Jane Betts Director of Primary Care Strategy Brent Practice Managers Forum 22 January 2016
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
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 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 of 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
CQC Operating Model
CQC Rating Scale Outstanding Good Requires Improvement Inadequate
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
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
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)
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
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
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.
Brent CQC visits
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
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
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
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
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
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
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?
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
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!
Preparing your patients Put notices in waiting area of CQC visit Inform your PPG and arrange for PPG chair or 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
Your 30 min opening presentation (1) 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 (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
Your 30 min opening presentation (3) 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/gppractices/service-provision/care-qualitycommission/cqc-inspection
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
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
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
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
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
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 on them in an open and transparent way
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
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 out medication reviews Paper & electronic prescriptions stored safely at all times Named GP prescribing lead (best practice) System for flagging prescribing alerts
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.
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
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
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
Meds Management (6) Nigel Sparrow s Myth buster 1 - http://www.cqc.org.uk/content/nigels-surgery-1-agreedprinciples-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.
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
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
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
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
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-barringservice-dbs-check
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)
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!
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
Further essential reading (1) GPC guidance on CQC inspections: http://bma.org.uk/practical-support-at-work/gp-practices/serviceprovision/care-quality-commission/cqc-inspection Londonwide LMCs guidance on CQC inspections: http:///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
Further essential reading (2) Nigel Sparrow s myth busters on CQC website: http://www.cqc.org.uk/content/mythbusters-and-tips-gps-andout-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:///visageimages/guidance/2015/gp%20sup port/cqc%20safeguarding%20themes_amalgamated%20table 2.pdf
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