Clinical Governance Practice Self-Assessment Toolkit (CGPSAT)

The Clinical Governance Practice Self-Assessment Toolkit (CGPSAT) is an updated version of the CGPSAT in use since 2015. It applies to all General Practices in Wales, which includes all General Medical Services Contractors (GMS), Alternative Providers of Medical Services (APMS) Practices and General Practices managed by Health Boards.

It has been developed by a Task and Finish Group which included representatives from GPC Wales, The Welsh Government, AMDs in Primary care, Heads of Primary Care, NWSSP, DHCW, Public Health Wales, and the Strategic Programme for Primary Care. Healthcare Inspectorate Wales (HIW) also observed the CGPSAT’s development. A selection of current Practice Managers also provided feedback during the development.

Aims and purpose of the CGPSAT update

This version of CGPSAT has been designed to:

1. Provide a nationally agreed tool for General Practices to reflect on and plan for improvement in their Clinical Governance processes and systems.
2. Provide a tool for Practices to demonstrate compliance with the GMS Contract requirements to ‘have an effective system of clinical governance.’ [GMS The National Health Service (General Medical Services Contracts) (Wales) Regulations 2004 (legislation.gov.uk) Part 9 Miscellaneous Clinical Governance 119].
3. Provide the self-assessment component of the Unified Contract Assurance Framework for GMS Unified contract assurance framework: health boards and practices | GOV.WALES [2^nd October 2023].
4. Provide evidence to external bodies (such as The Welsh Government, Health Boards or Healthcare Inspectorate Wales) seeking assurance of an effective system of clinical governance in General Practices.

This update has been required for the CGPSAT to meet the following challenges:

1. The existing IT platform hosting the CGPSAT was no longer maintained by DHCW, and a new platform had been created (Caforb). This new platform sits on the same platform already in use for the IG Toolkit.
2. The framework applied for the previous CGPSAT was based on the Health and Care Standards 2015, and these standards have now been superseded by the Quality Standards 2023.
3. The GMS Contract, based on the 2004 version, has been updated. The NHS (General Medical Services Contracts) (Wales) Regulations 2023 (2023 Regulations) underpinning the Unified Contract came into effect on 1 October 2023.
4. The role of the CGPSAT in the overall assurance framework has been clarified and published October 2023.
5.  The updated version of the General Medical Council’s Good Medical Practice and six more detailed guidance, which came into effect on the 30 January 2024. Good medical practice 2024 – GMC (gmc-uk.org)

How to use CGPSAT

The key aim of CGPSAT is to provide a standard tool for Practices to use to support active reflection of their Clinical Governance system. It will also provide a standardised tool for recording their Practice plan for improvement of their system of governance.

The Practice must complete all self-rating scales, declarations and plan, and submit the CGPSAT online by 31^st March each year. However, how the Practice chooses to use the CGPSAT to support an effective clinical governance system is the Practice’s individual decision. For example, some Practices may choose to:

• Discuss one chapter at a time at partnership or team meetings (e.g. one chapter a month), or
• choose to share out the chapters according to existing leadership responsibilities within the team, or
• work through the CGPSAT in one sitting.

The online toolkit guidance will allow any team member to see the requirements to meet the standards, review available evidence and educational resources, and read ‘gold standard’ documents submitted by other Practices for comparison and inspiration.

It is not necessary for the Practice to demonstrate completion of Practice Improvement Plan by 31^st March.

• The Assurance Indicators created as part of the Unified Contract published October 2023) include the requirement to complete all parts of the CGPSAT. Failure to complete any or all parts, or deterioration in score, may be viewed as failure to demonstrate an effective system of Clinical Governance, and may be used to trigger a higher degree of scrutiny, such as an in-depth Practice governance visit.
• As part of the Practice visits conducted by Health Boards under the Unified Contract Assurance Framework 2023, Practices may be asked to share some of their Practice Improvement Plan.
• Furthermore, Healthcare Inspectorate Wales (HIW) states on its website, ‘How the Practice Inspect’ GP Practices  GP Practices | Healthcare Inspectorate Wales (hiw.org.uk), that “The Practice also consider information from self-assessment tools such as the Clinical Governance Practice Self-Assessment Toolkit (CGPSAT)“.

What is effective clinical governance? 

This toolkit is primarily to help a Practice team to reflect on their Clinical Governance processes and systems, and plan how they can improve or maintain their performance. Every Practice must have ‘have an effective system of clinical governance.’ This is helpfully defined in the GMS contract as…’a framework through which the contractor endeavours continuously to improve the quality of its services and safeguard high standards of care by creating an environment in which clinical excellence can flourish.’

So to demonstrate compliance with the contract, each Practice must consider…

• Is there an existing framework for this governance topic? What are its components?
• Does the practice ‘endeavour continuously to improve quality of [our] services’?’
• Does the practice ‘safeguard high standards of care?’

Has the practice created an environment in which clinical excellence can flourish?

Is there a framework for this?

The CGPSAT  is based on the Welsh Government’s Duty of Quality Standards 2023 in particular. Furthermore, the CGPSAT is an integral part of the nationally agreed Unified Contract Assurance Framework 2023. Therefore, using the CGPSAT  as the basis of discussions in the practice team, completing all rating scales and entering a Practice Improvement Plan, and then submitting online before 31^st March, is itself evidence that the Practice is consciously participating in a recognised system of clinical governance.

For some sections of Standards, more detailed frameworks may exist, and these may be the ones the Practice uses to position themselves, e.g. PHW Guidance on Infection Control in the Treatment Room. A Framework will often describe the components required to create an effective system (e.g. policy or protocol, checklist, audit, schedules for review, meeting notes, training and induction, nationally agreed pathways and guidance etc.) Consequently, the Practice will need to consider whether the necessary components are adopted in the Practice, are up-to-date and are in use.

Does the Practice ‘endeavour continuously to improve quality of [our] services’?’

The word ‘continuously’ implies a cycle – in which a Practice is iteratively reviewing performance against standards and making changes to see if the outcomes are better than before and repeating the process.

To ‘improve quality of services’ suggests that the Practice must have some way of measuring or establishing how well they are performing, and some process of planning changes to processes, making those changes, and reviewing whether those changes worked. Recognised approaches to improve quality include ‘Plan, Do, Study, Act’ (PDSA) cycles, Quality Improvement (QI) methods, and Significant Event Reviews, with discussion of learning at GMS Collaboratives. All of these methods can be summarised as ‘Plan-Evaluate-Act‘ or ‘React-Evaluate-Act‘.

The word ‘endeavours’ simply reflects that not all genuine attempts to improve processes and outcomes do result in improvements. This is to be expected, and any unsuccessful cycles should be seen as learning opportunities, not failures.  It is not expected that a Practice gets it right every time, but the Practice is expected to learn.

Does the Practice ‘safeguard high standards of care?’

Here the Practice must consider how the team maintains achievement of high standards of care. This may involve recognising standards have been achieved in the first place (and celebrate!), and then systematically monitoring achievement to see if performance dips. An effective system of clinical governance would have triggers in place to detect early warning signs of a reduction of quality service delivery, with agreed processes in place to escalate any concerns, and action plans ready, if needed, to correct the downwards trajectory.

If a Practice believes it has met a standard or matrix at the highest level, it will need to demonstrate how it will ensure its continued delivery. Furthermore, it may wish to share its ‘gold standard’ documents or processes more widely to ensure its learning can inform and support other Practices across Wales.

Has the Practice created an environment in which clinical excellence can flourish?

This question is more difficult to define or answer and depends significantly on how the earlier questions have been answered.

The GMC suggests that “Organisations create an environment which delivers effective clinical governance [by ensuring that the organisation’s leaders have] the knowledge, skills, competences and access to relevant information to enable it to exercise [their] responsibilities effectively “. Those same leaders should provide ‘leadership on promoting the importance of clinical governance’ and ‘actively [encourage] a culture of honesty, learning and improvement.’ Finally, the leaders should monitor “risks associated with clinical governance systems.”

Bottom line for busy Clinicians and Practice Managers?

In short, Practices need to demonstrate and record that they are operating an effective system of clinical governance. This means identifying what frameworks/policies/protocols they are following, recording relevant incidents/activity/outcomes, recording that these measures were evaluated/reported/discussed, and that a decision on future action was made to either improve or maintain quality. Practices are probably already doing much if not all of this – but perhaps have not always formally linked the processes together to make an effective system of clinical governance.

What guidance is in the chapters below?

Each chapter relates to one of the Quality Standards 2023.

• Summary of the national definition of a Quality Standard.
• Description of how this can be applied to General Practices.
• Summary of any changes in relevant matrices since the last edition.
• One or more matrices – specific governance topics that have been identified as worthy of reflection by the Practice. Many are simply a continuation of the matrices used in the CGPSAT 2017. Where possible, existing matrices have been merged, but a few new ones have been added to reflect new clinical challenges, contractual and legislative changes. Matrices have been allocated to the most relevant quality standard to distribute workload evenly, although for many matrices, more than one quality standard may be applicable. Each Matrix contains:
  • A brief description of what is in scope and what is out of scope in the matrix.
  • Examples of the type of relevant evidence to support each self-assessment level.
  • A button to click if the Practice want to share further examples of evidence to this list.

Who should provide the self-rating on behalf of the Practice?

The Practice can choose who completes the self-rating – it can be an individual, a group of professionals (e.g. Practice nursing team or the Partners) or even the whole Practice team.
The online guidance is publicly available and so all members of the team can be encouraged to use it, to guide their engagement with any practice discussions about the CGPSAT and the Quality Standards.

When self-assessing, what should the Practice use as its benchmark for any one matrix? i.e. it’s best example, its worst example or somewhere in between?

The matrices in CGPSAT tend to cover a wider range of topics than in previous versions of CGPSAT. Consequently, it may be found that the practice could self-assess some topics in a matrix at a high level, and others at a lower level. There is no absolute right or wrong with self-rating.

It is advised to consider all the topics within a single matrix and determine what would be the ’typical’ self-rating level for most of them. Use that ‘typical’ self-rated level as the overall self-assessment level the Practice record on the Caforb form for that matrix.

It could therefore be helpful to self-rate the Practice by what usually happens every day, and not focus on that single day something was missed, or that one day everyone had 3 The Weetabix! It is also absolutely OK to consider the same material in more than one matrix, as often there is overlap.

Ultimately, the Practice will need to make a Practice Improvement Plan, and this should focus on the matrices with the lowest self-rating levels, especially any at level 1 or 2.

The Generic Self-Rating Scale

Most matrices use the following self-rating scale:

Level 1:  No assurance. The Practice cannot demonstrate that the Practice have achieved any of the other levels, but the Practice is working towards it.

Level 2: Limited Assurance. The Practice can demonstrate some elements of a process (e.g. a framework, checklist, policy or protocol, staff training, a plan, measures, a named practice leader for the project), but the Practice has not completed a cycle yet.

Level 3: Reasonable Assurance. The Practice can demonstrate that the Practice have completed a learning cycle as a practice and made changes to processes as a result.

Level 4: Substantial Assurance. The Practice can demonstrate that the practice team works with an effective monitoring system, with multiple learning cycles across the breadth of the matrix.

Level 5: Exemplar. The Practice can demonstrate the Practice has an effective monitoring system, with multiple learning cycles, AND the Practice can demonstrate the Practice has discussed the learning with peers outside of the Practice (e.g. at a GMS Collaborative/Cluster meeting, Primary Care Nursing Collaborative, GP Practice Premises Training Assessment etc).

How can the Practice demonstrate learning cycles?

There are several models for demonstrating the Practice has an effective system of clinical governance. The Practice can choose which models to use, and the Practice may wish to use different models for different topics at different times. For example: Significant Event Analysis, Quality Improvement etc.

There are two broad approaches:

1. React- Evaluate-Act
2. Plan – Evaluate -Act

In the first category – React-Evaluate-Act, the practice responds to an incident, complaint or concern, by investigating and discussing the findings, before finally making changes to reduce the risk of a recurrence or maintain high standards.

• For example, a patient complains about a delayed diagnosis, a test result is not read for a week, or the practice is identified as an outlier in prescribing a particular drug.
• A practice with an effective system of clinical governance will have investigated the event, – perhaps using Significant Event Analysis or Review, ‘Putting Things Right’ procedures, Root Cause Analysis etc.  and then discussed the findings at an appropriate level in the Practice such as a partners’ meeting, practice team meeting, practice nurse team meeting, admin team meetings etc).
• Finally, the Practice will have agreed any actions necessary to endeavour to improve compliance or performance, or even maintain performance if the Practice has achieved a high standard of delivery. The Practice would need to consider how the risk of recurrence could be reduced for this patient or staff member now, and for any patient or staff member, now and in the future.  

In the second category – Plan–Evaluate–Act, the Practice has agreed in advance what its official process is for a particular topic, then checked how well it was being applied, and finally made changes to improve or maintain performance.

• For example, it has a repeat prescription ordering policy, infection control policy, a vaccine fridge temperature monitoring book, or antibiotic stewardship policy etc.
• A Practice with an effective system of clinical governance will have evaluated the official process in some way – perhaps using an audit tool, a quality improvement project, a PDSA process, a survey or checklist, and then discussed the findings at the appropriate level of the Practice (such as a partners’ meeting, practice team meeting, practice nurse team meeting, admin team meetings etc).
• Finally, the Practice will have agreed any actions necessary to endeavour to improve compliance or performance, or even maintain performance if the Practice has achieved a high standard of delivery already.

What are the elements of a process and learning cycle?

The elements can be roughly mapped to the three stages of Plan-Evaluate-Act, or the four stages of a PDSA or an Audit cycle. For example:

For Plan-Evaluate-Act, the Practice would be expected to demonstrate at least one piece of evidence to illustrate:

What the Practice had planned to do

• Evidence the Practice have an agreed way of doing things can be shown by having:
  • An agreed up-to-date Practice policy, protocol or written process.
  • Local endorsement of a National or Health Board document e.g. HealthPathway.
• Clearly identified leadership, such as a named lead.
• Evidence that staff are appropriately trained, updated, induction etc.
• Risk Assessment/Register.
• Audit standards to be applied e.g. 95% of people with diabetes to have all 8 essential care review processes checked annually.
• Agreed coding, flagging or standard method of recording activity or outcomes.
• Use of Communication Tools (e.g. Posters, newsletters, texts, emails, directories of service).

What evaluation was undertaken

• Incident records and reports.
• Significant Event Reviews or Root Cause Analysis reports.
• Staff/patient surveys.
• Use of Checklists for completion.
• Inspection Schedules.
• Premises & Equipment Assessments.
• Minutes of Meetings where the topic was discussed.

What actions were agreed as a result

• Learning/Action Plans following SEA reports.
• Reports of Audits/QI projects, with action plans.
• Minutes of Meetings where the topic was discussed, and actions agreed.
• Updating of protocols, policies and procedures to reflect and embed agreed actions.

This list is not exhaustive. Some of the evidence might cover more than one stage e.g. an audit report might cover several stages.

Using this approach helps make it easy to see the minimum three key stages needed to evidence achievement of level 3. It is not necessary to provide all the documents listed in each of the bullet points, but the Practice would be expected to demonstrate at least one piece of evidence from each to illustrate what the practice had planned to do, what evaluation was undertaken, and finally what actions were agreed as a result.

Achievement of level 4 would require dated evidence of at least two learning cycles being undertaken and discussed at a wider practice level.

Evidence for level 5 would require evidence of an external reviewee, peer review, or GMS collaborative/cluster discussion having occurred (e.g. the evidence for level 4, plus the minutes from a GMS Collaborative meeting stating the practice has presented and discussed their learning on a governance topic).

For the React–Evaluate–Act model, it is likely that the investigation of the event would include a description of the event triggering the investigation. So, a Significant Event Review, Root Cause Analysis, or Putting things Right complaint response letter will probably cover both the ‘react’ and ‘evaluate’ elements. There would also need to be a clear statement or recording of any actions to be undertaken after the report had been discussed at the appropriate level of the practice.

More detailed information on suitable evidence relating to each governance matrix will be found in the related sections of the CGPSAT online guidance.

Who should provide the self-declaration on behalf of the Practice?

The self-declaration is where the Practice signs that the entries are true reflection of the Practice’s performance at that time. This should be signed by or with the agreement of the Partner or Manager responsible for clinical governance in the Practice.

Practice Improvement Plan

Given the self-rating scale is based on the degree to which the Practice can provide assurance that it is working within a system of effective clinical governance, it is important that the Practice is able to demonstrate it is endeavouring to improve its services. The Practice must therefore agree a single Practice Improvement Plan to cover all the 12 Quality Standards 2023. However, the Practice does not need to have actions for every matrix, standard or chapter, but just the areas the Practice consider to be a priority for the year ahead.

A templated page for the Practice Improvement Plan is found at the end of the CGPSAT Form.

It is for the Practice to decide which actions in the plan are a priority, and should base this on its self-rating decisions, workforce and population challenges. However, it is expected, where no assurance (Level 1) or limited assurance (Level 2) is recorded against a matrix, the Practice would aim to address these matrices first before improving a matrix already at a higher level.

Frequently asked questions

How often does each learning cycle need to occur?
This depends on the topic addressed by the learning cycle. Some are higher risk and need constant vigilance occurring multiple times a year (e.g. Infection control), others might not need such close monitoring and could occur every couple of years or so (e.g. application of an inclusion policy).

How detailed must a Practice Improvement Plan be?
The plan is for the Practice to use to make its system of clinical governance more effective. Therefore, the plan must be detailed enough for the Practice’s team to know what it needs to do to ‘endeavour continuously to improve quality of [our] services.’ Failure to progress and improve self-rating levels over time would suggest the self-rating or planning processes were ineffective.

What is the minimum level a Practice must achieve to ‘pass’?
There is no absolute minimum ‘pass mark’ as such. What is absolute, is the Practice must demonstrate that it endeavours continuously to improve quality of its services. This can be achieved by noting evidence of all the elements of a learning cycle and creating a credible plan to move from a lower self-rating level to a higher one or demonstrating that systems are in place to maintain a high one.

How much evidence of the elements of a learning cycle do the Practice need to provide?
As a minimum, to achieve level 2, a Practice must be able to demonstrate evidence for some of the stages of a learning cycle – Plan-Evaluate–Act or React-Evaluate-Act.
For level 3, a Practice must be able to demonstrate evidence for all stages of a learning cycle. For example, a Practice may have achieved an improvement in quality, through a one-off project undertaken by one clinician to look at prescribing of statins in heart disease.

For levels 4 and 5, the same evidence is required as for level 3, but repeated to show more than one cycle. This evidence must be dated to show which cycles it relates to. Furthermore, Level 4 attainment will reflect that such a project has become mainstream for the Practice, involving the whole team, and has become embedded in the Practice’s culture, rather than just one clinician repeating the same project without sharing with others. It is for the leadership of the Practice to ensure that this wider team involvement is occurring.
Level 5 requires the additional evidence from external or peer review, from outside of the Practice.

If a doctor has done an audit or quality improvement project for their appraisal, can the Practice use that as evidence?
If a GP has performed an audit or quality improvement project, and submitted this as an appraisal entry, this would only allow the practice to self-assess as level 3 if the findings of the learning cycle had been shared within the practice and changes implemented across the practice. An audit where the results have not been shared within the practice would not qualify as level 3.

An ”8-point” audit, where two learning cycles have been completed, is usually the minimum accepted standard for GP appraisals. It is therefore really helpful for CGPSAT as it would automatically count as evidence for self-rating at level 4 if the findings had been shared with the wider practice team and actions agreed.

How old can evidence be and still be used?
The Practice must demonstrate that it ‘endeavours continuously to improve the quality of its services and safeguard high standards of care ‘.   ‘Continuously’ can be defined as ‘without interruption or gaps’ or ‘repeatedly without exceptions or reversals.’ Whilst there is no absolute minimum frequency to update evidence, it is essential that the age or currency of the evidence used to demonstrate a learning cycle is considered.  For example:  using a Practice policy that has not been reviewed or updated for 5 years as evidence for the ‘plan’ stage of a learning cycle is likely to result in a Practice Improvement Plan that includes an action to ‘update the Practice policy’.

Do the Practice need to do Learning Cycles for every matrix?
The Practice must demonstrate how it is operating an “effective system of clinical governance.”  The matrices are key topics that Practices should aim to consider, and demonstrate, how it is learning from incidents and monitoring of its performance in that topic. If a Practice is not able to demonstrate a completed cycle or cycles, then it will select Level 1 or 2 as its self-rating.

What about learning from individual incidents or SEAs? How can these be ‘learning cycles’?
A well-executed Significant Event Analysis (SEA) or Review is certainly a learning process that can used as evidence in CGPSAT. An SEA would typically involve a few members of the team.

For a ‘Plan,’ Practices would need to have an agreed way of responding to incidents, complaints, and concerns, such as Practice procedures or protocols based on ‘Putting Things Right.’ Consider how a team member notifies the Practice Manager or a Partner, or records that an incident has occurred; do they use DATIX RL, a paper form or electronic message or some other process? That agreed standard process should be part of a written Practice policy or protocol for responding to incidents.
For ‘Do,’ Practices would demonstrate agreed methods of investigating incidents in a proportionate manner, such as through appointing an Investigating Officer to interview staff or patients concerned. Evidence of this would include the investigation report in an incident or notes from interviews.
For ‘Study,’ a Practice would perform significant event reviews, or minute the discussion of an investigation report at a team or Partners’ meeting.
For ‘Act,’ the Practice would document any changes agreed at such discussions, such as agreement to apologise to the complainant, a change a Practice policy or a decision to maintain current processes.

This is likely to be enough to justify a level 3 for some matrices. However, if a practice is going to aim for level 4, a more embedded and planned approach would be required which would typically require more than repeated SEAs (which would be by their very nature one-off events prompting reactive analysis/study/action). For example, how would the Practice demonstrate that not only achieved learning from the first incident result in planned changes for this one patient, but for every patient in a similar position, and for every similar patient every time?

Another way to use SEAs to demonstrate effective governance at level 4, is to periodically review all the incidents of one type and look for themes. So, if the Practices already achieves level 3 through effective use of SEAs, then a further reflection and discussion of all incidents in the last 3 or 6 months or so, may identify common themes. This could be done as part of an existing meeting or a separate meeting itself. The discussion should be documented as should be any decisions on actions.

Do I need to upload documents as evidence for every matrix?
No. Nobody will look at them. However, the Practice ask the Practice to record the document name and/or location of each piece of evidence on Caforb so that they have an auditable record for themselves. The Practice may be asked about a policy or protocol or evidence during a Practice visit by the Health Board or HIW, and it just saves time and embarrassment if the Practice can see what the Practice was thinking about several months beforehand.

The one exception is when the Practice choose to upload a document because the Practice believe it is worthy of sharing with a wider audience. For example, a Practice policy, protocol or report that the Practice think is robust and useful and deserves wider recognition. In this case the Practice can share it using the upload button in each chapter of the Caforb (DHCW’s Primary Care Team). It will be forwarded to the editorial team of Primary Care One (GPCW, Health Board, WG and PHW) to consider for publication on the CGPSAT website. Please do not include any patient or staff identifiable data before sending. This is an opportunity to get the Practice team’s hard work and talent recognised and share the learning!

Why do I have to sign a self-declaration at the end of each chapter?
Our intention is to set up the CGPSAT form so that evidence and self-ratings from the previous year are visible the following year, to minimise repetitive data entry and bureaucracy. To ensure that CGPSAT remains a valid and credible tool for assuring clinical governance, the self-declaration at the end of each chapter creates a ‘pause’ and prompts reflection on each of the Quality Standards 2023, to make sure none are missed.

Does presenting at a Collaborative meeting automatically qualify for level 5?
No. Whilst the GMS or Professional Nursing Collaborative would certainly qualify as an external or peer review audience for the purposes of Level 5, the Practice would still need to be able to demonstrate it had also met the criteria for level 4 with evidence of multiple learning cycles.

The GMS Contract does require some Practice work to be discussed at the GMS Collaborative, such as QI Projects or incidents/complaints. Again, the Practice would still need to be able to demonstrate it had also met the criteria for level 4 with evidence of multiple learning cycles in order to use this discussion as evidence for level 5. A good QI project presentation will demonstrate multiple learning cycles had occurred within the project; in which case it would qualify for level 5 after the presentation at the GMS collaborative.

What is the difference between elements, a process, and a system?
Elements of a learning cycle are the individual separate items of evidence that demonstrate a particular stage of a learning cycle have occurred. For example: a Practice policy for Infection Control demonstrates a Practice has a considered approach to how this topic will be managed. However, it does not mean that anybody has actually read it, or acted on it, or whether the contents are even working.

A process is where elements have been linked together to form a rational approach to how the Practice deals with a quality or safety issue. For example: a Practice policy or contract for cleaning public areas may state what needs to be done [Plan]. A checklist, based on that policy or contract, may describe how adherence to the policy is assessed. However, somebody still needs to complete the checklist [Do].  A meeting with the cleaner or company may occur every quarter to discuss cleaning performance, and whether this performance is acceptable or needs improvement is documented [Study]. Any agreed actions need to be documented too, perhaps changing the contract or the Practice policy or checklist [Act].

Achieving some of the above stages would suggest a process was in place (level 2).
Achievement of all four stages (Plan, Do, Study, act) indicates a single learning cycle has occurred (level 3).
Repeating the learning cycle would suggest that the processes and learning cycles had been systematised: creating a system of learning (Level 4).
If this System of learning had then been peer or externally reviewed, it would suggest it was robust and effective system of clinical governance (level 5).

Can the Practice just copy over the levels from the last CGPSAT the Practice completed?
No. The levels in the self-rating scale used in this new version of CGPSAT do not map directly to the old scales. The matrices used have also changed significantly, with some new ones, and some being merged or deleted.

Isn’t this just a lot of work for Practice Managers who are already very busy?
The Practice have tried hard to update the CGPSAT so that the new version requires less form-filling, more support and access to resources for learning, easier to delegate the work across the whole Practice team, whilst still being a valid and reliable tool for assurance. One key measure of success is whether Practices are able to use their existing in-house processes to evidence their achievement when self-rating. The Practice encourage Practices to use this as a useful, working tool in order to assess, improve and demonstrate their achievements.

Definition

“Our health care system has visible and focused leadership at all levels, with its activities driven by the organisations’ vision and values for quality. Our leaders and managers take a long-term, stakeholder-centric view to develop a clear organisational vision. They have the appropriate skills and capacity to create the conditions for a functioning quality management system. We ensure our governance, leadership and accountability is effective in sustainably delivering care.” – Duty of Quality Statutory Guidance 2023

How this relates to General Medical Practice

• General Medical Practices must have leaders and managers who are present and dedicated to delivering the high-quality services needed for the population it serves.
• Practice leaders and managers consult with their patients and staff to determine those needs and aspirations, before setting out the long-term plans of the practice.
• Practice leaders and managers acquire the skills to create the environment in which all staff can flourish, within a quality management system.
• Practice leaders are accountable and will ensure services are sustainable with excellent systems of governance.

List of matrices in this chapter

• 1.1    Leading the Planning of Services for Our Populations  
• 1.2    Leading the Multi-Professional Team to Deliver Services

Changes to matrices from last CGPSAT (where relevant) 2015 Standard: Governance, Leadership & Accountability and its matrices has been distributed across several new chapters including Leadership and Safe.

“Our healthcare system recruits, retains, develops and extends roles to ensure we have enough, confident people with the right knowledge and skills available at the right time to deliver safe care. We value our people and the commitment and resilience they demonstrate in the care they provide. We care about their wellbeing, protect their rights and support them to feel well and happy at work; and provide them with the tools, systems and environment to work safely and effectively. Our workforce planning focuses on investing in our people and nurturing, growing and transforming our workforce to create a sustainable workforce for the future.”  – Duty of Quality Statutory Guidance 2023

How this relates to General Practice 

• Practices should recruit the staff they need to provide the services they are contracted to provide by the Health Board.
• By ensuring the Practice uses fair and legal recruitment processes, it is more likely to develop a team of motivated, committed and skilled professionals.
• With such an investment in staff, the Practice must train their staff from the start of employment and help them maintain and update their skills throughout their working life.
• General Practice is a rapidly evolving clinical specialty, and new challenges emerge frequently that require new skills and adjustments to working practices.
• When Practices undergo significant change, such as through mergers or leadership changes, it is important to continue to support team members through the period of change.

List of matrices in this chapter 

• 2.1 Recruitment and Retention of Staff 
• 2.2 Staff Health & Wellbeing  

Changes to matrices from last CGPSAT (where relevant)

The Blood Borne Viruses matrix has been merged with the Infection Control matrix and moved to the Safe chapter.

The Competency and Skills matrix has been merged with the Workforce training because of the significant overlap and moved to the Leadership Chapter.

Our healthcare system creates the right climate and culture to nurture and encourage quality and system safety, valuing people in a supportive, collaborative and inclusive workplace so that our people feel psychologically safe to raise concerns and try out new ideas and approaches. Relationships within teams and with the people we serve are effective and based on transparency, accountability, ethical behaviour, trust and just culture, where people can thrive.” – Duty of Quality Statutory Guidance 2023

How this relates to General Medical Services 

• The practice has the ‘Just Culture’ needed to systematise quality and safety, yet value staff.
• Staff feel able to innovate.
• Relationships between team members and with our populations are based on openness, accountability and ethical behaviour.

List of matrices in this chapter 

• 3.1 Managing Concerns Raised by Patients and their Representatives.    
• 3.2 Managing Concerns Raised by Staff (including Whistleblowing and Duty of Candour) 

Changes to matrices from last CGPSAT (where relevant) 

Culture was not specifically mentioned in the 2015 Health and Care Standards.

Since the last edition the new Duty of Organisational Candour legislation, and the Guardian Service for raising concerns, have been introduced across Wales. The Community Heath Councils have been replaced by Llais Wales. Visit the Llais Wales website. 

“Our healthcare system ensures information is available and shared appropriately for all who need it. We turn data to knowledge by triangulating quantitative and qualitative performance, experience and outcome measures to understand the quality of services, efficacy of improvement work and impact of decisions made. We monitor, report and escalate indicators through our governance structures to ensure that appropriate action is taken at every level in terms of learning, improvement and accountability.” – Duty of Quality Statutory Guidance 2023

How this relates to General Medical Services 

• General Medical Services must have processes that accurately code incoming information into standard formats using the lifelong computer record.
• Quality of services can be improved through the efficient and effective management of Patient Safety Incidents and concerns.
• Practices use data from a variety of sources to develop knowledge of how their services are performing.

List of matrices in this chapter 

• 4.1 Managing Information 

Changes to matrices from last CGPSAT (where relevant) 

The 2015 Standard ‘Information Management & Communications Technology’ and its matrices of Information governance assurance, and Record Keeping have been included. However, the Information Governance Toolkit is the formal method of assurance for the data protection and GDPR aspects of persona information management in GMS

The 2025 matrices of ‘Standardised data entry’ and ‘Information for patients’ is included in this matrix. However, ‘Consent for clinical examination & treatment’ is dealt with elsewhere.

The broad topic of ‘Data to Knowledge’ is a key principle for all chapters in this updated CGPSAT, as practices can self-rate according to how well they use data to knowledge to create effective learning systems based on quantitative and qualitative evidence.

“Our healthcare system is a high quality, highly reliable and safe system that avoids preventable harm, maximising the things that go right and learning from when things go wrong to prevent them occurring again. People’s health, safety and welfare are actively promoted and protected; risks are identified and monitored and where possible, risks to safety are reduced or prevented.  We promote and protect the wellbeing, and safety of children and adults who become vulnerable or at risk at any time.  Where children or adults may be experiencing or are at risk of abuse or neglect, we take appropriate, timely action and report concerns.” – Duty of Quality Statutory Guidance 2023

How this relates to General Medical Services 

• General Practices are contractually required to operate a system of effective clinical governance, which is a framework through which the contractor endeavours continuously to improve the quality of its services and safeguard high standards of care by creating an environment in which clinical excellence can flourish.
• General Practices are contractually required to carry out its obligations under the contract with reasonable care and skill and consider the application of national condition pathways relevant for each patient.
• General Practices are contractually required to engage in discussion and peer review of clinical incidents that have occurred within the practice and local services and co-operate with the Local Health Board in relation to the Local Health Board’s patient safety functions.
• General Practice must act to safeguard children and vulnerable adults.

List of matrices in this chapter 

• 5.1 Prescription Administration System
• 5.2 Infection Control
• 5.3 Managing Emergencies
• 5.4 Safeguarding
• 5.5 Patient Safety Alerts and Prescribing Safety

Changes to matrices from last CGPSAT (where relevant) 

The 2015 standard ‘Managing Risk & Promoting Health & Safety’ had multiple matrices many of which have been incorporated into this chapter. Other 2015 standards transferred to this chapter include Safeguarding Children & Safeguarding Adults at Risk,  Medical Devices, Equipment and Diagnostic Systems, and Safe & Clinically Effective Care.

“Our healthcare system ensures people have access to the high-quality advice, guidance and care they need quickly and easily, in the right place, first time. We care for those with the greatest health need first, and where treatment is identified as necessary, we treat people based on their identified and agreed clinical priority.” – Duty of Quality Statutory Guidance 2023

How this relates to General Medical Services 

• The following two paragraphs are based on the description of Unified Services in the GMS contract (2023);
• General Practice ensures patients are able to access primary medical services when they are or believe themselves to be—

(a) ill, with conditions from which recovery is generally expected,

(b) terminally ill, or

(c) suffering from chronic disease,

delivered in the manner determined by the contractor’s practice after consideration of relevant nationally agreed clinical guidance or pathways and in discussion with the patient.

• General practice management includes offering consultation and, where appropriate, physical examination for the purpose of identifying the need, if any, for treatment or further investigation, and the making available of such treatment or further investigation as is necessary and appropriate, including the referral of the patient for other services and liaison with other health care professionals involved in the patient’s treatment and care.

List of matrices in this chapter 

• 6.1 Access to General Medical Services   
• 6.2 Time to test, diagnose and refer

Changes to matrices from last CGPSAT (where relevant)

The 2015 Standard ‘Timely Access’ and its matrices ‘Access to consultations’ and ‘Referrals at practice level’ have been included in this chapter.

“Our healthcare system ensures decision-making, care and treatment reflects evidence-based best practice, to ensure that people receive the right care to achieve the optimal and possible outcomes that matter to them. We design transformative, evidenced-based, whole-of-life pathways that cover prevention, care and treatment, rehabilitation and embed these into local service delivery.” – Duty of Quality Statutory Guidance 2023

How this relates to General Medical Services 

• General Practices are contractually required to provide services required for the management of patients who are or believe themselves to be— (a) ill, with conditions from which recovery is generally expected, (b) terminally ill, or (c) suffering from chronic disease, delivered in the manner determined by the contractor’s practice after consideration of relevant nationally agreed clinical guidance or pathways and in discussion with the patient.
• “Management” includes (a) offering consultation and, where appropriate, physical examination for the purpose of identifying the need, if any, for treatment or further investigation, and (b) the making available of such treatment or further investigation as is necessary and appropriate, including the referral of the patient for other services, and liaison with other health care professionals involved in the patient’s treatment and care.
• Antimicrobial Stewardship is considered to be an important topic worthy of its own matrix, as the future effectiveness of all antibiotics is in jeopardy due to growing antimicrobial resistance.

List of matrices in this chapter 

• 7.1 Using Nationally Agreed Guidance and Clinical Pathways  
• 7.2 Antimicrobial Stewardship

Changes to matrices from last CGPSAT (where relevant) 

The 2015 standard “Safe & Clinically Effective Care” has been subsumed into other more relevant chapters.

The 2015 matrix ‘Anti-microbial stewardship’ has been preserved as a separate matrix and moved to this chapter.

The 2023 Unified GMS Contract contains new contractual requirements on practices to use nationally agreed guidance and clinical pathways.

“Our health care system takes a Value-Based approach to improve outcomes that matter most to people in a way that is as sustainable as possible and avoids waste.  We make the most effective use of resources to achieve best value in an efficient way.  We only do what is needed and undertake treatments that ensure any interventions represent the best value that will improve outcomes for people.” – Duty of Quality Statutory Guidance 2023

How this relates to General Medical Services 

• General Practices must balance the competing pressures to manage patients in a way that meets their individual needs, with the wider duty to conserve resources for their registered population, so that those in the greatest need are prioritised.
• These principles are exemplified by Prudent Healthcare
• General Practices are also contractually required to avoid prescribing drugs, appliances and treatments whose cost are excessive compared to what a patient requires.

List of matrices in this chapter 

• 8.1 Value-Based Healthcare 

Changes to matrices from last CGPSAT (where relevant) 

Efficient Care was not mentioned in the 2015 CGPSAT and neither was Value-Based Health Care.

“Our health care system provides everyone with an equal opportunity to attain their full potential for a healthy life which does not vary in quality by organisation providing care, location where care is delivered or personal characteristics (such as age, gender, sexual orientation, race, language preference, disability, religion or beliefs, socio-economic status or political affiliation). We embed equality and human rights in our health care system.” – Duty of Quality Statutory Guidance 2023

How this relates to General Medical Services 

• General Practices already have a contractual requirement to not discriminate against patients on the grounds of race, social class, age, religion or belief, sexual orientation, appearance, gender or gender reassignment, marriage or civil partnership, pregnancy or maternity, disability or medical condition, when registering or removing patients.
• As employers, Practices are already required to apply the Equality Act 2010 and not discriminate in the workplace.
• As advocates for its registered population and its staff, Practices are able to make an ethical case, business case, economic case and legal case for practices to pay attention to equality and human rights.
• Practices have specific Welsh Language responsibilities to deliver in the GMS Unified Contract (2023) and also under “More than Just Words” (Welsh Government, 2022).

List of matrices in this chapter 

• 9.1 Equality, Inclusion and Welsh Language 

Changes to matrices from last CGPSAT (where relevant) 

The 2015 standard ‘People’s Rights’ has been included in this chapter.

The Welsh language was not an identified matrix in 2025

“Our health care system meets people’s needs and ensures that their preferences, needs and values guide decision-making that is made in partnership between individuals and the workforce. We care about the wellbeing of individuals, their families, carers and our staff. We ensure that everyone is always treated with kindness, empathy and compassion and we respect their privacy, dignity and human rights. We are committed to working better together to put people and their families at the centre of decisions, seeing them as experts working alongside professionals to get the best outcome and experience.” – Duty of Quality Statutory Guidance 2023

How this relates to General Medical Services 

• General practices are contractually obliged to manage a patient delivered in the manner determined by the contractor’s practice after consideration of relevant nationally agreed clinical guidance or pathways and in discussion with the patient.
• General Practices ensure best practice in consent before any examination or treatment is performed.
• General Practices ensure best practice in offering and providing chaperones is followed.
• General Practices are contractually required to ensure that the premises used for the provision of services are suitable for the delivery of those services, and sufficient to meet the reasonable needs of the contractor’s patients.

List of matrices in this chapter 

• 10.1 Patients’ involvement in their own care (including Consent & Chaperones)
• 10.2 Practice Premises  

Changes to matrices from last CGPSAT (where relevant) 

The 2015 standard “Listening and Learning from Feedback” has been mapped in part to this chapter to include the matrix “Patient & User feedback”. However, ‘Raising Concerns’ and ‘Managing Concerns’ have been moved to Chapter 3.

The 2015 ‘Dignified Care’ standard has been included in this chapter, including chaperones.

The 2015 standard “Health Promotion, Protection & Improvement” has been included as far as its matrix ‘Patients’ Involvement in their own care – shared decision making’.

“Our healthcare system ensures safety in healthcare goes beyond individual patient safety. We will look within and beyond our organisational boundaries to learn how we can continually, reliably and sustainably meet the evolving needs of people. We will strengthen relationships and work with all of our partners to achieve good outcomes. Our policies incorporate the broader ambitions within the seven well-being goals and five ways of working in the Well-being of Future Generations Act.” – Duty of Quality Statutory Guidance 2023

How this relates to General Medical Services 

• General Practices already have a contractual ‘Duty of Cooperation with other practices ‘, a ‘Duty of co-operation in relation to out of hours services’, and a ‘’Duty of co-operation: cluster working’.
• General Practices also have a contractual obligation to work within their GMS Collaborative,  to  contribute relevant information, including demand and capacity planning, to the cluster

Integrated Medium Term Plan and demonstrate how they have engaged in planning and delivery of local services. Specifically, they must demonstrate evidence of wide partnership, multi-professional/multi-agency working, and development of integrated services, and contribute to delivering specific cluster-determined outcomes,.

• Nationally agreed guidance and clinical pathways are best devised with primary care and secondary care in the room. Whether the subject matter is urgent  or emergency care, or planned care,  the contractual requirement for all practices to consider these clinical pathways in every consultation does mean that General Practices are able to work across boundaries if adequate resources are provided.
• General Practices operate within a system that is directed by the Wellbeing of Future Generations Act. An practical illustration of this is the ‘Greener Primary Care project’.

List of matrices in this chapter 

• 11.1 Working with Our Partners 

Changes to matrices from last CGPSAT (where relevant) 

There was no specific reference to ‘Whole-System Approach’ in the 2015 standards or CGPSAT. Some aspects of a mixture of matrices have been brought into this chapter.

“Our healthcare system creates the conditions and capacity for an organisation and system-wide approach to continuous learning, quality improvement and innovation, which it actively promotes. We use new knowledge to influence improvements in practice and to inform our decision-making. We ensure our learning and improvement activity is linked to our strategic vision to deliver transformational, organisation-wide change. We commit to participating in research because research-active organisations provide improved quality of care and outcomes for people.” – Duty of Quality Statutory Guidance 2023

How this relates to General Medical Services 

• General Practices have a contractual obligation to have in place an effective system of clinical governance, defined as a framework through which the contractor endeavours continuously to improve the quality of its services and safeguard high standards of care by creating an environment in which clinical excellence can flourish. The CGPSAT is considered to be a component of this framework.
• The CGPSAT guidance pages on PC-One will be updated continually as new guidance and learning is published, so practices can rely on the CGPSAT pages to act as a key source of up-to-date guidance.
• General Practices have an extensive history in primary care research and this needs to continue and expand.

List of matrices in this chapter

• 12.1 Research Governance 
• 12.2 Learning from using the CGPSAT 

Changes to matrices from last CGPSAT (where relevant) 

Research was not explicitly mentioned as a standard or matrix in 2015.

Learning from using the CGPSAT is a new matrix designed to help every practice to reflect on how it has used this toolkit, embed it as business as usual, and plan how will it deal with it in future to help meet the practice improvement plan.

Every Practice must have one improvement plan document for this CGPSAT.

It can be as short or as long, or as simple or as complex, as needed. Having reflected on how the practice rates against each of the CGPSAT matrices, and therefore the Duty of Quality Standards 2023, the practice should now be in a good position to identify what is important to improve quality or maintain high standards, and what requires urgent action.

The Practice Improvement Plan is primarily for the benefit of the practice.  There is no expectation that every Practice Improvement Plan will be read by the Health Board.

Practices are asked to upload it using Caforb so that there is a documented record of having one and it is available to the Health Board should they choose to discuss it with the practice. However, Practices may be asked to produce it at a later date by Health Inspectorate Wales (HIW), or by a Health Board Primary Care Management Team, at a practice governance visit. They may wish to ask how it is progressing and how the practice evidenced the self-rating level for a matrix.

The plan must be uploaded as a document file.

The format the plan can take is at the discretion of the practice: it could be a bespoke version, one of the examples below, or one found elsewhere.

• Plan on Page (Word Document)
• Change Control Template (Excel Spreadsheet)

The practice action plan must be uploaded, and the final form submission button clicked, by the 31st March. Please note, this does not mean there is a requirement to have completed the actions noted on the action plan by 31st March, just that they should be noted on the submitted plan.

1. Is the log-in the same as the previous CGPSAT?

No. The previous IT platform has been withdrawn and replaced by Caforb (the same IT platform as the IG Toolkit). Users will need to access Caforb and register for the CGPSAT ‘team’. Registration is a one off requirement as all future CGPSAT submissions will be managed through this log-in.

2. Is the link for the CGPSAT still accessible via the Surgery Self-Service Portal?

The CGPSAT submission form can be accessed in two ways; The link from the CGPSAT webpage hosted on Primary Care One: Access  the CGPSAT form here and the link on the Surgery Self-Service Portal which has been updated to direct users to the new platform also.

Each chapter in the submission form includes a hyperlink to the website chapter concerned, this is to support easy navigation between the form and the guidance on completing it.

3. I am having issues logging in or registering for the first time. When I log on all I can see is the IG toolkit?

Caforb hosts various teams. In order to access the CGPSAT team click on the “DHCW” icon at the top right of the screen then click on “Register” and choose the CGPSAT team registration form from the list.

If not already registered, then click here to access the CGPSAT registration page. 

If still experiencing log in issues, please email [email protected] and title the query ‘CGPSAT registration issue’. Screen shots and specific detail of the issue being experienced is encouraged.

4. Can multiple users from same practice be registered?

Multiple users (with different Portal accounts) can complete a form together. In fact it is encouraged, as it is a way to delegate and therefore share the responsibility for completing the submission. However, only one user can make changes to a Section at a time.

Practices may wish to encourage practice teams to include one or two of the chapters as agenda items at regular team meetings, so the workload can be spread throughout the year.

5. My organisation is coming up as ‘invalid organisation has been selected’ and my practice has a triangle next to it and won’t let me submit a registration request. What should I do?

A triangle next to a practice name indicates there is already a user registered. Additional users can be added manually, such requests need to be submitted by email to nwssp.pcs-gms&[email protected]

6. How long does it take to get access granted and will I get a notification once approved?

The request is sent to the primary care services web team in Shared Services and (dependent on time of day submitted) access will be granted without much delay. You should receive an email after your request has been approved.

7. I have lost or forgotten my CGPSAT password. How do I get it reset?

Users can submit password reset requests to the Caforb team by emailing [email protected]

8. I am experiencing technical issues with CGPSAT that are not listed here. Who do I contact?

Users can submit requests for technical support in relation to Caforb by email [email protected]. Screen shots and specific detail of the issue being experienced is encouraged.

9. Who do I contact regarding content queries for the CGPSAT Toolkit Guidance?

Queries submitted via Primary Care One will be directed to the content curators for review and feedback.

10. Who do I contact regarding any other CGPSAT related issues I may be having that are not listed here?

Queries submitted via Primary Care One will be directed to the most appropriate person for review and feedback.

11. GPs could be asked to look at the indicators in the old CGSPAT. The new CGPSAT involves reading and building plans; which could lead to more work for me, the Practice Manager, as the rest of the practice may not have time to do this, how can this be mitigated?

The new CGPSAT is designed to allow for the delegation of matrices to different team members and support discussions in existing team meetings. For example: chapters can be delegated to others in the practice who may be more knowledgeable about that subject area, thus freeing up the Practice Manager from the responsibility for completing the whole submission themselves.

Not everything can or should need a plan – encourage the team to identify what needs the greatest improvement rather than try to tackle everything and fail. An effective system of clinical governance should be business as usual, so working with or tweaking existing practice processes.

12. Do Practices have to upload evidence? E.g. If wanting to mark as level 3 or 4 is evidence of having completed a PDSA or clinical audit mandatory?

There is no mandatory requirement to submit evidence. However Practices should be able to provide evidence upon request if asked why they self-rated at a specific level. The Caforb form has a free text box for each matrix so the name/ location of any documents used to justify the self-rating can be recorded. This is simply an aide-memoire so that if asked, it can be  referred back to. This will be helpful if responsibility for completing the CGPSAT has been delegated to several team members. The free text box contents will be included in the printout  of the CGPSAT summary should the user choose to print it out, to  keep a hard copy of the submission.

13. Is there a template for a Practice Development Plan available for adaptation to suit individual practice needs?

Yes, example templates are available on the CGPSAT toolkit page under chapter 13. These can be used as they are or adapted to suit the practice needs. Alternatively practices can use a preferred template if they have one.

14. Will we have feedback on what we have submitted?

The CGPSAT is essentially a self-rating tool that has been designed to support and guide practice teams to develop an effective system of clinical governance. In its first year, practices are only required to submit a rating for all the matrices, together with a single practice development plan, by 31st March. If feedback is desired, then practices are free to ask other practices in the GMS or Primary Care Nursing or AHP  collaborative to give feedback on policies/processes. This has the advantage that if a practice has already achieved level 4 (significant assurance), then opening the practice processes up to review by the collaborative and receiving feedback, could qualify  level 5 (exemplar). Alternatively, if a practice receives a governance visit from the Health Board, under the Unified Contract Assurance Framework, then feedback can be asked for from the visiting team.

15. Will HIW (Health inspectorate Wales) ask for practice policies if they are cited on CGPSAT as evidence?

HIW may ask practices how they came to select a specific self-rating level, and it would be helpful to refer to the relevant documentation or have it readily available on screen for this purpose. This would also apply to Health Boards at a governance visit.

16. Is there an expectation for actions noted in the practice development plans to be completed annually? and will this be checked?

Clinical Governance is about continually learning and improving or maintaining high standards. Some actions to improve will take longer than a year to completed, some will be completed in days. CGPSAT requires just one practice development plan to be submitted by 31st March. Whilst there is no expectation that every practice development plan will be reviewed by a Health Board, if a practice receives a governance visit under the Unified Contract Assurance Framework, then review of the content of and progress with the practice development plan is likely to be a focus of discussions. This is the opportunity for the practice team to demonstrate how they truly have a system of clinical governance that is truly effective, always improving quality or maintaining high standards.

17. Are there plans to link practice performance on CGPSAT to the tiered QA visits linked to the Contract Assurance Framework?

Failure to submit a self-rating scale or a Practice Development Plan is already a trigger indicator in the Unified Contract Assurance Framework. There is no requirement to achieve a minimum level for all matrices at this stage. However, it is a GMS contractual requirement to endeavour to continually improve quality and maintain high standards. We therefore advise that practice development plans reflect those topics/matrices where the self-rating level is 1 or 2, before trying to increase the self-ratings at level 4 or 5.

18. Where would a copy of the last CGPSAT submission be available from?

CGPSAT forms submitted prior to May 2024 are still accessible to anyone who has used the Formbuilder system to create them, and those designated as Form Reporters/ Administrators. Simply visit https://phw-forms.wales.nhs.uk and log in using the Formbuilder log in details to retrieve a copy. Note submissions prior to May 2024 will not be comparable with later submission as the questions have all changed.

From May 2024 any new CGPSAT forms will be submitted using the Caforb system and users can go to the “Reports” page on Caforb and see the list of submissions made for that practice.

19. Who would I contact to advise of a Practice merger or similar reconfiguration?

As Caforb in administrated by the NHS Wales Shared Services Partnership any Practice mergers or reconfigurations will automatically be applied to CGPSAT.

20. Can an already submitted CGPSAT form be re-opened?

Additional submissions can be granted for the current submission period which would allow Practices to resubmit in the current cycle. If submitted in error, then a request for technical support can be raised via the Caforb team by email to: [email protected]