Care Quality Commission (CQC)

Following our inspection by the Care Quality Commission on Nov 2023

Report Outcome 

Following the CQC inspection in November, we now have received the final report outcome (April 24). Building on our culture of transparency, our aim is to be open with our patients. Therefore, we wanted to give some background and update on our progress since the inspection. 

The final report and the evidence table with full details, is linked below.  

The report outcome in summary:

The five individual categories ratings are:

  • Effective – Good
  • Caring – Good
  • Responsive – Requires improvement (from 2018)
  • Well-led – Good
  • Safe – Requires improvement

Our overall rating has now been altered from ‘good’ to ‘requires improvement’. The way CQC works is that they have five different categories, and these are assessed individually. If two or more categories receive a ‘requires improvement’ then this alters the overall rating. Unfortunately, despite requesting that the historic ‘responsive’ category from 2018 was reassess as part of this inspection, along with providing up to date evidence, this was declined by CQC due to their current policies.

Areas of Improvement highlighted

The issues identified in the safe category resulting in ‘requires improvement’ are listed below as presented in the last half day training:

  • The provider had not ensured consistent standards of infection prevention and control through audit and expected standards of practice. However, the senior leadership team had recognised the need for improvement and had implemented new processes, which needed time to be embedded and deliver results.

We acknowledge our IPC audits were not in a date range in accordance with CQC requirements. All six surgeries have now up to date IPC audits and action plans have been created and being progressed.

  • Staff did not always ensure patients with complex conditions or long-term prescribed medicines received timely reviews and appropriate follow-up

We acknowledge this was the case for a small number of patients, however we disagree with the sweeping nature of this statement. We recall patients with long term conditions and certain medications in line with national guidelines. Our rates of monitoring and review of our patients are well above national average in almost all areas: for example in the National Diabetes Audit data for Dec 2023 shows that 96% of our patients had undergone HbA1C monitoring compared to the national average of 90%. However, since this time, our processes have been updated and we now have a more robust system in place in response.  

  • Not all Medicines and Healthcare products Regulatory Agency (MHRA) alerts had been acted on.

We stand by our approach in relation to this – we have also contacted MHRA directly for advice and their thinking is aligned with our process. This information has been passed to CQC so they can reflect on their policies.  

  • The provider had not ensured all staff had up to date vaccinations in line with UK Health and Security Agency requirements.

We acknowledge we did not hold 100% of staff vaccinations records. This has now been rectified in line with the CQC requirement. 

Areas of Outstanding 

  • The practice had an extensive programme of data-driven care development. A GP partner had established data
    monitoring to help track demand and capacity based on disease prevalence and comorbidities. This was more
    extensive and up to date than national monitoring and meant the provider had a comprehensive, holistic
    understanding of regional population health
  • Frailty was a key focus for the practice and the frailty lead had established an evidence-based, multidisciplinary,
    system-wide programme of work to improve the lives and outcomes of patients. This had improved the accuracy of
    frailty coding on healthcare information systems, reduced the need for unplanned hospital admissions, and meant
    patients had access to more appropriate, individualised care


We embrace feedback on areas we can improve and have implemented some tangible improvements since November in response. We are taking the learning and reflection seriously and have carried this forward to prevent this in the future.

The rating we feel is by no means a reflection of our team or the service we provide our patient population and it is not a metric we of Pathfields success.

The report highlights many areas of high compliance and we encourage all our patients to read the reports in full. We would also be very interested in your feedback.

Complaint raised with CQC

We have entered into the appeals process of a formal complaint to CQC in response to the inspection, with concerns regarding both the inspection and grading methods applied. May 2024. 

What is the CQC? 

The CQC is an independent regulator of health and social care in England. They make sure that the services we offer to patients and the local community, are safe, effective, compassionate and are of the highest standard.  

As part of the inspection, the CQC monitors, inspects and regulates our services before publishing what they find.  

You can learn more about the CQC by clicking on the link below. 

Go to the CQC