Dr Alastair Blake (pictured) and Professor Nigel Sparrow explain the role of the Care Quality Commission, what general practices can expect from inspections, and how to prepare for them

blake alastair

Read this article to learn more about:

  • the purpose of the Care Quality Commission
  • the new four-point system used to grade practices
  • what documentation should be prepared for an inspection team visit.

Key points



The Care Quality Commission (CQC) is the independent regulator of healthcare and adult social care in England.1 The organisation was established by the Health and Social Care Act 20082 to ensure that healthcare and social care services provide people with safe, effective, compassionate, high-quality care.

In primary care, the CQC has the responsibility for regulating general practices, out-of-hours services, urgent care services, NHS 111, dental practices, prison medical services, and independent primary care doctors. The largest part of this work is the regulation of general practices, of which there are approximately 8000 in England. We plan to have inspected each of these practices at least once by April 2016.

Why do we inspect general practice?

We know that the majority of general practice is of good standard in England; however, we also have seen unwarranted variation in the quality of care delivered and know that some patients receive poor care.3 As the regulator, we have a statutory duty to ensure that patients receive high-quality care, and we are committed to being transparent with the public about where this variation is occurring.

We also believe that inspecting and rating general practices is a powerful way of encouraging improvement in the quality of care. By celebrating areas of 'Outstanding' care we can help the diffusion and adoption of innovative practice across the country. Likewise, by shining a spotlight on areas of 'Inadequate' practice, we can identify areas for providers to focus their improvement efforts, and can share learning about common problems more widely. In this way, while the CQC is not an improvement agency, it can be a powerful agent for improvement.4

How do we inspect general practice?

The CQC first started to regulate and inspect general practices in April 2013. The aim of these inspections was to assess compliance with the essential standards of care outlined in the Health and Social Care Act 2008.5 However, our commitment to celebrating excellence was not fulfilled with this compliance-focused approach, so we adopted a new methodology which we began piloting in April 2014. This was fully rolled out nationally on 1 October 2014.

In order to regulate general practice, we use a combination of intelligent monitoring data and information gathered from inspections to make judgements. Intelligent monitoring data is used to prioritise practices for inspection based on nationally available data sets and our new inspection methodology involves asking five key questions:

  • is a practice safe?
  • is it effective?
  • is it caring?
  • is it responsive to people's needs?
  • is it well led?

By asking these questions, we undertake a more holistic assessment of quality and can identify 'Good' and 'Outstanding' care.

As well as focusing on the five key questions, we will always look at how services are provided to people in specific population groups:3

  • older people
  • people with long-term conditions
  • families, children, and young people
  • working-age people
  • people in vulnerable circumstances, who may have poor access to primary care
  • people experiencing poor mental health.

Practices will be rated as 'Outstanding', 'Good', 'Requires Improvement', or 'Inadequate' for each of the five key questions and for each population group. Practices will also receive an aggregate overall rating. We publish ratings as we believe it is important to be open and transparent with the public about the quality of the services they use. These ratings should also encourage providers to improve the quality of services they offer and is the mechanism by which we can celebrate outstanding practice as well as identify areas of poor care. The process of regulating providers involves four key steps (see Box 1, below, and Figure 1 below).

Box 1: Four key steps in the regulating process

  • Step 1: Registration

    Organisations delivering 'regulated activities' must register online with the CQC and provide some basic information about their service; for example, the location of the organisation and the name of its registered manager
  • Step 2: Intelligent monitoring

    We use a range of data metrics to build a profile of practices in order to help us prioritise which ones we inspect first
  • Step 3: Expert inspections

    We use an expert CQC inspector and a GP specialist advisor on each team. They may be joined by a practice manager or practice nurse specialist advisor or an 'expert by experience', who is a lay person with extensive experience of using services
  • Step 4: Publication of reports with ratings

    By publishing our findings, we can inform the public about the quality of the services they use and encourage providers to improve.
  • CQC=Care Quality Commission
Figure 1: Care Quality Commission's overall operating model6
Care Quality Commission's overall operating model

What to expect from the process

Below is a summary of the key events before, during, and after our inspection process.

Two weeks before

You will be given 2 weeks' notice of your inspection date. Although you may already have read our Handbook,6 it is advisable to re-read it so that you refresh your memory as to how the inspection will be conducted and what key lines of enquiry the inspector will be pursuing. At this point, it would be advisable to prepare folders containing information the inspector will want to see; for example, clinical audits, staff recruitment and appraisal, and minutes of staff meetings.

Between 1–2 weeks before the inspection day, the inspector will telephone the practice to introduce themselves and answer any questions the practice may have.

On the day of inspection

The inspection team will arrive on the morning of the inspection and will comprise at least one inspector and one GP specialist advisor. Depending on the size of your practice, there may be a second inspector, or additional specialist advisors such as a practice manager or nurse, or 'expert by experience'.

The day will start with a 30-minute presentation from the practice. This is an opportunity for staff to showcase particular strengths of the practice, and highlight any key challenges or important pieces of context. The inspection team will then begin holding interviews with members of staff (GPs, practice manager/s, nurses, healthcare assistants, and administrative staff) as well as patients. At lunchtime, the inspection team will meet to corroborate their early findings before continuing their discussions with patients and staff. The day ends with a brief feedback session between the inspector and the practice manager/GP principal. In rare circumstances, the inspector may need to return for a second day to collect further information. This may occur if the practice is very large, or if there was insufficient time to collect all the necessary information on the first day.

After inspection day

In the days following the inspection, the inspector will collate all the evidence collected and draft the report. The report then goes through our Quality Assurance process of peer review by another inspector and an inspection manager. After this, our Regional (or National, if necessary) Quality Assurance Panel reviews the report to decide an overall rating. Before the report is published, the draft report is shared with the practice for a 'factual accuracy check' and the practice will have 10 days to raise any issues. This whole process from inspection day to publication typically takes 6–8 weeks. If a practice is not compliant with regulations, further follow-up visits may be required to ensure improvements are made. The timing of these visits will vary depending on the nature of the problems identified, but are typically weeks or months later.

Frequently-asked questions about the inspection process

We understand that inspection can be a stressful time for practices. We try to make the process as easy as possible by providing information in our Handbook6 and Appendices,7 which outline our inspection process in detail, and by writing 'Mythbusters'8 about frequently-asked questions. These can be found on our website.

Key points

  • The purpose of the CQC is to ensure that healthcare and social care services in England provide people with safe, effective, compassionate, high-quality care
  • The CQC wants to celebrate excellent general practice as well as shine a spotlight on poor care
  • Our inspection methodology changed in April 2014 and was rolled out nationally on 1 October 2014
  • Inspections now involve clinical input from a GP specialist advisor and may also involve a nurse or practice manager
  • Practices:
    • will be given 2 weeks' notice before their inspection
    • should prepare for the inspection by reading our Handbook6 and Appendices7 as well as our Mythbuster page on the CQC website (see here)
    • should prepare folders containing documentation of clinical audits, staff recruitment and appraisal, and practice meetings for review by the visiting inspection team
    • are rated on a four-point scale: 'Outstanding', 'Good', 'Requires Improvement', and 'Inadequate'—this is done to encourage practices to improve and to be transparent with the public
  • Once the report is written, practices will be sent a draft to check for factual accuracy and will be given 10 days to respond
  • The CQC will inspect all general practices in England at least once by April 2016.

CQC=Care Quality Commission

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  1. Care Quality Commission website. How we do our job. www.cqc.org.uk/content/who-we-are (accessed 12 January 2015).
  2. Health and Social Care Act 2008. www.legislation.gov.uk/ukpga/2008/14/contents (accessed 12 January 2015).
  3. Care Quality Commission. The state of health care and adult social care in England 2013/14. October 2014. Available at: www.cqc.org.uk/sites/default/files/state-of-care-201314-full-report-1.1.pdf
  4. Care Quality Commission. Healthy regulators: Regulating for quality requires trust and independence. July 2014. Available at: www.cqc.org.uk/sites/default/files/20140729_cqc_regulators_2014_05_final_low_res.pdf
  5. Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. SI 2010/781, as amended. Available at: www.cqc.org.uk/sites/default/files/documents/health_and_ social_care_act_2008_regulated_activities_ regulations_2010.pdf
  6. Care Quality Commission. How CQC regulates: NHS GP practices and GP out-of-hours services. Provider handbook. October 2014. Available at: http://www.cqc.org.uk/sites/default/files/20141008_gp_practices_and_ooh_provider_handbook_main_final.pdf
  7. Care Quality Commission. How CQC regulates: NHS GP practices and GP out-of-hours services. Appendices to the provider handbook.  Available at: www.cqc.org.uk/sites/default/files/20141008_gp_practices_and_ooh_provider_handbook_appendices_final.pdf
  8. Care Quality Commission website.Mythbusters and tips for GPs and out-of-hours services.www.cqc.org.uk/content/mythbusters-and-tips-gps-and-out-hours-services (accessed 12 January 2015).