and supporting business plans to achieve priorities.
  • The partnership promoted succession within the sector through its development and training placements. The practice had successfully recruited a new GP partner and nursing staff to increase the team.
  • 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 in line with financial management systems and support.


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 and promoted evidence based care.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values in the practice competency framework.
  • 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 was a whistleblowing policy which was updated to include the contact details for the Speak Up Guardian at the Kernow local medical committee.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. The majority of staff received regular annual appraisals in the last year. There had been a period when the practice was without a practice manager and some appraisals had fallen behind, but were scheduled and being completed when we inspected. 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, for example, the practice reduced the risk of professional burnout by setting limitations on the number of sessions a GP could work before having a break.
  • 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 in respect of prescribing and dispensary management, quality improvement, safeguarding and infection prevention and control. Two leaders were accountable for each key area.
  • Practice leaders had established policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

There were some areas where improvements were needed:

  • The security of blank prescriptions within the dispensaries did not entirely meet with national guidance.

  • There were gaps in infection prevention and control arrangements to promote patient and staff safety, which the practice had already identified and was taking action on.

  • Whilst some audits were evident, the practice did not have an overall quality improvement programme with regular audits carried out across all staff groups and services.

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 and staff 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. However, whilst there had been some audits carried out over the last two years, the practice did not have an overall quality improvement plan incorporating regular audit across all services and performed by all staff groups. We highlighted this in our feedback at the end of the inspection as an area for improvement.
  • 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. 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, for example: The practice reviewed patient records following the implementation of a new IT system and had found medicines review dates were missing and were rectifying this. A successful bid had secured funding for a joint post shared with another practice for a new member of staff to review and code patient records so effective searches and audits could be carried out.
  • 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 which met regularly and practice updates were published in local village newsletters to raise awareness about developments.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

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

  • There was a focus on continuous learning and improvement as a training 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.
  • 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