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CQC Readiness Checker

CQC Readiness Guest session
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This tool is provided to help GP practices prepare for CQC inspection. It does not guarantee an inspection outcome and is not a substitute for professional advice. You should carry out your own due diligence and seek specialist support where needed. CQC inspection outcomes are determined by the inspector on the day.

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Sustainable inspection readiness is about embedded culture, not a document trail.

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Safe
0/8 green 0/8 reviewed
1
Learning culture
0/5 sub-questions confirmed
Description
A culture of safety and learning from incidents is embedded across the practice.
Guidance
Evidence: significant event audit log, learning minutes shared with team, incident reporting system in use.
Preparation sub-questions
1. Do you have a significant event audit (SEA) log with completed reviews in the past 12 months?
Check the log is up to date, reviews are completed, and learning outcomes are documented.
2. Are learning outcomes from SEAs shared with all relevant staff?
Look for evidence in team meeting minutes or a learning log that changes in practice resulted.
3. Is there a named clinical safety lead and is their role documented?
Should be referenced in the governance structure or job description.
4. Do you have a near-miss and incident reporting process that all staff know how to use?
Check staff awareness — front desk, nursing and clinical staff should all be able to describe it.
5. Can you show evidence that feedback from incidents has led to changes in practice?
Look for before/after examples or a "you reported, we changed" log.
2
Safe systems, pathways and transitions
0/5 sub-questions confirmed
Description
Safe handovers between services, including medicines reconciliation on discharge.
Guidance
Evidence: referral and discharge processes, medicines reconciliation records, communication with secondary care.
Preparation sub-questions
1. Do you have a documented process for medicines reconciliation on hospital discharge?
Check who is responsible, what the timescale is, and where completed reconciliations are recorded.
2. Are referral acknowledgement and tracking processes in place with clear accountability?
Check how two-week-wait referrals and urgent referrals are tracked to completion.
3. Can you demonstrate a safe handover process for out-of-hours coverage?
Look for a documented handover protocol and examples of urgent information being passed on.
4. Are test result follow-up processes documented with clear accountability?
Check how abnormal or unexpected results are actioned and who is responsible if the patient cannot be reached.
5. Is there evidence of coordinated communication with secondary care for complex patients?
Look for MDT letters, shared care arrangements, or care plan correspondence.
3
Safeguarding
0/5 sub-questions confirmed
Description
Adults and children at risk are identified and protected from abuse, neglect and exploitation.
Guidance
Evidence: safeguarding policy (up to date), training records (all staff), named safeguarding lead, case review examples.
Preparation sub-questions
1. Is the safeguarding policy current, covering both adults and children, and reviewed within the last 2 years?
Check date of last review and whether it reflects current legislation and local procedures.
2. Are training compliance records in place for safeguarding levels 1, 2, and 3 for all appropriate roles?
Check the training matrix — clinical staff should be at level 3, non-clinical at level 1 or 2.
3. Is there a named safeguarding lead for adults and a named lead for children?
These can be the same person but their role and contact details should be documented and visible to all staff.
4. Can you demonstrate examples of safeguarding referrals or multi-agency case discussions?
Anonymised examples showing appropriate escalation and follow-through are ideal.
5. Do all staff — including reception — know what to do if they have a safeguarding concern?
Test awareness of the reporting process; staff should know who to go to and what to document.
4
Involving people to manage risks
0/5 sub-questions confirmed
Description
Patients are involved in identifying and managing their individual risks.
Guidance
Evidence: personalised care and support plans, patient safety alerts acted on, shared decision making examples.
Preparation sub-questions
1. Do you have personalised care and support plans for patients with complex or multiple long-term conditions?
Check that plans are co-produced, accessible, and reviewed at least annually.
2. Are patient safety alerts (MHRA, NHS England) acted on, documented, and closed?
Look for an alert management log or evidence that actions are tracked to completion.
3. Can you evidence shared decision-making conversations in clinical records?
Look for documented treatment options discussed, patient preference recorded, and consent noted.
4. Are reasonable adjustments documented for patients with disability or protected characteristics?
Check there is a process to flag and record adjustments in the patient record.
5. Is there a process for reviewing and updating individual risk assessments for high-risk patients?
Look for structured reviews of falls risk, frailty, mental health risk, or other identified risks.
5
Safe environments
0/5 sub-questions confirmed
Description
Premises, equipment and facilities are safe and fit for purpose.
Guidance
Evidence: health & safety risk assessment, equipment calibration records, fire risk assessment, COSHH records.
Preparation sub-questions
1. Is there a current health and safety risk assessment with all identified actions completed?
Check the date of the last assessment and whether remedial actions have been signed off.
2. Are all clinical equipment calibration and service records up to date?
Check spirometers, ECG machines, blood pressure monitors, and any other clinical equipment.
3. Is the fire risk assessment current and has a fire drill been completed in the past 12 months?
Both the assessment and the drill record should be available and dated.
4. Are COSHH records maintained, reviewed, and accessible to all relevant staff?
Check that substances used in the practice are listed, with appropriate data sheets.
5. Is emergency equipment (AED, oxygen, anaphylaxis kit) checked regularly with signed logs?
Check for a weekly or monthly check log with signatures and any faults recorded and resolved.
6
Safe and effective staffing
0/5 sub-questions confirmed
Description
Sufficient, skilled staff are deployed at all times.
Guidance
Evidence: staffing rota, skill-mix review, DBS checks, mandatory training matrix, appraisal records.
Preparation sub-questions
1. Can you produce a live training compliance report showing current completion percentages by role?
This is one of the first things an inspector asks for — it should be available immediately, not built on the day.
2. Are DBS checks current for all staff, including zero-hours, locum and recently joined staff?
Check the recruitment file for all active staff — gaps are a common trigger for Requires Improvement.
3. Are immunisation records held for all clinical staff, with any gaps documented and risk-assessed?
Hepatitis B, varicella, and MMR status should be recorded; gaps should be noted with a management decision.
4. Are staff appraisals completed and documented for all staff in the past 12 months?
This includes receptionists, managers, and nursing staff — not just clinical staff.
5. Is there a staffing rota or skill-mix review showing appropriate clinical cover at all times?
Check there is always a suitably qualified clinician on duty and a process for unplanned absence.
7
Infection prevention and control
0/5 sub-questions confirmed
Description
Effective IPC measures are in place and monitored.
Guidance
Evidence: IPC policy, cleaning schedules, hand hygiene audits, IPC lead training certificate, decontamination logs.
Preparation sub-questions
1. Is there a current IPC audit that is completed, signed, dated, and has all actions resolved?
The audit should be recent (within the last year) and all recommended actions should be closed out.
2. Are cleaning schedules in place, signed after each clean, and monitored for completion?
Spot check whether schedules are up to date and whether any missed cleans are followed up.
3. Is an IPC lead designated with documented, up-to-date training?
Their name, role, and training certificate date should be on record.
4. Are hand hygiene audits conducted and results shared with the team?
Check for a regular audit programme — at least annually — with results communicated to all staff.
5. Are decontamination logs for reusable instruments maintained and compliant with HTM 01-05?
Check the decontamination room log, autoclave validation records, and test strip records.
8
Medicines optimisation
0/5 sub-questions confirmed
Description
Medicines are prescribed, dispensed and managed safely.
Guidance
Evidence: prescribing audits, structured medicines reviews, cold chain records, controlled drug register, high-risk medicines monitoring.
Preparation sub-questions
1. Is there a clinical audit of prescribing in the last 12 months?
Look for audits covering high-risk medicines, antibiotic prescribing, or QOF exception reporting.
2. Are structured medicines reviews (SMRs) being completed for appropriate patients?
Check SMR completion rates for care home residents, patients on polypharmacy, and STOPP/START criteria.
3. Are fridge temperature records maintained with documented actions for any out-of-range readings?
Both the recording and the response to excursions must be evidenced.
4. Is the controlled drug register complete, accurate, and subject to regular audit?
Check the CD register is up to date, balances correct, and that running balance checks have been completed.
5. Are processes in place to monitor patients on high-risk medicines (e.g. lithium, warfarin, methotrexate)?
Check monitoring schedules, how overdue tests are flagged, and what happens when a patient does not attend.
Effective
0/6 green 0/6 reviewed
1
Assessing needs
0/5 sub-questions confirmed
Description
Patients' physical, mental and social needs are fully assessed.
Guidance
Evidence: review templates, multidisciplinary team meeting records, health and wellbeing plans.
Preparation sub-questions
1. Do you have a systematic process for identifying and calling in patients with long-term conditions for review?
Check that recall systems are working and that patients who do not attend are followed up.
2. Are multidisciplinary team (MDT) meetings taking place regularly with documented outcomes?
Meeting minutes should show discussion of complex patients, actions agreed, and responsible persons named.
3. Are frailty and mental health needs being proactively identified in the practice population?
Check use of frailty tools (e.g. eFI), mental health register, and referral pathways.
4. Can you evidence how patients' social needs are being identified and addressed?
Look for social prescribing referrals, carer identification, and housing or debt support signposting.
5. Do review templates cover physical, mental and social health needs holistically?
Check consultation templates or care planning tools — they should prompt for all three dimensions.
2
Delivering evidence-based care and treatment
0/5 sub-questions confirmed
Description
NICE guidance and clinical best practice are followed.
Guidance
Evidence: clinical audits, QOF data, exception reporting review, protocol library up to date.
Preparation sub-questions
1. Is your clinical protocol library up to date and accessible to all clinical staff?
Check the date of last review for key protocols — any over 2 years old should be flagged.
2. Can you demonstrate compliance with NICE guidelines through audits or QOF performance data?
Look for audit reports or QOF dashboards showing performance against key indicators.
3. Are exception reporting decisions documented with clinical rationale in patient records?
Check a sample of exception-reported patients — rationale should be clear in the notes.
4. Do you have a process for monitoring and acting on new MHRA or NICE guidance updates?
Check who receives guidance updates, how they are reviewed, and how changes are communicated to clinicians.
5. Can you show clinical audit activity in the past 12 months covering at least 2 key clinical areas?
Completed audits with results, actions, and re-audit evidence are the gold standard.
3
How staff, teams and services work together
0/5 sub-questions confirmed
Description
MDT working is embedded; services are well integrated.
Guidance
Evidence: MDT meeting minutes, referral pathways, care co-ordination examples, ARRS roles working effectively.
Preparation sub-questions
1. Are MDT meetings taking place with ARRS roles and community services included?
Check that meeting records show all relevant disciplines attending and contributing.
2. Is there evidence that patients are not asked to repeat their story when moving between services?
Look for shared care records usage, referral letters that include patient history, or patient feedback.
3. Are referral and care co-ordination processes clearly documented and communicated to staff?
Check that all staff know who to refer to and how — not just clinical staff.
4. Can you evidence collaborative working with secondary care, community services or social care?
Look for joint care plans, shared protocols, or examples of co-ordinated patient journeys.
5. Are handover and communication processes between team members documented and followed consistently?
Check end-of-day handover records, duty doctor notes, and any urgent task management system.
4
Supporting people to live healthier lives
0/5 sub-questions confirmed
Description
Health promotion, prevention and early intervention are prioritised.
Guidance
Evidence: NHS Health Check uptake, cancer screening rates, social prescribing referrals, smoking cessation activity.
Preparation sub-questions
1. What is your NHS Health Check uptake rate for eligible patients and how does it compare to your PCN?
Check your Health Check completion data and whether there is a recall or outreach process.
2. Can you show cancer screening uptake rates (cervical, bowel, breast) against local and national benchmarks?
Check QOF and screening dashboards — rates below the national average need an improvement plan.
3. Is there an active social prescribing offer and can you evidence referral pathways and outcomes?
Look for social prescribing link worker activity, referral numbers, and any outcome data.
4. Are smoking cessation referrals and outcomes tracked and reviewed by the practice?
Check referral numbers, cessation rates, and whether there is a proactive identification process.
5. Do you have a structured approach to addressing health inequalities in your practice population?
Look for a health inequalities plan, use of deprivation data to target services, or PCN-level programme involvement.
5
Monitoring and improving outcomes
0/5 sub-questions confirmed
Description
Outcome data is collected, reviewed and used to drive improvement.
Guidance
Evidence: clinical outcome dashboards, QOF performance review, patient-reported outcome measures, QI projects.
Preparation sub-questions
1. Do you have clinical outcome dashboards reviewed at regular governance meetings?
Check that dashboards are presented with context, trends discussed, and actions agreed.
2. Can you show QOF performance trends and evidence of improvement activity where below target?
Look for a QOF improvement plan that identifies underperforming indicators and assigns ownership.
3. Are patient-reported outcome measures or experience data collected and acted on?
Check Friends & Family Test data, patient survey results, or any PROMs in use.
4. Do you have at least one documented quality improvement project in the past 12 months?
Look for a QI project log with a defined aim, PDSA cycles, and outcomes recorded.
5. Are immunisation and screening rates tracked against national targets with follow-up action?
Check childhood immunisation, influenza, and COVID vaccination rates with a clear process for under-performance.
6
Consent to care and treatment
0/5 sub-questions confirmed
Description
Valid, informed consent is obtained and documented.
Guidance
Evidence: consent policy, Mental Capacity Act training records, Gillick competency awareness, consent documentation.
Preparation sub-questions
1. Is there a consent policy that is current, reviewed within the last 2 years, and accessible to all clinical staff?
Check the policy is not out of date and that clinical staff can locate it easily.
2. Are staff trained in the Mental Capacity Act and can they describe when it applies?
Training records should show MCA training; clinical staff should be able to give an example of applying it.
3. Are Gillick competency assessments documented when relevant for under-16 consultations?
Check the clinical records — where Gillick competence has been applied it should be noted.
4. Is there a process for documenting and reviewing consent for ongoing treatment or invasive procedures?
Look for consent forms in use for minor surgery, coils, implants, or other procedures.
5. Can you show how patients are informed of their right to refuse or withdraw consent?
Check patient information leaflets, consultation templates, or examples of withdrawal of consent handled appropriately.
Caring
0/5 green 0/5 reviewed
1
Kindness, compassion and dignity
0/5 sub-questions confirmed
Description
Patients are treated with kindness, respect and dignity at all times.
Guidance
Evidence: Friends & Family Test results, patient feedback, complaints response, observation of care.
Preparation sub-questions
1. What are your latest Friends & Family Test scores and how are they trended over time?
Check whether scores are improving, stable, or declining and whether any themes emerge from comments.
2. Is patient feedback actively reviewed and acted on at practice level?
Look for a complaints or feedback log with responses and evidence of changes made.
3. Are staff trained in communication skills, dignity and respect, with training records evidencing this?
Check the training matrix — this should cover clinical and non-clinical staff.
4. Are complaints acknowledged within required timescales and responded to with genuine reflection?
CQC will look at your complaint handling — acknowledgement within 3 working days, response within 40 working days.
5. Can you show how patient dignity is maintained in your physical environment and during consultations?
Check privacy screens, consultation room soundproofing, chaperone policy, and any observation or audit evidence.
2
Treating people as individuals
0/5 sub-questions confirmed
Description
Care is personalised and responsive to individual preferences and needs.
Guidance
Evidence: reasonable adjustments register, interpreting services available, communication preference recording.
Preparation sub-questions
1. Is there a reasonable adjustments register or process for patients with additional needs?
Check that adjustments are proactively identified, recorded in the patient record, and acted on.
2. Are interpreting and translation services available and their use recorded in patient records?
Look for the interpreting service contract, and check whether staff know how to book it.
3. Can you show how communication preferences are recorded and respected across consultations?
Check the system for recording preferred contact method, language, and format.
4. Do you have a process for identifying and supporting patients with a learning disability?
Check the learning disability register, annual health check completion rate, and health action plans.
5. Are protected characteristics considered in care planning, service delivery, and complaints handling?
Look for equality impact assessments on service changes and any disaggregated outcome data.
3
Independence, choice and control
0/5 sub-questions confirmed
Description
Patients are supported to make informed choices and remain in control of their care.
Guidance
Evidence: shared decision making tools, personalised care plans co-produced with patients, self-management support.
Preparation sub-questions
1. Are shared decision-making tools in use and their use documented in clinical records?
Look for option grids, decision aids, or patient decision support tools referenced in consultations.
2. Do patients have access to co-produced personalised care and support plans?
Check that care plans are written with the patient, not just for them, and that patients receive a copy.
3. Are unpaid carers identified and offered their own health assessments?
Check the carer register, carers' health check uptake, and referrals to carer support services.
4. Can you show evidence of self-management support or education programmes offered?
Look for diabetes education, COPD self-management plans, social prescribing, or other structured support.
5. Is there a process to ensure patients with capacity understand and can exercise their right to make choices?
Check how staff approach treatment decisions — patients should lead, not be passive recipients.
4
Responding to people's immediate needs
0/5 sub-questions confirmed
Description
Urgent and immediate needs are addressed quickly and appropriately.
Guidance
Evidence: triage process, duty doctor/on-call system, same-day access data, urgent care pathways.
Preparation sub-questions
1. Is there a documented triage process for urgent and same-day requests that all staff follow?
Check the triage protocol — it should be documented, trained on, and consistently applied.
2. Can you show same-day appointment availability data for an average working week?
This is one of the key access metrics — have the data readily available and trended over time.
3. Is there a clear escalation pathway when an urgent clinical need is identified during triage?
Check how calls are escalated from reception to clinical staff and what the expected response time is.
4. Do staff know how to respond to a patient in distress or experiencing a mental health crisis?
Check whether mental health first aid training has been completed and crisis pathways are documented.
5. Are urgent care pathways aligned with local urgent treatment services and out-of-hours provision?
Staff should be able to direct patients to the right service without confusion.
5
Workforce wellbeing and enablement
0/5 sub-questions confirmed
Description
Staff wellbeing is actively supported and staff are enabled to deliver good care.
Guidance
Evidence: staff survey results, supervision records, wellbeing policy, occupational health referrals, peer support.
Preparation sub-questions
1. Do staff surveys cover wellbeing, and are the results reviewed and acted on?
Look for results shared with the whole team and improvement actions agreed in response.
2. Is there a named workforce wellbeing lead or champion and are they active in the role?
Check whether the role has been communicated to staff and what activity has taken place.
3. Are clinical supervision and regular 1:1s in place for all clinical and non-clinical staff?
Check supervision records — gaps are a risk to both staff wellbeing and patient safety.
4. Is there a wellbeing policy and access to occupational health, EAP, or peer support?
Check the policy is available, and that staff know how to access any support services.
5. Are workload concerns and burnout risks actively monitored and addressed by the leadership team?
Look for workload data reviewed at governance meetings and any actions taken to reduce unsustainable demand.
Responsive
0/7 green 0/7 reviewed
1
Person-centred care
0/5 sub-questions confirmed
Description
Care is designed around the needs, preferences and goals of the individual.
Guidance
Evidence: personalised care and support plans, patient-reported outcomes, key worker system, care planning discussions.
Preparation sub-questions
1. Are personalised care and support plans co-produced with patients who have complex needs?
Check that plans include the patient's own words, goals and preferences — not just clinical data.
2. Can you show examples of care designed around patient preferences and goals rather than clinical convenience?
Look for flexible appointment formats, home visits, and adjusted care pathways based on patient preference.
3. Is there a key worker or named contact for patients with the most complex needs?
Check that complex patients have a named person responsible for co-ordinating their care.
4. Are patient preferences recorded in the system and shared across the care team?
Check that preferences are visible to all clinicians who interact with that patient.
5. Do patients with long-term conditions have access to their care records and understand what is in them?
Check patient access to records and whether they are supported to understand and use them.
2
Care provision, integration and continuity
0/5 sub-questions confirmed
Description
Continuity of care is maintained and services are well integrated.
Guidance
Evidence: named GP system, discharge follow-up processes, care co-ordination for complex patients.
Preparation sub-questions
1. Is there a named GP or clinical lead for patients with complex needs and high service use?
Check that the named GP system is working in practice, not just in policy.
2. Are discharge follow-up processes in place for patients who have been admitted to hospital?
Check how the practice is notified of admissions and discharges and what the follow-up process is.
3. Can you show how care is co-ordinated for patients with multiple services involved in their care?
Look for a multi-agency care plan or evidence of communication between services for individual patients.
4. Are care plans updated and shared when a patient moves between services?
Check that care plans are not static documents — they should be reviewed at key transitions.
5. Do you have an approach to reducing unplanned admissions for high-risk patients?
Look for a high-risk patient register, a care plan for each patient, and proactive outreach activity.
3
Providing information
0/5 sub-questions confirmed
Description
Patients receive clear, accurate and accessible information.
Guidance
Evidence: patient leaflets, website accessibility, Easy Read materials, information prescription use.
Preparation sub-questions
1. Are patient leaflets and information resources on display or available in your waiting area up to date?
Check that leaflets are not out of date and cover key topics relevant to your population.
2. Does the practice website meet basic accessibility standards and contain current, accurate information?
Check that opening hours, access arrangements, and key policies are up to date.
3. Are Easy Read or alternative format resources available for patients with communication needs?
Check what formats are available and whether staff know how to access them.
4. Is health information available in the main community languages of your practice population?
Check whether translated materials are accessible and whether staff know how to source them.
5. Do patients routinely receive written or printed information about their diagnosis, treatment plan and next steps?
Check whether consultation summaries or printed information are offered as standard.
4
Listening to and involving people
0/5 sub-questions confirmed
Description
Patient feedback is actively sought and used to improve services.
Guidance
Evidence: patient participation group minutes, complaints log and responses, annual patient survey.
Preparation sub-questions
1. Is there an active patient participation group (PPG) with documented recent meeting minutes?
Check that the PPG meets at least annually, has genuine patient representation, and that actions are followed up.
2. Is the complaints log maintained and are responses completed within required timescales?
CQC expects acknowledgement within 3 working days and a full response within 40 working days.
3. Can you show evidence of specific changes made as a direct result of patient feedback?
Look for a "you said, we did" record — inspectors value this highly.
4. Are patients informed of the outcome of their complaint or suggestion in writing?
Check that complaint responses are signed by the practice manager or GP and address all points raised.
5. Is there a process for staff to capture and record patient feedback informally during or after consultations?
Check whether staff know how to log positive or negative feedback and whether it is reviewed.
5
Equity in access
0/5 sub-questions confirmed
Description
Everyone can access care when they need it.
Guidance
Evidence: appointment availability data, extended access provision, reasonable adjustments for disabled patients, translation services.
Preparation sub-questions
1. Can you show same-day and routine appointment availability data for a typical week?
This may be reviewed live on the day — have access data to hand at all times.
2. Are extended access services being used by your patients and monitored for equitable uptake?
Check whether your extended access sessions are used and whether certain groups are missing out.
3. Are access barriers for patients with disability, learning difficulty, or language needs proactively addressed?
Check your reasonable adjustments log, interpreting provision, and any specific access arrangements.
4. Do you have your National GP Patient Survey access scores and an improvement plan if below average?
Inspectors review GPPS data before arrival — if your scores are below average, have an explanation and plan ready.
5. Is appointment booking available through multiple channels and promoted to all patient groups?
Check online booking, telephone, and walk-in availability; and how each is communicated to patients.
6
Equity in experiences and outcomes
0/5 sub-questions confirmed
Description
No group experiences poorer care or outcomes.
Guidance
Evidence: QOF data analysed by demographic, health inequalities review, targeted outreach, equality impact assessment.
Preparation sub-questions
1. Have you analysed QOF or clinical outcome data by demographic group or deprivation decile?
Look for evidence that outcomes are reviewed for inequality — not just at practice-level aggregates.
2. Is there a health inequalities review or plan at practice or PCN level?
Check whether a health inequalities assessment has been done and what the priority areas are.
3. Do you conduct targeted outreach for patient groups less likely to engage with services?
Look for proactive recall, community engagement, or outreach activity for under-served groups.
4. Is there an equality impact assessment for any significant service changes made in the last 2 years?
Check that EIAs are completed before changes are implemented, not as a retrospective exercise.
5. Can you show population health data for your area and how your services are adapted in response?
Look for use of JSNA, Primary Care Networks' population health plans, or practice-level data analysis.
7
Planning for the future
0/5 sub-questions confirmed
Description
Future care needs are anticipated and planned for.
Guidance
Evidence: advance care plans, end of life register, DNACPR records, carer support identification.
Preparation sub-questions
1. Are advance care plans (ACPs) in place for patients on the end-of-life register?
Check the proportion of end-of-life patients who have an ACP and whether it is up to date.
2. Is the DNACPR process documented, with decisions communicated to relevant out-of-hours services?
Check that DNACPR records are accessible to OOH providers and ambulance services.
3. Are carers identified and involved in future care planning where the patient consents?
Check how carers are recorded and whether they are included in care planning conversations.
4. Do you have a process for reviewing and updating end-of-life care plans at least annually?
Check that end-of-life care plans are not set-and-forget documents.
5. Are patients supported to document and communicate their future wishes, including preferred place of death?
Check whether patients are routinely offered the opportunity to record their preferences.
Well-led
0/8 green 0/8 reviewed
1
Shared direction and culture
0/5 sub-questions confirmed
Description
A clear vision, values and strategy are understood and shared by all.
Guidance
Evidence: practice business plan, staff awareness survey, vision displayed, values embedded in recruitment.
Preparation sub-questions
1. Is there a documented practice vision, strategy and set of values that is reviewed at least every 2 years?
Check whether the vision is written down, accessible, and current.
2. Can staff at all levels — including reception — articulate the practice vision and their role within it?
Inspectors often speak directly to receptionists; staff should be able to describe the practice values without prompting.
3. Are all-staff meetings held regularly and minutes shared with every team member?
Check the frequency of meetings and the mechanism for communicating outcomes to part-time or absent staff.
4. Are staff engaged in reviewing and shaping the practice direction, not just informed of decisions?
Look for staff surveys, suggestion processes, or involvement in developing the practice plan.
5. Is the practice values statement visible to patients and embedded in day-to-day working?
Check waiting room display, website, and how values are referred to in recruitment and appraisal.
2
Capable, compassionate and inclusive leaders
0/5 sub-questions confirmed
Description
Leaders have the skills, knowledge and compassion to lead effectively.
Guidance
Evidence: leadership development records, appraisal of partners/managers, succession planning, 360 feedback.
Preparation sub-questions
1. Are all partners and managers undertaking leadership development activity?
Look for evidence of CPD, leadership programmes, coaching, or mentoring.
2. Are appraisals completed for all partners, salaried GPs, and managers in the past 12 months?
Check that partners appraise each other and that this is documented — not just done for employed staff.
3. Is there a succession plan or approach to developing the next generation of leaders?
Look for a workforce development plan, GPST involvement in leadership, or formal succession arrangements.
4. Can you show how leaders model the practice values in their own behaviour?
Look for examples in meeting minutes, feedback mechanisms, or staff survey comments.
5. Do staff feel supported by and confident in their leaders, evidenced through survey data?
Check the latest staff survey results for leadership-related questions and any follow-up actions.
3
Freedom to speak up
0/5 sub-questions confirmed
Description
Staff can raise concerns without fear of detriment.
Guidance
Evidence: whistleblowing policy, speak-up champion identified, staff survey culture questions, example of concern acted on.
Preparation sub-questions
1. Is there a current whistleblowing (Freedom to Speak Up) policy accessible to all staff?
Check the date of last review and that it is available to all staff including locums and zero-hours workers.
2. Is a Freedom to Speak Up guardian or champion identified and known to all staff?
Check whether the role is filled, communicated to staff, and whether the person is actively available.
3. Do staff survey results indicate that staff feel safe to raise concerns without fear of detriment?
Look for responses to culture-related questions and whether scores have improved over time.
4. Can you show an example of a concern being raised and acted upon?
Anonymised examples demonstrate that the culture is real, not just a policy on paper.
5. Are staff aware of external routes for raising concerns (CQC, NHS England, NHSR)?
Check whether the whistleblowing policy includes external referral options and how staff are made aware.
4
Workforce equality, diversity and inclusion
0/5 sub-questions confirmed
Description
Equality, diversity and inclusion are promoted across the workforce.
Guidance
Evidence: EDI policy, workforce equality data, EDI training records, staff network or forum.
Preparation sub-questions
1. Is there an EDI policy in place, reviewed within the last 2 years?
Check the date of last review and that it covers recruitment, development and day-to-day practice.
2. Is workforce equality data collected, reviewed at governance level, and acted on?
Check whether data on workforce diversity is reviewed and whether any patterns are addressed.
3. Have all staff completed EDI training, with records evidencing completion?
Check the training matrix — EDI training should be mandatory for all staff.
4. Are EDI considerations embedded in recruitment — job descriptions, interview panels, shortlisting criteria?
Check your recruitment process for evidence of structured equality measures.
5. Is there a staff network, forum, or EDI champion who is active and resourced to make a difference?
Look beyond the policy — is there genuine staff engagement on EDI issues?
5
Governance, management and sustainability
0/5 sub-questions confirmed
Description
Robust governance and risk management ensure sustainability.
Guidance
Evidence: risk register, up-to-date policy library, business continuity plan, financial oversight records.
Preparation sub-questions
1. Is there a risk register that is maintained and reviewed at every governance meeting?
Check the date of last update, whether risk owners are named, and whether mitigations are tracked.
2. Is the policy library up to date, with all key policies reviewed within the last 2 years?
Check for policies not reviewed since 2022 or earlier — this is a common trigger for Requires Improvement.
3. Is there a business continuity plan (BCP) that has been tested, with testing recorded?
Check that the BCP covers IT failure, premises loss, and key staff absence — and that it has been rehearsed.
4. Are professional registration checks completed for all clinical staff and evidence retained?
Check that GMC, NMC, HCPC and GPhC checks are documented — not just done, but evidenced.
5. Do governance meeting minutes record actions, owners, and completion dates, shared with all relevant staff?
CQC will ask to see minutes — they should show real accountability, not just discussion.
6
Partnerships and communities
0/5 sub-questions confirmed
Description
The practice works effectively with partners and the wider community.
Guidance
Evidence: PCN meeting records, ICS engagement, voluntary sector partnerships, community events.
Preparation sub-questions
1. Do you attend and contribute to PCN meetings, with minutes retained?
Check that attendance is regular and that the practice can demonstrate active contribution.
2. Is there engagement at ICS or ICB level, including attendance at relevant forums?
Look for evidence of system-level involvement beyond the PCN.
3. Are voluntary sector or community partnerships documented and actively maintained?
Check that partnerships are current and that there is a named contact for each.
4. Can you show examples of collaborative improvement work undertaken with partner organisations?
Look for joint QI projects, shared protocols, or co-designed services.
5. Is there a process for sharing learning with partners — and for receiving and acting on learning from them?
Check whether learning from serious incidents, audits, or inspections is shared across the PCN or ICS.
7
Learning, improvement and innovation
0/5 sub-questions confirmed
Description
There is a culture of continuous learning, improvement and innovation.
Guidance
Evidence: QI project register, PDSA cycles documented, innovation examples, staff ideas acted on.
Preparation sub-questions
1. Is there a register of quality improvement (QI) projects with documented aims, methods, and outcomes?
Check that QI work is structured — not just informal improvement — and that results are recorded.
2. Are PDSA cycles or other improvement methodologies being used and documented?
Look for evidence that improvement work is structured, tested, and evaluated.
3. Can you show an innovation implemented in the last 2 years that has improved care or efficiency?
Look for examples of new models of care, digital tools, or service redesign.
4. Are staff encouraged and resourced to bring forward improvement ideas?
Check for a suggestions process, a staff improvement forum, or examples of staff-led change.
5. Is learning from external sources (national audits, benchmarking data, inspection reports) acted on?
Look for evidence that external data is reviewed, discussed, and acted on at governance level.
8
Environmental sustainability
0/5 sub-questions confirmed
Description
The practice understands its environmental impact and takes steps to reduce it.
Guidance
Evidence: sustainability plan, inhaler choice data, energy monitoring, net zero commitments.
Preparation sub-questions
1. Is there a sustainability or green plan at practice or PCN level?
Check whether the practice has signed up to the NHS net zero ambition and has a documented plan.
2. Are initiatives to reduce carbon footprint in place, such as inhaler choice policy or waste reduction?
Look for a low-carbon inhaler formulary, evidence of waste reduction, or single-use plastics reduction.
3. Is energy use monitored and are reduction targets set and reviewed?
Check for energy monitoring data and whether any actions have been taken to reduce consumption.
4. Are travel-related carbon impacts considered, such as patient transport or remote consultation use?
Check whether video and telephone consultations are being used where clinically appropriate to reduce travel.
5. Are staff aware of the practice's sustainability goals and how they can contribute?
Check staff awareness through surveys, team meetings, or a sustainability champion.

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  • Sub-question responses and evidence notes
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  • Compliance disclaimer included
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