1. This document provides guidance and a framework for carrying out inspections to follow up on concerns identified at previous inspections, including when to re-inspect practices that have already received a comprehensive inspection: Concerns identified at previous inspections can either be followed up using a comprehensive or a focused inspection depending on the circumstances. The following table describes the key differences between comprehensive and focused inspections: Where a GP practice has already been rated following a comprehensive inspection, a focused inspection may result in a change to ratings: a rating can always be changed at the lowest level inspected on the focused inspection (ie safe for all population groups). But please note that a focused inspection can only lead to a change in rating if it looks at all issues that led to a previous rating: this is likely to not be limited to breaches of regulations. If a focused inspection is carried out within six months of the comprehensive inspection report being published then the normal aggregation principles will apply and key question, population groups and overall practice ratings may also be amended. 1 Comprehensive inspectionsFocused inspections Covers all five key questionsIs a follow up to a previous inspection or is in response to a particular issue or concern Assesses all population groups (GP inspections only)May not look at all five key questions (or all population groups for GP inspections) Usually announcedMay be announced or unannounced depending on the focus of inspections

2. 2 The following slides set out a framework, agreed by SLT, for re-inspecting GP practices that have already received a rating What does this mean for the inspection schedule? Always consider with your manager, when to carry out a focused inspection. Focused inspections will vary in scope depending on the reason for the inspection so always consider the scope of the focused inspection: in some instances they will be focused on breaches of regulations but in other instances they will look at a whole key question or population group. A focused inspection can only lead to a change in rating if it looks at all issues that led to a previous rating: this is likely to not be limited to breaches of regulations If we have not yet carried out a comprehensive inspection of a GP practice and concerns arise about the practice a comprehensive inspection should be scheduled (because focused inspections cannot lead to ratings where a practice is not already rated). Scenarios 1 and 2 in the table will always require re-inspection within six months. For Scenario 3 onwards the re-inspection period can be 12 months from publication – although a professional judgement is always required based on the level of risk and our knowledge of the practice. Consider the fact that a focused inspection can usually only change aggregated ratings if it takes place within six months of the publication of the initial comprehensive inspection report. Beyond the six months you are likely to need to do a comprehensive inspection if the inspection is intended to enable the overall rating to be amended*. This means that the majority of re-inspections arising from reports published after the end of September 2015 may be scheduled for after the end of September 2016. It is expected that when we have completed the programme of comprehensive inspections, a significant proportion of our work between October 2016 and March 2017 will be the re-inspections that have arisen from the previous 12 months. We shall also communicate this to GPs through the provider newsletter and other communications in October. *We are continuing to work with the policy team to consider whether there may be some situations where a focused inspection which takes place more than six months after the publication of the initial comprehensive inspection report, could lead to changes to the overall aggregated ratings.

3. Scena rio RatingsBreaches of regulations? Timing of re-inspectionComprehensive or focused inspection Amend overall rating? 1Overall Inadequate (two or more Inadequate ratings for key questions) YesSpecial measures approach specifies timelines: Inspection takes place within six months of publication of initial report. Potential need for focused inspection before six months to follow up any enforcement action. ComprehensiveYes. Comprehensive inspection = new rating 2RI overall, with one Inadequate rating for a key question or population group YesSpecial measures approach specifies timelines: Re-inspect and if any inadequate rating for any key question or population group, enter special measures Inspection takes place within six months of publication of initial report. Potential need for focused inspection before six months to follow up any enforcement action ComprehensiveYes. Comprehensive inspection = new rating. 3RI overall, four or five key question ratings are RI (no Inadequate ratings for population groups) Yes, likelyRe-inspect within 12 months of publication of initial report. ComprehensiveYes. Comprehensive inspection = new rating 4RI overall: two or three key questions are rated as RI (the rest are good or outstanding) YesRe-inspect within 12 months of publication of initial report. Focused on issues identified at previous inspection if within six months of publication of initial report Or Comprehensive inspection if outside of six months of publication of initial report Yes. If focused inspection must be within six months of initial report being published. To lead to a change in the rating all issues leading to that rating need to be looked at, this will not always be limited to regulatory breaches. If a comprehensive inspection = new rating 5RI overall: two or three key questions are rated as RI (the rest are Good or Outstanding) NoRe-inspect within 12 months of publication of initial report. Focused on issues identified at previous inspection if within six months of publication of initial report Or Comprehensive inspection if outside of six months of publication of initial report Yes. If focused inspection must be within six months of initial report being published. To lead to a change in the rating all issues leading to that rating need to be looked at. If a comprehensive inspection = new rating

4. Scen ario RatingsBreaches of regulatio ns? Timing of re-inspectionComprehensive or focused inspectionAmend overall rating? 6Good overall, one RI rating for key question or population grp YesRe-inspect within 12 months of publication of initial report. (Note: where the one RI rating only is limiting a service from being rated as Outstanding, then a focused inspection should take place within six months to ensure that the service is given the opportunity to have their overall rating amended to outstanding) Focused on issues identified at previous inspection: to lead to a change in the rating all issues leading to that rating need to be looked at, this will not always be limited to regulatory breaches Yes, if within six months of initial report being published. In these instances the practice is rated as good overall anyway so it may not be as necessary to go back within six months (because changing the one RI rating wouldn’t change the overall rating). No, if longer than six months after publication of initial report. 7Good overall, one RI rating for key question or population grp NoRe-inspect within 12 months of publication of initial report. (Note: where the one RI rating only is limiting a service from being rated as Outstanding, then a focused inspection should take place within six months to ensure that the service is given the opportunity to have their overall rating amended to outstanding) Focused on issues identified at previous inspection Yes, if within six months of initial report being published. In these instances the practice is rated as good overall anyway so it may not be as necessary to go back within six months (because changing the one RI rating wouldn’t change the overall rating). No, if longer than six months after publication of initial report. 8Good overall, no RI ratingsNoInspected from September 2016 and awaiting policy decision on frequency after this date N/A 9Good overall, elements of Outstanding and close to being given Outstanding rating NoInspected from September 2016 and awaiting policy decision on frequency after this date N/A 10Dentists and independent drs – no ratings YesTiming not specified in policy, flexible approachFocused on issues identified at previous inspection No ratings

5. Further notes about focused inspections (this is not new guidance: further guidance on the intranet) Focused inspections can be desk based if only following up breach of regulation that has led to a requirement notice (if warning notice should be site visit). Guidance on intranet. In some cases, when a practice is rated as RI (either at key question, population group or overall) there will be issues which led to that rating which are not related to a breach of regulation: so to amend the rating in these cases, the focused inspection should cover all issues which led to the RI rating, not just the breaches of regulations. If, during the course of a focused inspection, it becomes apparent that there are more widespread concerns than originally envisaged, the inspector should consider whether it would be appropriate to change the inspection type to comprehensive (where possible in agreement with the inspection manager and the practice should be informed) Writing focused inspection reports: full, detailed guidance is available in the report writing guidance on the intranet. The publishing tool should be used to write all focused inspection reports: a separate focused inspection report is written (previously we asked for the previous inspection report to be cloned and edited additional content). The report template is the same as that used for comprehensive inspections: you must report by key question. In the publishing tool, each section of the report has a checkbox or dropdown that can be used to exclude it from the final report. A focused report will not need to duplicate any of the findings already reported on in a previous comprehensive inspection report. 5