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The All Wales Clinical Governance Practice Self-Assessment Tool (CGPSAT) for general medical practices

CGPSAT 2019 to 2020 submission (GMS contract)
Practices are required to review their previous CGPSAT responses, please enter a ‘level’ for each topic in the CGPSAT and make notes for your Practice Development Plan.


  • Access the All Wales CGPSAT 2019/20 here.  Please note that the CGPSAT is hosted on an NHS Wales intranet site
  • All practices are strongly advised to read the CGPSAT Tutorial
  • Practices will need to review, update and submit their completed CGPSAT on or before the 30th September 2021
  • User name and password
    If you have forgotten your login details please use the ‘Forgotten Password’ link on the login page, refer to CGPSAT tutorial 2018/19.
    Please note: The forgotten password process is linked to your current email address.  If the email address is not up to date the link will not generate an email to allow a reset of the forgotten password
    Contact: NWIS Primary Care Service Desk / Tel: 0333 200 8048
  • Administrative Queries
    If you encounter any administrative difficulties, have queries about the CGPSAT or its completion (perhaps due to a unique circumstance in your practice), or if you have any other questions, please contact your LHB primary care lead for advice.
  • What is the CGPSAT? 
    The All Wales Clinical Governance Practice Self-Assessment Tool (CGPSAT) encourages practices to bridge the gap between understanding and thinking about their governance systems and completing the actions needed to improve them.  

Practices are asked to consider how mature their systems are by means of a matrix.
Broadly speaking the matrix levels are arranged in the following hierarchy of delivery:

Level 0 We have not achieved level 1
Level 1 We do some of it (a partial system, reactive, opportunistic)
Level 2 We do it well (i.e. in a structured way, a complete system, proactive, planned)
Level 3 We ensure we continue to do it well (i.e. monitoring, safety netting, review, Plan, Do, Study, Act (PDSA) and audit cycles)
Level 4 We do it consistently and sustainably (we have a formal policy, the whole team takes ownership). We engage with and contribute to our local GP cluster.
Level 5 We strive to do it even better and we share it (Best practice, working in clusters, local planning, developing effective collaborative working with community services)We adopt a leadership role outside our practice and we bring what we learn from our cluster work back into our practice.


Practice Development Plans within the CGPSAT

The current version of the CGPSAT does not have a single PDP area but each matrix has its own text area which can be amalgamated into a report – practices need to use the print function to print a PDP report.  Please see the CGPSAT tutorial for how to do this

The GMS contract in Wales 2019 / 20 – Learning from the CGPSAT and using this for practice and cluster network development

The QOF Cluster Network Development domain aims to support development of cluster networks and provide some focus for improvement activity to strengthen the delivery of local health care in Wales.

CND011W. The contractor updates the Clinical Governance Practice Self-Assessment Toolkit, completes the Information Governance Self-Assessment Toolkit and utilises learning / outcomes from same in peer review at cluster meeting the contractor agrees to peer review the designated inactive QOF indicators within the practice at a designated cluster meeting mid-way through year and at the end of the year. The outcome of the inactive QOF peer review to be completed and shared with the Local Health Board by 31 March 2020. The contractor will include appropriate actions resulting from this analysis within the Practice Development Plan and will consider whether any issues need to be discussed at cluster network meetings.

Practices who have indicated they will be applying for a QOF payment for completion of the CGPSAT will need to be aware by doing so you are agreeing to make your practice results available to the Health Board and the Health Boards will be informed which practices are engaged with the toolkit. 

If you have any queries regarding completion of QOF indicator CND011W submission of the CGPSAT please contact your LHB

The CGPSAT is based on the Welsh Government Health and Care Standards 2015 (formerly the Standards for Healthcare Services in Wales). We have given an interpretation of the standards for the General Practice context and have tried to align the CGPSAT matrices with the revised standards. Matrices often cover more than one standard and some do not fit neatly into any.  


Updated 19/10/2021