Getting it right first time, every time

The five standards of the Care Quality Commission (CQC) are: safe, effective, caring, responsive and well led. Quality is the demonstrable and objective achievement in these areas. Within the sphere of clinical governance and quality, all our activity and the data generated is designed to fall clearly into these domains, so that attainment of ultimately an excellent standard becomes routine and demonstrable.


Our goals

  • 100% of our inspected services achieve “Good” or “Outstanding” ratings from CQC (or equivalent in Scotland and Wales).
  • To innovate within the boundaries of the NHS framework to promote greater patient access.
  • To be sector leaders in demonstrating the high quality of our care.
  • To be a dynamic employer offering support and development to all employees. Our goals are underpinned by our values, demonstrating accountability, being respectful, acting with courage, and delivering excellence.



Delivering outstanding clinical quality

Outstanding clinical quality demands that the CQC’s five standards are embedded in the organisation, and achievement of these goals is demonstrable both within the organisation and to the outside world.

We are uncompromising on patient safety. We work hard to ensure all our staff, and consultants, have the skills and support they need to improve patient safety across our entire organisation.

We have tight feedback loops on patient safety incidents and can respond quickly to every and any incident as we focus on the best possible care.

We already conform with most of the elements of NHS England’s new PSIRF and are confident that we will be able to demonstrate complete compliance with all aspects before its universal adoption.

Safety, quality, effectiveness and patient experience underpin everything we do, with a focus on getting it “Right First Time”. This is an essential part of delivering on our purpose to improve healthcare access and outcomes across the UK and in Ireland.

At a clinical level, we are committed to delivering excellent care, with “Good” or “Outstanding” CQC ratings (or equivalent in Wales) across all of our inspected services and a focus on good patient engagement and feedback. 100% of our inspected services are rated as “Good” by the CQC.

The healthcare sector faces and will continue to face considerable challenges. Year on year there is increased demand which we respond to against a backdrop of staff shortages and increasing cost. We have processes in place to support services when challenges are faced, and mechanisms to share learning across the Group. This framework is being simplified by the restructure of the business, bringing together all our healthcare operations under one leadership, helping us achieve consistently high standards.


A framework for continuous improvement

At an organisational level, we have a clear Quality Assurance Framework, based on the domains of quality outlined. To ensure standards are met, the Group Clinical Governance Board, a sub-committee of Totally’s Board, oversees this assurance. It is chaired by the Medical Director and, for further Board assurance, joined by a Non-Executive Director.

The Clinical Governance Board’s key responsibilities are to:

  • Set standards for clinical governance within the Group;
  • Give guidance and direction for service delivery;
  • Drive standardisation of approach in policy, process and infrastructure;
  • Set expectations for development or recovery and set timescales for delivery;
  • Ensure that a clinical governance structure which monitors key quality indicators (“KQIs”) is in place; and
  • Hold operational leaders to account in matters of clinical governance

The work of the Group Clinical Governance Board is underpinned by:

Subject matter experts (“SMEs”) work across the Group to ensure we meet national standards for their area of expertise.

Infection prevention and control (“IPC”):

High quality infection prevention and control processes are mandatory in delivering safe healthcare. Our IPC programme is led by a Clinical Nurse Specialist who monitors our approach to IPC, ensures we meet and exceed mandatory requirements and supports SERCLE/relevant audit studies.


Safeguarding is about protecting a citizen’s health, wellbeing and human rights to enable them to live free from harm, abuse and neglect. It is a legal, contractual and moral duty of all healthcare providers, and we have worked hard to ensure that our structures, staff and expertise deliver safe systems.

Across Totally, staff have access to safeguarding training, weekly group supervision sessions and regular safeguarding content through our all-people intranet, My Totally, providing updates on work within the Group and, importantly for clinicians, legal and national updates. We continue to enhance our training content and schedule, and recent staff feedback confirmed the relevance, depth and delivery of training for clinicians. One important part of the work of the safeguarding team, led by our Named Nurse and Doctor for safeguarding, is monitoring the quality of our referrals into social services and local safeguarding teams. Assessing the quality of those referrals feeds an improving standard of practice across the Group.

Medicines management:

Medicines management is an evidence-based approach in prescribing, procurement, storage, distribution, administration, and disposal of medicines. The intention is to balance the safety, tolerability, effectiveness, cost, and simplicity of treatments based on current evidence, national guidelines and relevant local policy. Good medicines management ensures that patients receive better, safer, cost-effective, and convenient care.

Medicines management across the Group is provided by our subject matter expert pharmacists and a team of pharmacy technicians, working with local teams to ensure the appropriate storage, use and prescribing of medication and prescription stationery.

Clinical audit is a way to find out if healthcare is being provided in line with standards and lets providers and patients know where their service is doing well and where there could be improvements.

As a minimum, clinical audit seeks to provide assurance of compliance with contractual and clinical standards (whether these are national, professional or statutory). It identifies suspected or hidden risk, clarifies underlying activities involving waste and inefficiencies, identifies opportunities for the improvement of care and patient outcomes and supports the re-validation process for clinical staff.

During the 2022/23 year we completed in excess of 10,000 audit cycles in 45 audit areas. In all cases the audit showed our processes to be fully compliant against national standards and exceeded required performance.

Examples of audits undertaken include NHS 111 call review, NHS 111 welfare ambulance review calls, controlled drug prescribing, compliance with safeguarding referral and level 3 training and ongoing case notes review audits in specific clinical areas.


Our internal SERCLE review process carries out regular inspections of our services. The process is matched against CQC’s inspection criteria and identifies opportunities to capture best practice across equivalent services or, where there are shortfalls, address them with the local teams.

FFT feedback

This includes patient feedback and complaints, reporting of adverse incidents, monitoring of risk and the engagement of frontline staff in quality, service provision and personal development. Totally utilises the NHS-led Friends and Family Test (“FFT”) to monitor patient experience, which is carried across all services.

FFT results are monitored through monthly reports and services are able to access patient comments relevant to their area via an online dashboard. Totally is committed to maintaining good positive scores for FFT to ensure a positive patient experience in all services.


Totally values complaints as an important source of patient feedback. We provide a range of ways in which patients and families can raise concerns or make complaints. All concerns, whether they are presented in person, in writing, by telephone or email are assessed and acknowledged within three working days wherever possible and all complaints are investigated. Formal complaints are rare. All such complaints are investigated and learnings developed and shared.

We aim to respond to informal concerns quickly. If the concern or issue cannot be dealt with informally or if the enquirer remains concerned, the issue is always categorised as a formal complaint and processed accordingly.

Clinical risk is the assessed chance and severity of an adverse event occurring to a patient or group of patients. All clinical activity carries risk.

Appropriate identification of areas of risk is of vital importance and requires assimilation of raw performance data as well as incidents identified from Datix, complaints and litigation. It also requires attention to external events, policy changes and anything that impacts on the provision of healthcare.

Risks are identified at every level of the organisation, they are recorded and graded on risk registers with a plan formulated to minimise or where possible to eliminate them entirely. Every service area carries its own risk register with risks seen as relating to the wider organisation being promoted centrally.


“All clinician” calls are recorded and hosted for on‑demand viewing on our all-people intranet, My Totally, to ensure that all clinicians can stay up to date with the latest essentials on patient safety.

Training and development of the clinical workforce

Our clinical workforce is our face to the world and the team which patients come into contact with when they need our services.

The main groups of staff are wholly employed clinical staff (including doctors, nurses, therapists, call handlers and pharmacy support), contracted staff (including doctors, nurses, therapists and theatre technicians) and administrative staff. All play key roles in providing high quality clinical care. We believe that all employed staff should have an annual appraisal and this forms the bedrock of their engagement in the Group’s quality programme. Good appraisal allows individuals to understand their own perspective and how their role supports continuous quality improvement at the individual level at the service level and Group-wide. Contracted individuals receive concise consolidated feedback on their engagement with quality processes which will be submitted as part of their appraisal process.

Quality Account 2023/4



Read our Quality Account for 2022/23