What does an ‘inadequate’ practice look like?

In a new series, using information provided by the CQC and real-life examples of service failure, Practice Business explores the factors than can contribute to your practice being deemed ‘inadequate’ – and what you can do to avoid them

Every practice is judged on how safe, effective, caring, responsive and well-led it is. These five dimensions of care are comprehensively outlined within the CQC’s key lines of enquiry (KLOE). The regulator describes ‘inadequate’ services simply as those that are ‘performing badly’; it’s a broad definition which can lead to confusion about just what ‘inadequate’ looks like. To help practices, the CQC provides useful guidelines on how to meet its inspection criteria and avoid a negative score.

To improve inspection outcomes and help practices understand why services may be rated as ‘inadequate’ – and, importantly, what they can do to improve patient care – the regulator has highlighted some of the common failings it finds in ‘inadequate’ practices.

Over the coming five weeks we will use these actual examples to explore what ‘inadequate’ means for each of the five dimensions of CQC inspections. We begin with ‘safe’.

Defining ‘safe’

The CQC defines a safe practice is one where patients are ‘protected from abuse and avoidable harm’. A safe practice is one which:

  • has systems, processes and practices in place that safeguard patients from abuse;
  • monitors and manages risk;
  • operates at safe staffing levels;
  • has adequate infection controls in place; and
  • demonstrates an ability to learn from its failures.

Practices may receive an inadequate rating for failing to demonstrate compliance with any of the KLOEs; the CQC notes three specific areas where practices commonly struggle:

  1. Failure to record, and learn from, significant events.
  2. Ineffective safeguarding systems and processes in place.
  3. Inadequate staff security checks.


  1. Significant events

 Practices should have mechanisms in place to record – and learn from – any significant events that have occurred; this can help to stop such events ever happening again. The lack of a strategy to manage significant events is a common reason why practices receive an inadequate rating.

In one practice investigated by the CQC no system was in place to record, report and monitor significant events when the GP wasn’t present. In another, while a system for recording adverse incidents had been in place, its use had lapsed, and nobody was now recording incidents.

In addition to a failure to record incidents the CQC noted that, in both cases, there was no formal process for practice staff to report any problems, leading to the potential for incidents to be repeated; incidents might have been missed, and learning lost.

To avoid an inadequate rating in this respect, a robust significant event analysis (SEA) approach can demonstrate to the CQC that you have a process in place to learn from events and to ensure that mistakes are not repeated.

  1. Safeguarding protocols

Practices should have reliable systems, processes and practices in place to safeguard vulnerable patients from harm – failing to do so will result in an inadequate rating.

In one inspection the CQC met with staff who had received safeguarding training; even so, they could not distinguish between different forms of abuse or identify their practice safeguarding lead, and they did not know how to raise concerns.


Another practice provided training, but important safeguarding documentation was difficult to access. Details of the local safeguarding team were not easy to find, and staff were unaware of how to identify at-risk children.

In both cases, the systems designed to keep vulnerable people safe weren’t implemented effectively. The CQC is clear that everyone in the practice has a role in protecting children and adults at risk of abuse. If any link in the chain is weak, the result could be patients put at risk and a poor rating.

In both examples practices needed to do more than simply identify what systems were in place; they needed to ensure that all staff were fully aware of how to identify, support and manage the care of someone at risk. By doing so, they would have better protected their patients and might have avoided an inadequate rating.

  1. Staff screening

Recruitment checks ensure that practice managers can have confidence that every member of staff in the practice is fit to work.

In one example of an inadequate practice, criminal checks by the Disclosure and Barring Service (DBS) hadn’t been carried out for two nurses, and references had been left unchecked for one. None of the non-clinical staff had been subject to criminal checks, and the practice made no attempt to assess whether such checks were required.

By failing to check and maintain records the practice could not be confident that those employed were fit and proper; as a result, the practice and its patients were exposed to unnecessary and avoidable risk.

Practices should follow up, and record, all references, check all medical qualifications and always explore and record whether DBS checks are required for staff. These checks should be conducted in a timely and satisfactory manner – and appropriate supervisory steps put in place while waiting for DBS outcomes – with action taken immediately if any issues are flagged.

Further learning

For practices looking for additional guidance Nigel Sparrow, the CQC’s senior national GP officer, has produced comprehensive and clear information on some of the common reasons for receiving an ‘inadequate’ rating.

In the next article in the series we will focus on the importance of delivering ‘effective care’, and what you can do to safeguard against an inadequate rating in relation to this dimension.

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