Rebuilding a GP compliance system in two weeks

Executive summary

In May 2026, an independent scoping exercise was commissioned at Haughton Thornley Medical Centres following concerns regarding CQC preparedness and the loss of significant Quality and Outcomes Framework (QOF) income.

Although the practice had previously achieved an Outstanding CQC rating in 2018, the review revealed that many of the underlying governance and compliance systems had deteriorated over the preceding few years. While clinical care remained strong, the infrastructure supporting quality assurance, governance, staff training and regulatory compliance had fallen behind.

The practice manager resigned the day after the initial assessment, leaving the practice without leadership for an already complex recovery programme.

Using the everythingCQC Quality Improvement System, Sansos implemented a complete replacement compliance infrastructure based on standardised quality management principles, enabling the practice to move from a position of significant regulatory risk to being substantially CQC-ready within two weeks. everythingCQC is a CQC-branded service provided by X-Genics.

This was as much a rebuilding of leadership, teamwork and culture as it was of systems, and the work continues: a second phase is now underway to embed these changes as lasting, everyday practice.

Background

This project formed part of a wider Quality Improvement Programme with successful pilot projects across Greater Manchester.

Previous programmes had demonstrated that compliance could be transformed by replacing fragmented document management with integrated quality systems.

Earlier successes included:

• Walkden Medical Practice - Transformation of a practice identified by CQC as having a toxic culture into one where inspectors subsequently verified a positive, self-responsible quality culture.
• Walkden Primary Care Network - More than 100 members of staff across multiple practices were prepared for CQC interviews in less than one hour per practice through structured quality systems and simplified staff guidance.

The learning from these projects formed the methodology used at Haughton Thornley Medical Centres.

Project objectives

The objectives were to:

• Assess the practice's current compliance position
• Identify governance weaknesses
• Rebuild the compliance infrastructure
• Simplify regulatory compliance
• Reduce unnecessary administrative burden
• Establish sustainable governance systems
• Prepare the practice for future CQC inspection

Initial scoping exercise

Assessment date: 18 May 2026

The practice requested an independent review to support CQC preparedness after ongoing concerns, including:

• Loss of QOF income and poor performance during 2025/26
• Increasing concerns regarding governance
• Uncertainty over compliance arrangements

The assessment immediately identified substantial weaknesses across the practice's quality systems, including:

• Significant gaps in governance
• Missing documentation
• Limited compliance evidence
• Inconsistent management oversight
• Absence of effective quality assurance processes

The overall assessment concluded that the practice carried a significant risk of receiving an adverse CQC outcome if inspected in its current state. Potential consequences included:

• Notice of Improvement
• Inadequate rating
• Special Measures

A practice that had once been Outstanding

The findings were particularly significant because the practice had previously demonstrated high standards.

This demonstrated that good regulatory outcomes cannot be sustained without continuous investment in governance systems.

A further challenge

The situation became considerably more difficult when the practice manager resigned on 19 May 2026, the day after the scoping exercise.

The practice therefore faced the challenge of rebuilding its entire compliance infrastructure without its existing compliance lead.

With no practice manager in post, Shabana Dehlavi took on day-to-day oversight of the recovery programme directly, providing not only the technical implementation but the on-the-ground leadership that would otherwise have been missing during the critical window.

Review of existing compliance systems

The practice relied primarily on TeamNet as its compliance platform.

A detailed review showed that the system had evolved into little more than a document repository rather than an active quality management system.

Key findings included:

• Over 1,000 documents had been uploaded
• Many documents bore little relation to the task they supposedly evidenced
• Only 16 documents showed evidence of formal managerial review
• The majority of uploaded documents consisted of research material collected from multiple unaccredited sources
• Many policies were no longer current
• Essential FPM policy subscriptions had been cancelled
• The practice had a large number of staff but inadequate training and support
• Training management had been delegated without effective oversight
• Meeting records did not include minutes of meetings
• Clinical alerts were not documented as having been reviewed

Rather than supporting governance, the system created additional complexity while providing limited assurance that regulatory requirements were being met.

Mandatory training review

Training data revealed similar issues. Completion rates among senior leadership were extremely low:

Partners (combined)

12%-17%

Practice manager

15%

Across the wider workforce:

• Most staff had completed less than 50% of allocated modules
• Approximately five of forty-two staff had completed all assigned learning
• Several staff had completed none

Further investigation found that:

• All staff had been allocated 42 mandatory modules regardless of role
• GPs had been allocated 47 modules
• Modules frequently lacked relevance to individual responsibilities
• Allocation focused on quantity rather than risk

The result was predictable. Staff became overwhelmed by the scale of mandatory learning and many simply disengaged altogether.

Overall assessment

The clinical operation remained well managed.

However, the supporting compliance infrastructure had steadily deteriorated over approximately three years until it was no longer capable of demonstrating effective governance.

It became clear that incremental improvement would not be sufficient. There was no realistic opportunity to repair the existing system.

A completely new compliance framework would be required. Achieving this required significant investment of time and resource, reflecting the scale of what needed to be rebuilt rather than repaired.

Selecting the solution

The practice appointed Shabana Dehlavi as consultant and project lead. Shabana had worked with GP practices since the establishment of CQC in 2009, with extensive experience implementing and reviewing most of the major compliance products used across primary care.

These included:

• Practice Index
• Agilio TeamNet
• FPM
• QCS
• X-Genics
• Numerous locally developed systems

Rather than attempting another document-management exercise, Sansos recommended implementing an integrated quality management system built around internationally recognised quality management principles.

The selected everythingCQC Quality Improvement System provided:

• Standardised governance
• Integrated evidence management
• Business process management
• Risk management
• Ready-made policy framework
• Automated planning tools
• Minimal implementation time
• Virtually no user training requirements

Implementation strategy

The implementation followed the methodology previously proven during the Walkden Quality Improvement Programme.

The programme focused on four principles:

• Implement one integrated management system
• Remove unnecessary complexity
• Standardise quality processes
• Make compliance simple enough that every member of staff could participate

A dedicated Evidence Management Lead was appointed to coordinate ongoing governance.

Rapid implementation

Implementation milestones

One of the most significant outcomes was the speed of implementation.

Results

Within two weeks the practice had moved from having fragmented governance systems and significant regulatory risk to operating within a structured quality management framework.

Key achievements included:

• Complete replacement of the compliance system
• Governance rebuilt from the ground up
• Standardised documentation
• Structured evidence management
• Simplified staff guidance
• Integrated risk management
• Significantly improved inspection readiness
• Sustainable quality assurance processes

Rather than relying upon hundreds of disconnected documents, the practice now operated a single integrated quality management system designed to support continuous compliance rather than periodic inspection preparation.

Sansos's hands-on involvement is expected to reduce once a permanent practice manager is appointed and settled into the role, with support available at a distance as needed until the new ways of working are fully embedded as business as usual.

Consultant reflection

This project demonstrated that compliance did not fail at Haughton Thornley Medical Centres for lack of policies - it failed for lack of a system, and of the people to run it.

At Haughton Thornley Medical Centres there was no shortage of documentation. More than one thousand documents already existed. What was missing was governance and oversight.

By replacing document management with an integrated quality management system, compliance became simpler, responsibilities became clearer and evidence became part of everyday practice rather than something assembled immediately before inspection.

The project reinforced an important lesson from previous Quality Improvement Programmes across Greater Manchester: sustainable compliance is achieved through well-designed systems, not larger policy libraries.

For organisations facing similar challenges, the experience at Haughton Thornley Medical Centres demonstrates that even practices with severely degraded governance systems can rapidly restore regulatory readiness when quality management is approached as a whole-system transformation rather than a document review exercise.

Conclusion

Haughton Thornley Medical Centres is now a live example of how quickly a practice can move from serious regulatory risk back to a defensible, evidenced position - without waiting for the next inspection letter to force the issue.

Practices facing similar challenges - gaps in governance, disengaged mandatory training, or uncertainty ahead of a CQC inspection - do not need to wait for an inspection letter to find out where they stand.