Hillingdon LMC All Practice Meeting 4 February 2016 How to prepare - - PowerPoint PPT Presentation

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Hillingdon LMC All Practice Meeting 4 February 2016 How to prepare for your CQC visit

Jane Betts – Director of Primary Care Strategy Nora Breen – Manager, GP Support Services

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New CQC Inspection Process - New Regulations

• The Health and Social Care Act 2008

(Regulated Activities) Regulations 2014 – published November 2014: http://www.legislation.gov.uk/uksi/2014/29 36/pdfs/uksi_20142936_en.pdf

• The new regulations cover:

– Fit and Proper Person (FPP) requirements – Duty of Candour – New 11 Fundamental Standards

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From the old to the new standards - came into force 1st April 2015

• Care and welfare of service users
• Assessing and monitoring the

quality of service provision

• Safeguarding service users from

abuse

• Cleanliness and infection control
• Management of medicines
• Meeting nutritional needs
• Safety and suitability of premises
• Safety and suitability of equipment
• Respecting and involving service

users

• Consent to care and treatment
• Complaints
• Records
• Requirements relating to workers
• Staffing
• Supporting workers
• Cooperating with other providers
• Person-centred care
• Dignity and respect
• Need for consent
• Safe care and treatment
• Safeguarding service users from

abuse

• Meeting nutritional needs
• Cleanliness, safety and suitability
• f premises and equipment
• Receiving and acting on complaints
• Good governance
• Staffing
• Fit and proper persons employed
• Fit and proper person requirement for

directors

• Duty of candour

16 Safety & Quality Standards 13 Fundamental Standards

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CQC Operating Model

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CQC Rating Scale

• Outstanding
• Good
• Requires Improvement
• Inadequate

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• There is no room for ‘adequate’, ‘satisfactory’, or

‘compliant’ – if you are not rated ‘Good’, you automatically ‘Require Improvement’

• Overall ratings are not calculated on statistical principles;

e.g. two Good + three RI = RI overall

• Not all 5 Key domains are equal – Safe and Well-Led

affect the overall rating more than the other three

• An RI or Inadequate rating in the Safe and/or Well-Led

domains, means this rating will be carried through ALL six population groups, regardless of any positive findings in relation to those population groups

CQC Rating Methodology

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5 Key Questions

• ALL GP practices and OOH to be inspected by April 2016
• 5 key questions:
• Safe - people are protected from abuse and avoidable

harm

• Effective - people’s care, treatment and support

achieves good outcomes, promotes a good quality of life and is based on the best available evidence

• Caring - staff involve and treat people with compassion,

kindness, dignity and respect

• Responsive - services are organised so that they meet

people’s needs

• Well-led - the leadership, management and governance
• f the organisation assures the delivery of high-quality

person-centred care, supports learning and innovation, and promotes an open and fair culture

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• CQC assessments are focusing on six

population groups:

– Older people – People with long term conditions – Families, children and young people – Working age people (including those recently retired and students) – People whose circumstances may make them vulnerable – People experiencing poor mental health (including people with dementia)

6 Population Groups

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Key Lines of Enquiry (KLOEs)

• Inspection teams use standard set of KLOEs,

that directly relate to the 5 key Qs

• Each KLOE is accompanied by a number of

questions, called prompts

• The info gathered before and during the

inspection will determine which prompt questions will be used by the inspectors

• Practices should familiarise themselves with

Appendix B of provider handbook:

http://www.cqc.org.uk/sites/default/files/20150327_GP_practi ces_provider_handbook_appendices_march_15_update.pdf

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CQC’s enforcement powers & ‘Special Measures’ regime

• CQC has enormous powers
• Backed up by the H&SCA 2012 with

political support across the board

• Warning & enforcement notices
• Suspension & cancellation of registration
• Special measures regime if ‘Inadequate’

rating on ONE key question or population group

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Critically appraising and challenging your draft report

• Two weeks for practices to make factual accuracy comments
• Despite being the regulator, CQC is not an expert on all the

legal, contractual etc requirements on GPs

• Good practice is often mistaken as a requirement
• You can influence your final report as long as you use factual

evidence to support your corrections

• Challenging inappropriate, unfounded, biased, ill informed etc

findings in a factually based and professional manner is extremely important – your report will be in the public domain and a negative CQC rating could seriously damage your practice

• Know what is expected of you so you can challenge

appropriately, but also -

• be prepared to accept and reflect on genuine criticism. Do not

let emotion guide your responses. Use facts.

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Hillingdon CQC visits

8 practices inspected so far Outstanding Good Requires improvement Inadequate 6 2 0% 75% 25% 0% Key Outstanding  Good  Requires Improvement  Inadequate 

Practices CCG Area Safe Effective Caring Responsive Well - Led Overall

Practice 1 Hillingdon

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Practice 2 Hillingdon

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Practice 3 Hillingdon

     

Practice 4 Hillingdon

     

Practice 5 Hillingdon

     

Practice 6 Hillingdon

     

Practice 7 Hillingdon

     

Practice 8 Hillingdon

     

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• Provider handbook lists the following:

– Practice’s Statement of Purpose – Action plan addressing patient survey results – Complaints of last 12 mths, actions & learning – Serious incidents of last 12 mths, as above – Two completed clinical audits in last 12 mths – Number of WTE staff by role – Recruitment policies – Staff training records

Info required prior to the visit (1)

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• Infection control audits
• Health & Safety, Fire Safety audits & PAT

testing registers

• Business continuity plan
• HR staff files, employment policies
• Staff training matrix, appraisal/CPD
• Equipment calibration reports
• Palliative care registers

Other key documentation to prepare (1)

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• Service information (e.g. key population

demographics, statement of purpose/ practice leaflet, treatment options, how to make comments and complaints etc)

• Care planning & assessment protocols,

meeting equality and diversity needs

• Medicines management policies including

storage, stock management, handling, recording and disposal; prescribing policies and protocols

• Medication audits/error reporting and action

plans, checks on emergency drugs, stock control policies

Other key documentation to prepare (2)

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• Review and amend any policies that are out of date
• Have either paper copies available on the day for

CQC inspectors and/or a dedicated electronic folder

• Ensure all staff know where policies are stored

electronically and manually

• Have a system to record that staff have read them
• Make sure your policies are a true reflection of the

way you work – CQC inspectors will compare staff answers to what is written in your policies. It is not a test but a way of accessing if staff are aware of procedures relevant to their role

• Have a clear and auditable system for updating

policies and communicating updates to all staff

Preparing your Policies

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Preparing your Staff (1)

• Inspecting team will interview staff members
• Ensure staff are aware of visit and that they

may be asked questions

• Know staff availability, prepare for staff

absence and front desk cover. If needed, book locums to free up partners on the day

• Carry out ‘mock’ inspections/staff interviews

in-house or with a neighbouring practice

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Preparing your Staff (2)

• Have dedicated meetings with staff to ensure

they are aware of what they may be asked – examples:

– Sharing/understanding policies, e.g. process for handling path lab results and hospital correspondence – Appointment system – Child & vulnerable adults safeguarding processes and training – Chaperone policy – Helping people with LD/mental health problems – Team meetings

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Preparing your Staff (3)

• Ensure staff familiarise themselves with

the CQC GP Provider Handbook and are aware of the Key Lines of Enquiry (KLOEs)

• Example Safety 1:

– Do staff understand their responsibilities to raise concerns, to record safety incidents, concerns and near misses, and to report them internally and externally where appropriate?

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Preparing your GPs (1)

• As soon as you know when the visit is, identify the lead GP
• In depth interview by the clinician on the inspection team with the GP
• Discussion areas will include:

– Clinical governance – Leadership role – Training especially child protection/ safe guarding vulnerable adults, BLS – Communication, this may include seeing care plans eg AU DES – Clinical meetings – Audits – Medicines management – How staff learning needs are identified – Team working e.g. all staff involved in assessing/planning/delivering care – Mental capacity assessment – End of Life care – Appointments, availability, run on time etc

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Preparing your GPs (2)

• Ensure partners understand their

leadership role and take responsibility for their areas of the CQC inspection

• Have dedicated meetings with the partners

to prepare well in advance

• The inspecting team will wish to see

evidence to back up what they are being told

• Evidence, evidence, evidence!

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• Put notices in waiting area of CQC visit
• Inform your PPG and arrange for PPG chair
• r a member to attend on day of visit
• Ensure you have a robust complaints policy

in place that is well publicised to patients

• Read CQC’s ‘Guide for Working Together’ –

http://www.cqc.org.uk/sites/default/files/docu ments/20130509_cqc_guide_for_ppgs_final.p df

Preparing your patients

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• Sets the tone for the day
• Decide who will lead it (RM, partners?)
• No specific format (Powerpoint, informal chat etc)
• Touch on history and development of the practice
• Evidence of practice’s performance against the 5 key

domains & 6 population groups

• Promote outstanding achievements
• Identify challenges & explain how you address them
• Be open and honest
• Focus on quality, safety and patient experience
• Involve patients or staff if possible

Your 30 min opening presentation (1)

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Your 30 min opening presentation (2)

• Use objective measures & evidence
• Show audit results and changes implemented
• Share patient stories
• Topics to cover:

– Partnership structure and leadership – Workforce & patient demographics – How you work with other professionals & organisations – Show how the practice is well led, e.g. staff training & supervision, how you deliver high quality care and safe services, how you listen and respond to patient feedback, how risks are identified and mitigated

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• Topics to cover (cont)

– Patient access, urgent & advanced appointments – Care plans and named GPs – Use specific examples or cases (anonymised) to show compliance with consent to care, response to safeguarding issues and patient involvement in decisions about their care – More tips on how to prepare for your 30 min presentation by the BMA: http://bma.org.uk/practical-support-at-work/gp- practices/service-provision/care-quality- commission/cqc-inspection

Your 30 min opening presentation (3)

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SAFE DOMAIN

Learning from safety incidents

• System for reporting, recording & monitoring

significant events, incidents & accidents

• SEA and complaints policy
• Incident/accident log book
• SEs = standing agenda item in practice mtgs
• SE and complaints reviews
• Evidence of action taken & lessons learned
• National patient safety alert system

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Monitoring safety & responding to risk

• Systems and processes to monitor and

manage risks to patients, staff & visitors

• Annual and monthly checks of the building,

environment, meds management, staffing, dealing with emergencies and equipment

• Health & Safety policy and named H&S

lead

• Fire Safety policy
• H&S information displayed

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Dealing with emergencies & major incidents

• BLS training for staff
• Emergency equipment available, staff know

its location & it is checked regularly

• Emergency meds (covered later)
• Business continuity plan - risks assessed,

rated and mitigated (inc. power failure, flood, adverse weather, IT system failure, unplanned staff sickness, access to the building etc)

• Fire risk assessments, staff up to date with

fire training, regular fire drills

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Safeguarding ‘SG’ (1)

• Systems to manage & review risks to

vulnerable children, YP & adults

• Child protection training level 2 for staff,

level 3 for clinicians

• Adult safeguarding training for all staff
• Staff to know how to recognise a vulnerable

pt, signs of abuse, what safeguarding means, their responsibilities, how to raise concerns and contact relevant agencies in & out of hours

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Safeguarding (2)

• Dedicated child protection and adult SG lead –

staff to know who lead is

• System in patient electronic records to flag up

vulnerable patients (very important)

• Health checks & care plans for vulnerable pts
• Chaperone policy, training, notices & DBS

checks for chaperones

• Staff training on Mental Capacity Act, DoLS

and Gillick Competency

• Tip: easy win – safeguarding training audit

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Safeguarding (3)

• Safeguarding is not only about patients,

but also staff

• Bullying & harassment policy
• Whistleblowing policy
• Practice culture needs to support and

empower staff to raise concerns and act

• n them in an open and transparent way

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Safeguarding (4)

• Policies/systems you need to have in place:

– Child protection & adult safeguarding policy – Chaperone policy – Patient consent policy – Significant events and complaints policy – Incident reporting policy – Induction policy and locum pack to cover SG – Risk management systems – System to flag vulnerable pts in electronic records – Process for handling hospital letters and path results – Bullying & harassment policy / Whistleblowing policy

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Meds Management (1)

• Repeat prescribing protocol
• Patients have clear info how to request repeat

prescriptions (include in practice leaflet)

• GPs review all prescriptions (inc repeats)

before authorising

• Clinicians follow clear guidance when carrying
• ut medication reviews
• Paper & electronic prescriptions stored safely

at all times

• Named GP prescribing lead (best practice)
• System for flagging prescribing alerts

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Meds Management (2)

• Dedicated clinician (often nurse) to use

documented stock control system to check meds expiry dates

• Make sure there are NO expired drugs or

vaccines in the practice

• Expired drugs disposed of in line with waste

regulations

• Emergency drugs to be stored securely and

be accessible only by authorised staff. All staff to know location of emergency drugs.

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Meds Management (3)

• DRUGS FRIDGES!
• Temperature checked and logged daily
• Dedicated person for temperature monitoring
• Clear policy for ensuring drugs/vaccines are

kept within the required temperature (2-8C) and action to be taken in the event of potential failure

• Internal thermometer recommended – in its

absence, monthly calibration of external thermometer required

• Air circulation very important in drugs fridge -

Do not overfill drugs fridge as it affects internal temperature

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Meds Management (4)

• System in place to ensure annual medication

reviews are carried out for LTC patients

• Staff appropriately trained and supervised in

prescribing duties

• Nurses & HCAs to demonstrate required

training in administering vaccines

• Appropriate PSDs and PGDs in place for

administration of vaccines

• Blank prescriptions to be stored securely

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Meds Management (5)

• Equipment tested and maintained regularly –

keep maintenance logs

• Emergency equipment – even though not

contractually required, CQC expects practices to have oxygen cylinder and defibrillator to manage emergencies

• If oxygen / defib not in place, risk assessment

should be carried out to justify decision not to have them

• If in place, they need to be checked regularly

and staff need to be trained in using them

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Meds Management (6)

• Nigel Sparrow’s Myth buster 1 -

http://www.cqc.org.uk/content/nigels-surgery-1-agreed- principles-defibrillators-oxygen-and-oximeters

• Oxygen: National Resuscitation Council: ‘Current

resuscitation guidelines emphasise the use of oxygen, and this should be available whenever possible’.

• Oxygen is considered essential in dealing with certain

medical emergencies (such as acute exacerbation of asthma and other causes of hypoxaemia). If the practice does not have oxygen they are unlikely to be able to demonstrate they are equipped for dealing with emergencies.

• Defibrillators: According to current external guidance

and national standards, practices should be encouraged to have defibrillators.

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Cleanliness & Infection Control (1)

• Premises clean and tidy
• Cleaning schedules, logs and records
• Cleaning contract
• Infection control (IC) policy & named lead
• Induction includes training on IC – staff

receive annual training updates on IC

• IC audit and actions taken
• Legionella risk assessment and

management plan

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Cleanliness & Infection Control (2)

• PPE (e.g. gloves, aprons etc) available
• Needle stick injury policy
• Spillage kit and policy
• Sharps policy (sharps boxes not more

than ¾ full and off the floor)

• Hand washing notices in staff & pt toilets
• Clinical waste stored separately from

domestic waste

• Clinical waste removal contract in place

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Staffing & recruitment (1)

• Appropriate pre-employment checks for

clinicians and admin staff

• Comprehensive staff files (to include as a

minimum: proof of ID, references, qualifications, prof. registration, DBS check, employment contract, appraisal records)

• Recruitment and selection policy
• Staff appraisal policy
• Staff handbook
• Induction policy

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Staffing & recruitment (2)

• Documented system showing all staff have

read and understood the relevant practice policies

• Need to have adequate staff levels &

demonstrate arrangements for planning and monitoring staff numbers and skill mix to meet patient needs

• Rota system and cover arrangements in

the event of sickness and annual leave

• Locum arrangements

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DBS checks (1)

• CQC will not tell you who needs a DBS check
• Down to the practice to have process in place

for assessing each staff role and eligibility for DBS check depending on staff responsibilities and contact with vulnerable patients or records

• Nigel Sparrow’s Myth buster 2:
• http://www.cqc.org.uk/content/nigels-surgery-

2-who-should-have-disclosure-and-barring- service-dbs-check

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DBS checks (2)

• All clinicians should be DBS checked

when appointed

• If they have not been, best practice says

they should all be DBS checked retrospectively even though there is no legal requirement for periodic or retrospective DBS checks (3-yearly repeats are NOT legally required)

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DBS checks (3)

• DBS checks valid only on date of issue,

HOWEVER they are a very significant requirement for CQC

• Have a risk assessment policy in place –

apply it to all staff to decide eligibility so if you get challenged, you can defend your decision not to DBS check a particular member of staff

• Remember – if in doubt, have them

checked!

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Additional areas of non-compliance

• Not involving patients in decisions about their care
• Lack of complete clinical audit cycles
• No business continuity plan
• No staff training, acting as a chaperone, Mental

Capacity Act, Safeguarding

• No evidence of PPG contribution
• No promotion of PPG
• No signage directing patients around the

practice

• No annual staff appraisals
• No record of staff meetings

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Further essential reading (1)

• GPC guidance on CQC inspections:

http://bma.org.uk/practical-support-at-work/gp-practices/service- provision/care-quality-commission/cqc-inspection

• Londonwide LMCs’ guidance on CQC inspections:

http://www.lmc.org.uk/visageimages/guidance/2015/Londonwide %20LMCs%20CQC%20Guidance.pdf

• How CQC Regulates: NHS GP practices and GP out-of-hour

services; provider handbook (updated 27 March 2015) http://www.cqc.org.uk/sites/default/files/20150327_gp_practices_ provider_handbook_march_15_update_01.pdf

• Provider handbook appendices ( March 2015)

http://www.cqc.org.uk/sites/default/files/20150327_GP_practic es_provider_handbook_appendices_march_15_update.pdf

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Further essential reading (2)

• Nigel Sparrow’s myth busters on CQC website:

http://www.cqc.org.uk/content/mythbusters-and-tips-gps-and-

• ut-hours-services
• DBS checks:

http://www.cqc.org.uk/sites/default/files/Disclosure%20and%20b arring%20service%20checks%20guidance%20100646.pdf

• Infection control:

The Health and Social Care Act 2008, Code of Practice on the prevention and control of infections and related guidance

• Londonwide LMCs’ detailed guidance on CQC’s safeguarding

requirements mapped against each key domain - http://www.lmc.org.uk/visageimages/guidance/2015/GP%20sup port/CQC%20safeguarding%20themes_amalgamated%20table 2.pdf

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THANK YOU!

Any queries, problems, adverse rating in your CQC report, help with your action plan etc, please contact us at: gpsupport@lmc.org.uk