DR KUMAR CQC INSPECTION ACTION PLAN REVIEWED: 28 TH DECEMBER 2015 RED NOT COMPLETED AMBER STARTED TO COMPLETE or SUPPORT AGREED WITH OTHER PARTNERS/ AGENCIES GREEEN COMPLETED
GENERAL CQC CONCERNS ASSURANCE EVIDENCE TO BE PROVIDED TO DEMONSTRATE ASSURANCE CQC Warning Notice responding to concerns and non-compliance noted at inspection Practice to work in partnership with the CCG, LMC and NHS England area team to develop remedial action plan to meet gaps in the regulatory requirements as described in the CQC warning notice and Quality Report. Schedule of review meetings to be agreed. Practice to provide regular updates to the CCG in accordance with agreed timescales. Practice will cooperate with agreed support package to address the CQC requirements Schedule of review meetings to be agreed Submission of regular updates within the action plan to the CCG. LMC and NHS England Area Team Record of cooperation and reviews recorded COMPLETE DATE RAG RATING AND UPDATE We have started to discuss our action plan with the CCG, LMC and NHS England Area Team to support in addressing areas of concern We will continue to engage on a regular basis to ensure that we respond to meeting all the concerns and can evidence all changes.
ARE SERVICES SAFE? CQC CONCERNS ASSURANCE EVIDENCE TO BE PROVIDED TO DEMONSTRATE We were told national patient safety alerts as well as comments and complaints received from patients, were used to identify issues that could affect either patient safety or that of the safe running of the practice The practice manager told us staff meetings were used to disseminate this information. We found no documented evidence to verify this. SAFE TRACK RECORD We communicate to all clinical staff Patient Safety information as relevant. The Practice manager has put in place a Patient Safety information file that the clinical staff will have access to and acknowledge. Complaints and patient Safety will be as a standing agenda item at all staff meetings. This is now in place To establish a complaints and compliments file to record and respond to all compliments and complaints and to have a standing agenda item at all meetings to discuss any relevant learning points or actions to take forward. We have in place a Significant Event Analysis policy and Template with a review every Quarter planned and discussed with all staff. ASSURANCE Staff Meeting minutes Patient Safety Information folder available to view. Significant Events Meeting held every Quarter and SEA outcomes and learning discussed with all staff. COMPLETE DATE RAG RATING AND UPDATE December 2015 We have now systems in place to meet the CQC concerns and can evidence this from staff meeting minutes, Patient Safety Information Folder available to clinicians and SE policy and template in place with reviews to be undertaken every quarter.
The practice had not sustained a systematic approach to documenting, investigating and evidencing learning from any significant event or incident Specific incident mentioned that did not cross reference to the minutes We did not see any evidence to verify this training. We only saw one certificate of external safeguarding training for the practice nurse There was a one page document titled Infection Control Quick Look in the IPC policy. This was signed by the GP and dated 17 August 2015,how ever this was not an audit of current IPC practices but an instruction to staff to follow hand decontamination procedures. LEARNING AND IMPROVEMENT FROM SAFETY INCIDENTS We now have standing agenda item at staff meetings to discuss any learning from significant events or other incidents We have invested in an learning package that will support the staff for this area of concern. We have a Significant event file to record and evidence any actions or learning Staff meeting minutes e-learning portal for staff training RELIABLE SAFETY SYSTEMS AND PROCESSES INCLUDING SAFEGUARDING All staff have been registered with an e Certificated evidence of learning package that covers Level 1 learning safeguarding. The Principle GP has already undertaken a level 3 Safeguarding training. All safeguarding events will be discussed at staff meetings as necessary. There is a standing agenda item to ensure that this is effectively covered and learning is disseminated accordingly. CLEANLINESS AND INFECTION CONTROL Clinical and non Clinical staff are signed up to undertake the e-learning module on infection control (clinical and non clinical) dependant on role. Infection control policy reviewed and implemented, with the staff nurse taking lead for implementation and audit, Principle GP Level 3 safeguarding certificate training available All safeguarding events and incidents discussed at staff meetings and minuted. Certificated evidence of learning Infection control policy implemented and Audit complete with outcomes and actions discussed with off at present off at present off at present Kath Healey Local Public Health
The practice manager informed us there was a cleaner employed and that cleaning schedules were in place. We did not see any evidence of these schedules or evidence of continued monitoring of these schedules. Annual portable appliance testing (PAT) had been due in July 2015. The practice manger informed us they were waiting for the company to contact the practice. The practice had a comprehensive recruitment policy; however this had not been fully implemented during the latest recruitment. supported by the practice manager and principle GP. The cleaning schedule are reviewed periodically and available to view at next inspection. This is managed and reviewed by the practice manager. EQUIPMENT PAT testing has been undertaken and certificate of conformity available for all appliance test undertaken STAFFING AND RECRUITMENT Recruitment policy, process and implementation with the support of Peninsula Group Limited will be undertaken. staff team. Cleaning Schedule available to view Certificate and register of items PAT tested Clear documented policy and support from Peninsula Group Limited that covers application form, interview, DBS etc process and passwords for practice access December 2015 November 2015 infection control lead has visited the practice and an audit has taken place. Cleaning Schedule in place managed by the practice manager. Cleaning Staff trained and supported to complete an evidence the cleaning undertaken Completed and PAT testing certificates available Peninsula business group limited booked to review on the 14 th Jan 2016 Again we were told that incidents were reported at practice meetings but the two meeting minutes provided did not have standard agenda items and it MONITORING SAFETY AND RESPONDING TO RISK Staff meeting agenda now has a standard Record of Agenda and item at all meetings for discussing minutes complaints, near misses and significant Completed Nov 2015 Staff Meeting agenda now with standing items to
was difficult to establish how the practice systematically monitored safety and responded to any identified risk. We did not see a risk register for the practice and there were no current risk assessments to identify and manage risks to patients and staff. The risk assessments seen were completed following incidents, such as spillage on the staircase. General risk within the practice was not assessed proactively, but rather reactively. events. We have a risk register with previous risk assessments undertaken. We are seeking support to develop and review our risk register and ensure that timely assessments take place. Access support from CCG and develop/review risk register and process for review and keeping alive Incidents to be reported on NRLS and significant event audits shared with the CCG. respond to this concern. Evidence available from recent staff meetings undertaken. Support from CCG to review risk assements and implement and action a process to manage risks There was now oxygen available for use on the premises during any medical emergency. However there was no defibrillator or Automated External Defibrillator (AED) available and as at the last inspection in February2015, there was still no risk assessment or protocol showing the rational explaining this decision. There were no policies or procedures available for staff to follow in the event of any healthcare emergency, which could occur in the practice. This is particularly important as the surgery opens at 9am but there is no clinical cover until after 10am.This had been highlighted at the inspections in July 2014 and in February 2015. Record of discussions at staff meetings ARRANGEMENTS TO DEAL WITH EMERGENCIES AND MAJOR INCIDENTS The Practice has now purchased AED in place and an AED and training to all staff is available at all planned in Jan 2016 on how to use times this. The Practice has a Health and Safety Policy in place that identifies process for emergencies and major incidents. All staff are signed up to the e-learning module to cover principles of health and safety All staff trained and record kept on the use of the AED e learning module completed on principles of health and safety. off at present. We are awaiting the delivery of the AED and with that we will have the relevant training for all staff
The practice did not have a system in place to ensure all clinical staff were kept up to date. The practice clinical governance policy stated that staff were to maintain knowledge of current developments and research, but it was not clear as to how this was achieved. We were told the GP had access to guidelines from NICE and used this information to decide how care and treatment was to be delivered to meet patient needs. The practice did not have any written guidance in relation to the Mental Capacity Act (MCA) 2005 or how the staff would assess the best interests of patients. The GP had undertaken update training in the MCA2005 but there was no evidence that this had been disseminated to the rest of the practice staff. We did not see any evidence of recent multidisciplinary meetings, were patient s care and treatments had been discussed. We did not see or were provided with any evidence of any meetings with external clinical professionals, such as midwives, health visitors or the palliative care team. ARE SERVICES EFFECTIVE All Clinical Staff have access to NICE guidance and up to date BNF for adult and Paediatrics available at all times. The clinical staff attend all CCG clinical meetings/ training and pathway updates on a regular basis. The principle GP meets with the peer group colleagues on a regular basis to support learning and development. The Principle GP has access to e learning through Pulse Learning, BMA Learning and RCGP learning modules. The Principle GP also uses various medical journals as learning aids. Practice has now a Mental Health Advanced Directive Protocol All staff now registered on the e learning platform and will undertake training on the metal capacity act Multi-disciplinary team meeting proforma has been created and meetings to be recorded and actions completed as necessary. Every 3 months a GSF meetings are held at the practice with the Principle GP, Practice Manager and consultants from the St BNF in all clinical rooms Record of attendance and CPD learning at clinical leads and other relevant training and development programmes organised by the CCG Advanced Directive protocol in place. All staff trained via the e- learning portal MDT meeting discussion notes available. Relevant notes also summarised on the patient notes as necessary. November 2015 Clinical staff can demonstrate further learning and development and have evidence of recent learning. off at present. There has been a GSF meeting that has taken place on the 26 th October 2015 with minutes available. There is another
The practice still did not have a system in place for completing clinical audit cycles. There was no plan in place for undertaking clinical audits in the future. This was highlighted at the last inspection. We found the GP had not undertaken a full audit cycle to evaluate the quality, impact or success of care and treatment. Catherine s hospice, District Nurses and Community Matrons attending. Double clinical audits have been undertaken by the principle GP and is available to view. The Principle GP appraiser has signed off the audits, with the next appraisal due end of June 2016 Programme of audits in place Evidence of two cycle audits and action plans Evidence of discussions at practice meetings. Meeting planned on the Monday 25 th Jan 2016 Double clinical cycle audits completed and ratified by appraisal lead. Next appraisal is in June 2016 which will lead to an audit plan discussion. Medication reviews for patients on multiple and frequently prescribed medicines had not been undertaken. The practice QOF Achievements for medication review is very high. A review on the 27 th December 2015 indicated that a 90% + achievement. Medication review QOF achievement data available to demonstrate achievement to date. We reviewed our QOF targets for medication review on the 27 th December 2015, and the results demonstrated our achievements as follows: Pts on 4 or more repeats with reviews in last 12M 95.21% achievement Pts on any repeat medication with medication review
in last 12M 75.25% Patients on any QOF registers for CHD, HF etc 91.8% Alert flags on the electronic system for five patients, diagnosed with learning difficulties were out of date one alert said the review was due in 2007. An additional five randomly selected patients also had no medication reviews undertaken and alerts were out of date SOP in place for medication reviews Evidence as indicated above demonstrates a high achievement in medication reviews. The practice is changing clinical systems to EMIS Health which will allow a more instant review of patient care rather than a delayed review that currently exists. QOF targets and Achievements demonstrating patient review. New clinical system in place to support effective patient record keeping and instant review alerts Our target for this work is by the 31 st March 2016 We are due to change clinical system and hope to have an effective system for review and recall. The alert flags on the INPS system viewed were redundant and still exists to be redundant with another flag in existence. No evidence of performance monitoring, identification of personal or professional development. Our targets for review of patients are by the QOF year 31 st of March 2016 EFFECTIVE STAFFING All staff have had an appraisal within the last 12months and up to date PDP, this to be supported by peninsula HR services going forward Record of Appraisal within the overall support by Peninsula HR Services Peninsula Business services due to come in Jan 2016 to support the HR and business
The practice did not maintain a record of completed training by staff or a matrix of training to be undertaken. It was difficult to verify what training staff had completed, requested or if outstanding All staff now registered with a username and password for e learning modules for their specific roles. Staff will also be supported to undertake any other relevant training as necessary not offered via the e learning modules Completion of the e learning modules and certificates awarded. Training Matrix Available processes for the practice off at present We were told the practice worked closely with other health care providers in the local area. The practice manager attended meetings with other managers of single handed GP practices. We were told these meetings provided opportunities for supporting each other, sharing information and good practice and reviewing national developments and guidelines. There was no evidence that any of this information was shared with other staff members. There was no progress since the last inspection in practice staff having access to a current consent policy. There was no consent policy in the policy folder provided. We were not provided with an updated policy or any guidance that related to the taking of consent or in relation to the Mental Capacity Act 2005. WORKING WITH COLLEAGUES AND OTHER SERVICES All Minutes of external meetings available for other staff at the practice to view on the shared drive. Standard agenda item at staff meetings to share external meeting information, good practice and other relevant developments. CONSENT TO CARE AND TREATMENT Consent and Mental Health Act policy now in place on the shared drive as well as a hard copy in the file Training for all staff will be undertaken via the e-learning module which is now in place Minutes of external meetings available Standard Agenda item at practice meetings External Meetings Update Policy in place and staff trained All staff trained on consent and Mental Health Act Standing agenda item at practice meetings and shared drive in place for all staff to view. off at present
ARE SERVICES RESPONSIVE TO PEOPLE S NEEDS CQC CONCERNS ASSURANCE EVIDENCE TO BE PROVIDED TO DEMONSTRATE However there was no documented evidence that the practice had effectively assessed the needs of its patient population or had engaged with the local Clinical Commissioning Group to secure future service improvements to meet patient needs. An equality and diversity policy was available. This had been seen at the inspection in February 2015. There was still no documented evidence to demonstrate if staff had received any training or updates about equality and diversity issues. Practice to ensure regular PPG meetings with service improvement feedback and actions. Work with the CCG, LMC and NHS England area team to look at service improvements and support available as part of the action plan delivery. e-learning module on equality and diversity in place for all staff to complete ASSURANCE Record of minutes from the PPG meetings Minutes and record of CCG discussions that support service improvements that meets patient needs Completion of e-learning module ARE SERVICES WELL-LED? CQC CONCERNS ASSURANCE EVIDENCE TO BE PROVIDED TO DEMONSTRATE We did not see a written strategy or business plan for the practice The Practice is seeking external support and discussions with the CCG to support in Developing a business plan for the practice in line with local and national developments. ASSURANCE Business plan in place COMPLETION DATE COMPLETION DATE RAG RATING AND UPDATE The practice manager and 3 members of the PPG met with the CCG and other practices to discuss the new Preston Quality Contract and the development of the PPG Chairs forum off at present RAG RATING AND UPDATE Discussions with external consultant to develop a business plan for the
We had spoken about a shared drive at the inspection in February 2015 to store policy guidance electronically to enable easier access for staff. The practice did not hold regular governance meetings and issues were discussed in an adhoc manner. The GP had implemented a clinical governance policy seen at the last inspection, dated September2014, which covered areas such as clinical audit (stating regular clinical audit would be undertaken), risk control, staff management, information governance, continued professional development and patient experience. We did not see any recent evidence of management or review of any of these areas. The practice did not have formal arrangements for identifying, recording and managing risks, for example responding to emergency medical procedures. Staff told us that at practice meetings they had the opportunity to raise any issue and give feedback on the service or suggest any improvements. The practice meeting minutes or appraisal documentation seen did not give any evidence of this. Shared drive now in place Practice will hold formal governance meetings that covered all aspects of implementation and review. The practice will ensure that there is clear leadership in the various aspects of the surgery delivery including clear management of the following governance areas : Clinical Governance Risk control Staff management Information Governance HR and PDP Patient Experience This work will also be demonstrated within the Business planning process. Shared drive with all policies and other relevant documents for staff to access Minutes and reports outlining governance reviews and actions undertaken. Clear Leadership and facilitation with clear policy reviews in place. Business plan in place PRACTICE SEEKS AND ACTS ON FEEDBACK FROM ITS PATIENTS, THE PUBLIC AND STAFF Peninsula Business services to support Appraisal support and PDP record keeping for all staff. We have now implemented a standing Minutes and appraisal documentation to give detail of any feedback from staff. November 2015 surgery Shared drive now in place which is accessible to all staff Governance reviews to take place in line with the business planning. The practice acknowledges that there needs to be some changes to ensure that the practice continues to evidence all the work undertaken effectively and efficiently, in addition to looking forward to implementing change in line with local and national changes. Peninsula Business services commissioned to support this area of work.
We saw no evidence of clinical audits being completed, and there was no future programme suggesting what clinical audits would be undertaken Although staff confirmed they had all undergone appraisals since the last inspection, the appraisal documents contained only self-evaluation against a set of questions. There was no performance management, personal or professional development or training needs identified. There was also no signature of the appraiser on two of the three appraisals seen There continued to be short falls in how the practice was managed and effectively learned and improved. The system to review policies and procedures was still not efficient. There was still no central register of policies. There was still no central register of training to demonstrate that staff had undertaken or were due to complete. The GP had not still implemented a Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) policy. agenda item for any concerns or feedback from staff to be raised. Standing Agenda item MANAGEMENT LEAD THROUGH LEARNING AND IMPROVEMENT 4 Audits with a 6 monthly review cycle have been done and audited by the appraisal lead and has been approved by the responsible officer. Evidence of the audits are available to view All practice staff have had an appraisal at least annually, with a review to be undertaken by Peninsula services in Jan 2016. A staff management plan and HR programme will be put in place in Jan 2016 by the practice, supported by Peninsula HR Services The Practice has reviewed all policies and all staff are aware of the policies on the Shared drive. The Practice have all staff registered on the e-learning portal and monitored for completion on the specific modules for the relevant roles. The practice has a DNR policy in place. The principle GP is attending an end of life care training in Jan 2016 Schedule of Audits for the year with completed audits as per schedule Staff Management and HR Programme in place with regular reviews Policies updated and central register created on the shared drive Staff completed e-learning modules. Policy in place and staff trained Standing agenda item on staff meeting agenda. Future Audits and cycle will be agreed at appraisal review in June 2016 Peninsula HR Services to support appraisal and HR management in Jan 2016 Policies reviewed and shared drive in place E learning package in place for all staff The Principle GP is attending end of life care training in Jan 2016
St Catherines Hospice are due to attend the practice mid Feb 2016 to train staff on end of life care. The consent policy still had not been updated to include information in regards to the Mental Capacity Act 2005 The practice has a Consent policy with the Mental Health Act updated within All staff to be trained on consent and Metal Health Act through the e Learning module Update policy and staff trained via the e-learning portal The principle has recently completed 2 DNR forms. Consent policy has been updated and information of Mental Capacity Act is within the policy. off at present The recording and analysis of, and learning from any incident remained adhoc, with little evidence of learning disseminated to staff. The practice will have an adequate incident recording process and learning disseminated to all staff through staff meetings. Standing agenda items are in place at all staff meetings. Minutes of staff meetings and standard meeting Agenda template in place with Incident monitoring as a standard item Standing agenda item and systems are in place to disseminate learning to all staff
The maintaining of accurate and up to date records of clinical treatment, particularly medicines reviews, for patients was still not effective. There was still little evidence that demonstrated the practice continually assessed, monitored and improved the quality and safety of the service provided. The practice is moving to EMIS Health which will support a robust and accurate record keeping system. Our QOF results shared within the action plan demonstrates our achievements the yellow notes are not active and other flags are used within the current clinical system to ensure patient records are kept up to date. As you can see from the action plan, a number of steps have been taken to address quality and safety Eg E learning, Double cycle Audits have been reviewed, facilities management services up to date, Infection control and lead in place etc. Clinical System updated and relevant training undertaken by administrative and clinical staff to support to maintain an accurate and up to date record of clinical treatment The action plan completed and reviews/ audits with CCG, LMC and NHS England Area team on regular basis Clinical System Change with training has now started and will help an effective system is in place. A detailed action plan in place to support to mitigate this area of concern Regular reviews of the action plan and planned changes will take place to ensure that a quality and safe services is provided to all.