H A R E S I G N

Primary care management consulting for GP practices and PCNs across England. IGPM Accredited Member.

Contact Info
Email

[email protected]

Connect

LinkedIn

Primary care consulting for GP practices & PCNs across England. Get in touch →

Get In Touch
  • Home
  • Tools
  • CQC Returning to Good & Outstanding

CQC Returning to Good & Outstanding

RTG Readiness Guest session
● 0 ● 0 ● 0 ● 10 0 / 10 complete
Export PDF
Create a free account to save your progress

Your responses are stored in this browser session only. Sign up or log in to save permanently.

Sign Up Log In
About this programme

From March 2026, CQC is reassessing NHS GP practices rated Good or Outstanding with inspection reports from 2017–2022. Use the overall RAG buttons for each statement, then expand rows to test the evidence underneath.

Need the full readiness checker instead?

This RTG tool focuses on the 10 non-clinical quality statements used in the focused programme. Switch if you need the wider full-readiness review.

CQC Readiness Checker

Use a recognisable label if you're keeping more than one personal checklist.

Workspace context

You are using a guest session. Progress stays in this browser until you create an account or sign in.

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.

1
Safe environments
Safe 0/6 sub-questions confirmed Overall: Not started
Description
The premises are safe, clean and well-maintained. Risks are identified and acted on. Equipment, emergency kit, IPC and cold chain controls are all in order.
Guidance
Walk every room before the inspector does. Check: fire exits clear, signage present, emergency kit accessible and in date. IPC audit present, dated, signed and every action closed. Cleaning schedules current, signed and monitored. Vaccine fridge logs complete with a documented response to any out-of-range readings. All remedial actions from previous risk assessments completed and evidenced. Legionella risk assessment current, water flushing logs maintained.
Preparation sub-questions
1. Walk the premises now: are fire exits clear, signage in place and emergency kit accessible and in date?
Do this yourself before the inspection. Look for blocked exits, out-of-date equipment, missing signage or a crash bag that hasn't been checked recently.
2. Is the IPC audit present, dated, signed and are all actions completed — not just recorded?
A completed IPC audit with outstanding actions is a red flag. Every action needs a completion date and evidence.
3. Are cleaning schedules current, signed and monitored for completion?
Inspectors check whether schedules are being followed in practice. A template with no signatures is not evidence.
4. Are vaccine fridge temperature logs complete, with a documented process for out-of-range readings?
Out-of-range readings with no follow-up action are a known RI trigger. The log should show what happened next.
5. Are all remedial actions from previous risk assessments or inspections completed and evidenced?
Inspectors will check whether actions from previous assessments were actually completed. Incomplete remedials are a direct RI trigger.
6. Is the legionella risk assessment current and are water flushing logs maintained for infrequently used outlets?
Flushing logs should be signed weekly. The risk assessment should be dated within the last two years and name a responsible person.
2
Safe and effective staffing
Safe 0/6 sub-questions confirmed Overall: Not started
Description
Recruitment checks, training, immunisation, induction, appraisals and clinical supervision are all in place and evidenced — including for zero-hours and ARRS staff.
Guidance
Inspectors request a live training compliance percentage on the day — you must be able to produce this immediately. Recruitment files must include DBS, references, right-to-work and immunisation records for every member of staff, including zero-hours and recently joined. Clinical supervision must be documented for nurses, ANPs, pharmacists and trainees. Training must be tracked with verified evidence, not self-reporting. Annual appraisals required for all clinical and non-clinical staff.
Preparation sub-questions
1. Can you produce a live training compliance percentage for ALL staff right now — including zero-hours and ARRS?
Inspectors request this on the spot. If training is tracked by self-reporting with no verified figures, that is a known RI trigger.
2. Are immunisation records held for all staff — including zero-hours and recently joined staff?
Missing immunisation history for zero-hours or new joiners is a known RI trigger. Check every file, not just permanent staff.
3. Are recruitment files complete for all staff — especially zero-hours and recent joiners?
Inspectors dip-sample files. Incomplete DBS, missing references or unexplained CV gaps are red flags, particularly for zero-hours staff.
4. Is clinical supervision documented for nurses, ANPs, pharmacists and trainees?
Undocumented clinical supervision is a known RI trigger. Evidence should include supervision logs, contracts or meeting notes with dates.
5. Is training tracked with verified evidence — not just self-reported completion?
Self-reporting with no verification is a known RI trigger. The matrix should show certificates, dates and the person who verified completion.
6. Are annual appraisals completed and documented for all clinical and non-clinical staff, including the practice manager?
The practice manager's own appraisal is frequently a gap. Inspectors expect the same oversight for managers as for clinical staff.
3
Infection prevention and control
Safe 0/6 sub-questions confirmed Overall: Not started
Description
IPC governance, training, audits, PPE, hand hygiene, decontamination and clinical waste are all in place and evidenced.
Guidance
Named IPC lead with current training. IPC audit completed at least annually with a signed action plan showing all actions closed. All staff trained in standard infection control precautions. PPE adequate, accessible and correctly used. Hand hygiene monitoring conducted, recorded and results shared. Sharps, clinical waste and decontamination processes documented, audited and followed.
Preparation sub-questions
1. Is there a named IPC lead with current IPC training and a clear, documented remit?
The IPC lead should be identifiable, trained in the last two years and staff should be able to name them.
2. Is the IPC audit completed at least annually, with a signed action plan and all actions closed?
An audit with outstanding actions is worse than a thorough audit with every action completed. Close the loop before inspection.
3. Are all clinical and non-clinical staff trained in standard infection control precautions?
This includes reception, admin and cleaning staff. IPC training should appear in the training matrix for every staff member.
4. Are PPE supplies adequate, accessible and correctly used — with evidence of monitoring?
Accessibility means available at the point of need. Evidence could include a stock check log or an IPC walkround record.
5. Is hand hygiene monitoring conducted and results recorded and shared with staff?
Monitoring results should feed back into the team. A hand hygiene audit with no follow-up action is weaker evidence.
6. Are sharps, clinical waste and decontamination processes documented, audited and followed in practice?
Check that sharps bins are not overfilled, waste segregation is correct and decontamination records (e.g. autoclave logs) are up to date.
4
Supporting people to live healthier lives
Effective 0/6 sub-questions confirmed Overall: Not started
Description
Patients are proactively supported with prevention, health promotion, care planning and social prescribing.
Guidance
Long-term condition registers used for proactive identification and care planning. Health promotion campaigns (smoking, alcohol, weight, mental health) actively offered. Social prescribing available and staff trained to refer. Evidence of proactive outreach to patients overdue health reviews. NHS Health Check and cancer screening actively promoted. Population health data reviewed to identify unmet need.
Preparation sub-questions
1. Are patients with long-term conditions proactively identified and do they have up-to-date care plans?
Evidence could include recall systems, a structured review programme or a register showing last review dates.
2. Are health promotion campaigns (smoking, alcohol, weight, mental health) actively offered to patients?
Actively offered means more than a leaflet rack. Look for evidence of coding, invitations, referral pathways or staff prompts.
3. Is social prescribing available and are staff trained to identify patients who would benefit?
Staff at all levels should be able to explain what social prescribing is and how to make a referral.
4. Is there evidence of proactive outreach to patients overdue health reviews, screening or immunisations?
This could include automated recall, targeted letters, or GP-initiated conversations for patients who have not engaged.
5. Is the NHS Health Check programme running and is uptake tracked?
Evidence includes a recall process, uptake data and any improvement actions where take-up is low.
6. Is population health data reviewed to identify unmet need in your practice area?
This does not need to be complex. A basic understanding of local deprivation, disease prevalence or health inequalities that informs any visible action is enough.
5
Monitoring and improving outcomes
Effective 0/6 sub-questions confirmed Overall: Not started
Description
Performance is tracked against national benchmarks. Clinical audit, quality improvement and screening and immunisation uptake are monitored and acted on.
Guidance
Inspectors review your National GP Patient Survey scores before arriving — know your numbers. Screening and immunisation uptake rates tracked with named actions where below target. At least one documented quality improvement project with measurable outcomes. Clinical audit used to drive improvement with results shared with the whole team. Evidence of improvement over time in at least one area. Outcomes benchmarked against national peers.
Preparation sub-questions
1. Do you know your current GP Patient Survey scores and how they compare to the national average?
The inspector reviews your scores before arriving. You should know your overall experience score, phone contact score and any areas below the national benchmark.
2. Are screening and immunisation uptake rates tracked, with named actions where rates fall below target?
Outstanding practices exceed national targets across all programmes. Knowing your rates is the minimum — having an improvement plan is what matters.
3. Can you show at least one documented quality improvement project with measurable outcomes?
A named QI project with a baseline, an intervention, a re-audit date and a result is strong evidence. A report with no outcome is weak.
4. Is clinical audit used to drive improvement and are results shared with the whole clinical team?
Audit that sits in a folder with no team discussion is not evidence of learning. Look for minutes that reference audit findings.
5. Is there evidence of improvement over time in at least one clinical area?
Before-and-after data, even for a small area, demonstrates that your monitoring actually produces change.
6. Do you benchmark your outcomes against national data or peers on a regular basis?
This could include QOF performance, NICE indicator data or ICS-level benchmarks. Regular means at least annually with a review discussion.
6
Kindness, compassion and dignity
Caring 0/6 sub-questions confirmed Overall: Not started
Description
Patients are treated with kindness, empathy and dignity by all staff. Patient experience scores are known, discussed and acted on.
Guidance
Know your GP Patient Survey scores for kindness, dignity and overall experience before the inspection. Practices scoring 4 are "exceptional at treating people with kindness, empathy and compassion." Patient experience scores discussed with the whole team including reception and admin. Staff trained to handle difficult conversations. Patient feedback that mentions kindness acted on and visible.
Preparation sub-questions
1. Do you know your current GP Patient Survey scores for kindness, dignity and overall experience — and the national averages?
Outstanding practices score 96%+ on overall experience (national: 70%) and 85%+ on phone contact (national: 53%). Know your numbers before the inspector does.
2. Are patient experience scores discussed with the whole team — including reception and admin staff?
Kindness is delivered by every member of staff, not just clinicians. Team discussion of scores should be recorded in meeting minutes.
3. Are staff trained and supported to handle difficult conversations with compassion and sensitivity?
Evidence could include communication skills training, debriefs after difficult consultations, or a named staff support contact.
4. Is there a process for supporting patients in distressing situations — bereavement, serious diagnosis, end of life?
This could include care coordinator support, bereavement signposting resources, or a staff protocol for managing distressed patients.
5. Can you show specific patient feedback that mentions kindness or dignity, and how it was responded to?
Positive feedback acted on and shared with the team is strong evidence. Even one specific example is more convincing than a general statement.
6. Is there evidence that staff treat each other with kindness and respect — visible in meeting culture and management style?
An inspection is a snapshot of culture. Staff who are treated well are more likely to treat patients well. A team that can give examples of management support is compelling.
7
Equity in access
Responsive 0/5 sub-questions confirmed Overall: Not started
Description
All patients can access care. Access performance, barriers and patient survey scores are reviewed and improvements made.
Guidance
The inspector checks actual on-the-day appointment availability live during the visit. They also review your National GP Patient Survey scores for overall experience and phone access before arriving — 96% vs 70% national and 85% vs 53% phone are what Outstanding looks like. If access scores are weak, have a documented improvement plan ready before the question is asked. Access reviewed against local demographic profile. Specific arrangements for patients with additional needs.
Preparation sub-questions
1. What are your current GP Patient Survey scores for overall experience and positive phone contact? Do you know the national benchmarks?
Inspectors review these before they arrive. Outstanding: 96%+ overall (national 70%), 85%+ phone (national 53%). If your scores are below average, have an improvement plan ready.
2. Is appointment availability visible and adequate on the day of inspection — the inspector may check live during the visit?
This is one of the 10 things inspectors actually do. If same-day or urgent appointments are unavailable or hard to book, that is a live risk on inspection day.
3. Have you reviewed access arrangements against your local demographic profile?
Outstanding practices tailor access to their population. Evidence could include extended hours for working-age patients, translated materials, or a targeted outreach programme.
4. Are specific access arrangements in place for patients with additional needs — carers, housebound patients, learning disabilities?
Flagging patients who need reasonable adjustments on the appointment system and having named pathways for them is stronger evidence than a general statement of intent.
5. If any access scores fall below the national benchmark, is there a documented improvement plan with milestones and progress?
A named improvement plan with a baseline, actions, owners and review dates is far stronger evidence than acknowledging the problem.
8
Equity in experiences and outcomes
Responsive 0/6 sub-questions confirmed Overall: Not started
Description
Patient experiences and outcomes are reviewed across different groups. Reasonable adjustments are applied and underserved populations are actively supported.
Guidance
Person-centred care embedded across all staff — not just clinical. Reasonable adjustments consistently applied for patients with disabilities or communication needs. Patient feedback from different demographic groups reviewed and acted on. National GP Patient Survey broken down by patient group and discussed at team level. Evidence of targeted provision for underserved populations.
Preparation sub-questions
1. Do you collect and review data on patient experiences and outcomes across different patient groups?
This could include GP Patient Survey data by age or gender, uptake data by ethnicity for screening programmes, or a local patient experience report.
2. Are reasonable adjustments consistently applied for patients with disabilities or communication needs?
Evidence includes a flagging system on the clinical system, accessible appointment options and staff awareness of individual patient needs.
3. Are there targeted interventions for underserved or vulnerable patient populations in your area?
This could include outreach to homeless patients, housebound visits, support for patients with learning disabilities or work with local community organisations.
4. Is patient feedback from different demographic groups reviewed and does it inform service changes?
Segmented feedback — even basic — shows that the practice looks beyond aggregate scores to understand who is having a poorer experience.
5. Is the GP Patient Survey broken down by patient group and discussed at team level?
NHS England publishes survey data by age, gender, ethnicity and deprivation. Using this to spot disparities and act on them is what equity in outcomes looks like.
6. Is the person-centred care ethos embedded across all staff — not just clinical?
Outstanding practices show that reception and admin staff understand that patient experience is their job too. A consistent approach across the whole team is what inspectors recognise.
9
Shared direction and culture
Well-led 0/6 sub-questions confirmed Overall: Not started
Description
A clear vision and values are known by all staff. There is shared direction across clinical and non-clinical teams, with staff involved in shaping how the practice works.
Guidance
Inspectors ask staff directly about the practice vision and their individual role in it — including receptionists and admin. A vision known only by the practice manager is not sufficient. Staff must be able to say what the practice stands for and how they know. Values embedded in recruitment, induction and appraisal.
Preparation sub-questions
1. Ask a member of admin or reception staff now: can they state the practice vision without prompting?
Inspectors ask staff directly — including receptionists and admin. A vision known only by GPs and the practice manager is not embedded. Test this before the inspector does.
2. Can every member of staff describe their individual role in delivering the practice's values?
Not "what are the values" — but "what does that mean in your job, today?" Staff who can answer this with a specific example are strong evidence of genuine culture.
3. Is the practice vision visible in day-to-day decisions and communications — not just on a poster?
Evidence could include values referenced in team meetings, in how decisions are explained to staff, or in how complaints are discussed.
4. Are staff involved in shaping how the practice operates, with examples they can point to?
Evidence could include staff suggestions that led to a change, team input on a new process, or a staff survey result that produced a visible action.
5. Are the practice values reflected in recruitment adverts, induction packs and appraisal frameworks?
If the values are embedded, they should be traceable through the staff lifecycle — from first contact to annual review.
6. Is there evidence of shared direction between clinical and non-clinical teams — not just a management-led strategy?
Shared direction means clinical and non-clinical staff can both describe what the practice is working towards and why.
10
Governance, management and sustainability
Well-led 0/6 sub-questions confirmed Overall: Not started
Description
Governance meetings, risk registers, policy control, professional registration and improvement tracking are in place and demonstrate grip.
Guidance
Inspectors review governance meeting minutes and check that actions are shared with all staff. Policy updates must be on the practice website. Evidence of professional registration checks must be retained on file — checked and noted is not enough. Named governance lead, live risk register reviewed at every meeting, policy index with review dates. Governance ties together incidents, complaints, staffing, access, policy, premises and risk.
Preparation sub-questions
1. Are governance meeting actions shared with ALL staff — not just the management team?
Sharing actions only with managers is a known RI trigger. Evidence that frontline staff receive meeting summaries or action updates adds real credibility.
2. Are all current policies published on the practice website and kept up to date?
Policy updates not reflected on the website is a known RI trigger. Check the website now: are the policies there, current and accessible to patients?
3. Is evidence of professional registration checks retained on file — not just checked and noted?
Checking registration without retaining evidence is a known RI trigger. The file should contain a printed record, screenshot or dated log for each check.
4. Is there a live risk register with named owners, risk ratings and action dates, reviewed at every governance meeting?
A risk register that is not discussed at governance meetings is a static document, not evidence of active risk management.
5. Can you produce governance meeting minutes from the last month showing actions completed, owned and followed up?
Inspectors review governance minutes. Minutes with recurring actions that never close, or actions with no named owner, suggest governance is not working.
6. Is the practice website up to date — including policies, opening times and patient-facing information?
An out-of-date website signals poor governance as much as a missing policy review. Check it as though you are a patient or inspector seeing it for the first time.

Save your RTG assessment as a PDF report

Your personalised report includes your full RAG summary across all 10 quality statements, every sub-question response, an action tracker for Partial and No items, and a compliance disclaimer — ready to share with your team or keep on file ahead of the focused assessment.

  • RAG status across all 10 quality statements
  • Sub-question responses and evidence notes
  • Action tracker: every gap with owner and next steps
  • Compliance disclaimer included
Export PDF