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

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 www.lmc.org.uk

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 www.lmc.org.uk

From the old to the new standards - came into force 1 st April 2015 16 Safety & Quality Standards 13 Fundamental Standards • Care and welfare of service users • Person-centred care • Assessing and monitoring the • Dignity and respect quality of service provision • Need for consent • Safeguarding service users from • Safe care and treatment abuse • Safeguarding service users from • Cleanliness and infection control abuse • Management of medicines • Meeting nutritional needs • Meeting nutritional needs • Cleanliness, safety and suitability • Safety and suitability of premises • Safety and suitability of equipment of premises and equipment • Respecting and involving service • Receiving and acting on complaints users • Good governance • Consent to care and treatment • Staffing • Complaints • Fit and proper persons employed • Records • Fit and proper person requirement for • Requirements relating to workers directors • Staffing • Supporting workers • Duty of candour • Cooperating with other providers www.lmc.org.uk

CQC Operating Model www.lmc.org.uk

CQC Rating Scale •Outstanding •Good •Requires Improvement •Inadequate www.lmc.org.uk

CQC Rating Methodology • 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 www.lmc.org.uk

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 of the organisation assures the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture www.lmc.org.uk

6 Population Groups • 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) www.lmc.org.uk

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 www.lmc.org.uk

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 www.lmc.org.uk

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. www.lmc.org.uk

Hillingdon CQC visits Key 8 practices inspected so far  Outstanding Outstanding Good Requires improvement Inadequate  Good 0 6 2 0 Requires 0% 75% 25% 0%  Improvement  Inadequate Well - Practices CCG Area Safe Effective Caring Responsive Overall Led       Practice 1 Hillingdon       Practice 2 Hillingdon       Practice 3 Hillingdon       Practice 4 Hillingdon       Practice 5 Hillingdon       Practice 6 Hillingdon       Practice 7 Hillingdon       Practice 8 Hillingdon www.lmc.org.uk

Info required prior to the visit (1) • 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 www.lmc.org.uk

Other key documentation to prepare (1) • 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 www.lmc.org.uk

Other key documentation to prepare (2) • 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 www.lmc.org.uk

Preparing your Policies • 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 www.lmc.org.uk

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 www.lmc.org.uk

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 www.lmc.org.uk

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? www.lmc.org.uk