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Pudding Pie Lane Surgery Good

Inspection Summary

Overall summary & rating


Updated 23 August 2018

This practice is rated as Good overall. (Previous published rating October 2017 – Requires Improvement)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Mendip Vale Medical Practice on 26, 27 and 28 June 2018. This inspection was to follow up the concerns we found at the previous inspection in August 2017. These areas of concern were relating to ensuring that appropriate disclosure and barring checks and training was in place for staff providing chaperone duties and there was proper and safe management of medicines including controlled medicines and prescription paper and pads. Also, the provider must have ensured that staff worked in accordance to the organisations policies and procedures in relation to significant event analysis, emergency medicines, complaints, medicines management and health and safety. In addition, the provider should have continued with the changes they were implementing for infection prevention, the immunisation status of staff, Control of Substances Hazardous to Health(COSHH), fire drills and checks on emergency equipment were sustained. Also, non-clinical staff responsible for telephone handling have the necessary training and guidance for the triage of patient's needs regarding the urgency of being seen by a clinician. The provider should have continued to notify the commission without delay any incidents of serious injury to a service user or events that may stop the service.

These concerns resulted in the practice being rated Requires Improvement overall, with the domains of Safe as Requires Improvement, Effective, Caring and Responsive as Good and Well Led as Inadequate.

At this inspection we found:

That the practice had responded and implemented a programme of improvement and the concerns previously found had been rectified.

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 found the appointment system easier to use and reported that they could 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:

  • The provider should develop its systems of checks and recording information regarding staff vaccinations in accordance to Public Health England (PHE) guidance.
  • The practice should strengthen their risk assessment processes for infection prevention and control regarding identified risks and the actions taken to mitigate risks.
  • The practice should review the safety and security of the external storage of their clinical waste.
  • The practice should review information available to patients regarding chaperone service and processes for offering a chaperone.
  • The practice should continue with monitoring and respond accordingly to patient feedback in regard to the concerns about the difficulty in making an appointment and access to appointments.
  • The practice should improve how it keeps patients informed about any delays in waiting for appointments.

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 23 August 2018

We rated the practice as good for providing safe services.

At the last inspection in August 2017 we found the provision of safe services was not consistently met. This was regarding ensuring that suitable Disclosure and Barring checks were in place for staff carrying out chaperone duty and the management of medicines did not protect patients from possible harm.

At this inspection we found that our previous concerns had mostly been addressed.

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. 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.) The practice had rolled out a programme so all staff had a DBS check in place and that it was renewed every three years.
  • Staff took steps, including working with other agencies, to protect patients from abuse, neglect, discrimination and breaches of their dignity and respect.
  • The practice carried out appropriate staff checks at the time of recruitment and on an ongoing basis.
  • There was an effective system to manage infection prevention and control.
  • The practice had arrangements to ensure that facilities and equipment were safe and in good working order.
  • Arrangements for managing waste and clinical specimens kept people safe.

Risks to patients

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

  • Arrangements were in place for planning and monitoring the number and mix of staff needed to meet patients’ needs, including planning for holidays, sickness, busy periods and epidemics.
  • There was an effective induction system for temporary staff tailored to their role.
  • The practice was equipped to deal with medical emergencies and staff were suitably trained in emergency procedures.
  • Staff understood their responsibilities to manage emergencies on the premises and to recognise those in need of urgent medical attention. Clinicians knew how to identify and manage patients with severe infections including sepsis.
  • When there were changes to services or staff the practice assessed and monitored the impact on safety.

Information to deliver safe care and treatment

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

  • The care records we saw showed that information needed to deliver safe care and treatment was available to staff.
  • 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 and 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.
  • There were effective protocols for verifying the identity of patients during remote or online consultations.
  • Patients’ health was monitored in relation to the use of medicines and followed up on appropriately. Patients were involved in regular reviews of their medicines.
  • 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 safety using information from a range of sources.

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.

Please refer to the evidence tables for further information.



Updated 23 August 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.
  • An advanced nurse practitioner(ANP) had been employed specifically to take the lead on monitoring and responding to patients needs who were living in a care or nursing home to provide continuity of care. We were told by representatives of two care homes whose patients were supported by the practice that this worked well, they received timely and responsive support when it was needed.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • The practice had equipment to offer 24-hour ambulatory blood pressure monitoring at all locations which reduced the need for patients to attend the local hospital.
  • 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 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.
  • There was a broader staff team, including pharmacists and and ANPs, who had been trained to undertake the responsibility of the reviews of patients with long term conditions.
  • 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 (high blood pressure) were offered ambulatory blood pressure monitoring and patients with atrial fibrillation (an irregular heart rhythm) were assessed for stroke risk and treated as appropriate.
  • The practice was able to demonstrate how it identified patients with commonly undiagnosed conditions, for example, diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension.
  • The practice’s performance on quality indicators for long term conditions was in line with local and national averages.

Families, children and young people:

  • Childhood immunisation uptake rates were in line with the target percentage of 95% or above.
  • 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 80%, which was similar to the coverage target for the national screening programme.
  • The practice’s uptake for breast and bowel cancer screening was above the national average.

  • The practice had systems to inform eligible patients to have the meningitis vaccine, for example before attending university for the first time.
  • Patients had access to appropriate health assessments and checks including NHS checks for patients aged 40-74. There was appropriate follow-up on the outcome of health assessments and checks where abnormalities or risk factors were identified.

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 held a register to identify those at risk such as carers and patients with a degree of frailty.
  • 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.
  • 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. Where appropriate, clinicians took part in local and national improvement initiatives.

  • The overall Quality Outcome Framework (QOF) score for the practice (out of maximum 559) was 557 in comparison to the CCG score of 544 and the national average of 539. (QOF is a system intended to improve the quality of general practice and reward good practice).
  • The overall QOF exception rate for the practice was 4.2% which was better in comparison to the CCG at 5.4% and the national average of 5.7%.
  • 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.
  • Dispensary staff were appropriately qualified and their competence was assessed regularly. They could demonstrate how they kept up to date.

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 hosted other clinicians from the Somerset Surgical Service and had held outpatient clinics for orthopaedics (hand and plastics) reducing the need for patients to travel further afield.
  • 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.
  • Staff encouraged and supported patients to be involved in monitoring and managing their own health, for example through their social prescribing scheme Patient Connect.
  • 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 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 23 August 2018

We rated the practice as good for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat people.
  • Staff understood patients’ personal, cultural, social and religious needs.
  • The practice gave patients timely support and information.
  • The practice’s GP patient survey results (July 2017) were in line with local and national averages for questions relating to kindness, respect and compassion. Information and feedback from patients through the Healthwatch surveys reflected this.

Involvement in decisions about care and treatment

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

  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available.
  • Staff helped patients and their carers find further information and access community and advocacy services. They helped them ask questions about their care and treatment.
  • The practice proactively identified carers and supported them.
  • The practices GP patient survey results (July 2017) were in line with local and national averages for questions relating to involvement in decisions about care and treatment. This was reflected in the feedback given by patients to Healthwatch.

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 23 August 2018

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

Responding to and meeting people’s needs

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

  • The practice understood the needs of its population and tailored services in response to those needs.
  • Telephone consultations were available which supported patients who were unable to attend the practice during normal working hours.
  • Most of the facilities and premises were appropriate for the services delivered. Where issues were identified there was usually a plan of action in place to continue to provide a suitable service to patients.
  • The practice made reasonable adjustments when patients found it hard to access services. Patients could obtain appointments or receive treatment at any of the other practice locations if it was required.
  • On line access was available to patients to book appointments or request their repeat prescriptions.
  • 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.
  • The practice was part of One Care Consortium, a GP-led organisation that represents practices in Bristol, North Somerset and South Gloucestershire, and participated through them in various pilots including a self-referral to a physiotherapist and community psychiatry nurse.
  • The practice had invested in the purchase of a practice electric car and employed a driver, with the relevant checks in place, for the provision of services including aiding patients to attend their appointments if they had difficulty through their frailty or wellbeing.
  • The practice has developed an urgent care team, which included a duty doctor, ANP, pharmacist and a duty receptionist to respond to requests for home visits and urgent same day appointments or consultations.
  • The practice had in recent months set up a Patient Connect scheme where patients who needed extra support were identified and provided with a named member of staff who regularly got in contact with to check there were any concerns, assist with making appointments, refer to a clinician and prescription management.
  • Patients were able to access screening and treatments for eye care at the practice as visiting services were accommodated. For example, Glaucoma treatment and monitoring.
  • The practice provided dispensary services for people who needed additional support with their medicines, for example a delivery service, weekly or monthly blister packs, large print labels.

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. A team of staff including ANPs and pharmacists also accommodated home visits for those who had difficulties getting to the practice due to limited local public transport availability.
  • There was a programme of offering including home visits for annual influenza immunisations.
  • The practice liaised with the village agents and village carers organisations to support patients receive the care assistance that they needed.

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 had further developed a service to assist treating patients with long term wounds of the legs and feet. A ‘Community leg club’ in conjunction with North Somerset Community Partnership was held regularly at one of the practice locations to support patients to receive treatment and support.
  • The practice provides a structured diabetes programme with a psychologist, practice nurses and GP to support patients to become more engaged in improving their health.
  • The practice held regular meetings with the local district nursing team to discuss and manage the needs of patients with complex medical issues.

Families, children and young people:

  • We found there were systems to identify and follow up children living in disadvantaged circumstances and who were at risk, 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 has a nurse led IUCD (commonly known as a ‘a coil’ a female contraceptive) service.

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 and Saturday appointments.

People whose circumstances make them vulnerable:

  • 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 worked with a local voluntary group to set up a befriending service, to visit patients in their own homes, which they now run for vulnerable patients. Although this has only been in existence for approximately nine months this is working well and patients have appreciated the support they had.

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.
  • Patients living with dementia were provided support in accordance to their needs. Patients not seen for a period or who failed to attend for an appointment were proactively followed up either by referring to the patient connect system, the village agent or by a phone call from a GP.
  • A Memory Café was held at St Georges on a Saturday once a month for patients with dementia and their carers.
  • The practice hosts the Alzheimer’s Society ‘Forget me not clinics’.

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 their experience of the appointment system had improved.
  • The practices GP patient survey results were in line or above local and national averages for questions relating to access to care and treatment. For example, results highlighted that 93% of patients were able to obtain an appointment when they needed one in comparison to the local of 81% and the national 76% figures. However, this was not fully reflected in the feedback received through the Healthwatch survey during the inspection process or information they had received during the preceding 12 months. Comments show that patients were at times still finding it difficult to obtain an appointment with the GP of their choice, at a location of their choice. We were told that the practice had listened to patient’s feedback and had reviewed how they staffed the different locations. Changes had been made to ensure clinical teams were based at one location so that they could offer continuity of care. Patients were still able to access urgent appointments with other clinicians at other locations if appointments were not available at the location of their choice.

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. The concerns found at the last inspection about the management of complaints and concerns received in had been addressed and there was an improved documentary and management process to respond to and act upon complaints made.

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

Please refer to the evidence tables for further information.



Updated 23 August 2018

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

At the last inspection in August 2017 we identified that the system for governance were operating ineffectively for some aspects of the activities and services provided. In particular the management of prescription paper, prescription pads and ensuring there was a clear audit trail. It was identified that staff were not working in accordance to policies relating to significant event analysis, complaints, chaperone support, medicines management, fire and health and safety.

At this inspection it was found that most of these areas had been fully addressed.

Leadership capacity and capability

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

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The practice had effective processes to develop leadership capacity and skills, including planning for the future leadership of the practice.
  • At the time of this inspection Mendip Vale Medical Practice was in the process of merging with two other GP services in the local area to be part of the organisation which would raise the number of patients supported to 43,000.

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. A programme of regular annual appraisals in the last year had almost been completed. Staff were supported to meet the requirements of professional revalidation where necessary.
  • There was an 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.
  • Practice leaders had reviewed and 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 and effective processes for managing risks, issues and performance.

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

Appropriate and accurate information

The practice acted on appropriate and accurate information.

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

Engagement with patients, the public, staff and external partners

The practice involved patients, 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 systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement.
  • Staff knew about improvement methods and had the skills to use them.
  • The practice made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.
  • The practice was able to support clinicians and others to develop their skills and knowledge this included current training for musculoskeletal, endoscopy and dermatology with the plan to offer a wider range of support to patients across the practice.
  • The practice participated in clinical research.

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