From Repeated CQC Failure to Sustainable “Good” Rating

Background

A mid-sized GP practice had been struggling for several years following consecutive CQC inspections that resulted in “Requires Improvement” ratings across multiple domains. Despite genuine effort from the partners and management team, the practice had become trapped in a cycle of reactive compliance.

Prior to engaging PCMS, the practice had worked with several non-specialist consultancy providers. These organisations supplied generic templates, standardised action plans, and remote advice — but without deep understanding of primary care operations or CQC methodology. Improvements were superficial and short-lived.

By the time PCMS were approached, the practice faced:

• Low staff morale

• Inconsistent governance systems

• Weak leadership structure

• Risk of further regulatory escalation

• Growing anxiety ahead of re-inspection

The partners recognised that incremental fixes were no longer enough. A full operational reset was required

The Core Issues Identified

PCMS conducted a comprehensive on-site diagnostic review rather than a paper-based compliance exercise. This revealed:

• Policies that did not reflect actual working practice

• Limited ownership of quality and safety at leadership level

• Incident reporting processes that existed but were not embedded

• Poor evidence alignment to CQC Key Lines of Enquiry

• Action plans that lacked measurable outcomes

Most critically, the practice was attempting to “prepare for inspection” rather than build a sustainable culture of quality.

The PCMS Intervention

PCMS implemented a structured turnaround programme focused on operational reality, not paperwork.

1. Leadership and Accountability Reset

Clear governance roles were defined. Clinical and non-clinical leads were assigned measurable responsibilities. Regular quality meetings were formalised with tracked actions and deadlines.

The leadership team received direct coaching to strengthen decision-making, delegation, and oversight.

2. Governance Systems Rebuilt

PCMS introduced:

• A live risk register with mitigation tracking

• A structured incident review process with learning feedback loops

• A documented quality improvement cycle

• A clear audit calendar linked to clinical outcomes

Within weeks, reporting culture improved and risks were actively managed rather than passively recorded.

3. Staff Engagement and Cultural Change

Instead of one-off compliance briefings, PCMS delivered practical sessions that translated CQC standards into day-to-day behaviours. Staff were shown how their roles linked directly to inspection domains.

Confidence improved significantly. Team members were able to articulate how the practice was safe, effective and well-led — not just where the policies were stored.

4. Evidence Alignment and Inspection Preparation

PCMS built a structured evidence framework aligned directly to CQC expectations. Documentation was refined to reflect real practice processes rather than template wording.

Mock inspection exercises were conducted to test readiness, identify gaps, and rehearse inspection-day responses.

The Outcome

At re-inspection, the practice achieved:

• Overall rating improved to “Good”

• Significant improvement within the Safe and Well-Led domains

• Positive feedback from inspectors regarding leadership visibility and governance clarity

• Improved staff morale and patient confidence

Importantly, improvements were not cosmetic. Systems were embedded and sustainable.

What Made the Difference?

Previous providers had focused on documentation. PCMS focused on behaviour, leadership and operational systems.

Conclusion

This case demonstrates that CQC success cannot be achieved through paperwork alone. Sustainable improvement requires:

• Strong leadership

• Embedded governance systems

• Staff engagement

• Expert understanding of primary care regulation

PCMS does not simply prepare practices for inspection — we strengthen them to operate safely, confidently, and sustainably long after inspection day.