care quality commission ‘100+’ inspection checklist...

Care Quality Commission ‘100+’ Inspection Checklist and Questions

PRACTICE NAME:Practice Manager: Registered Manager:ITEM EXPLANATION, RECOMMENDATIONS AND QUESTIONSGENERAL MANAGEMENT

1. Registered Manager(Amended)

Appointing a Registered Manager: It is vital that your Registered Manager is familiar with the requirements of the Care Quality Commission (CQC) and is present on the day of an inspection and available to see the Inspectors. If the Registered Manager leaves the Practice make sure that a new one is appointed promptly and that the CQC has been formally notified.

Meeting the Inspectors: There may be two or three inspectors. The Inspectors will meet with the Practice Manager, the Registered Manager and may speak randomly to staff on duty along with patients in the building at the time. Staff should wear name badges. The Inspectors may also ask to meet members of the Patient Participation Group and speak to patients attending the surgery that day.

Recommendation: The Practice needs to ensure that the Registered Manager is available on day of inspection, along with Practice Manager and Senior Nursing staff and those members of the Practice who take any lead responsibility. Date Checked: Lead Manager’s Name and Initials:

4. Statement of Purpose and Presentation (Amended)

Recommendation: The Practice has published a clearly defined statement of business purpose and that a Mission Statement which has been sent to the CQC.

Date Checked: Lead Manager’s Name and Initials:

6. Presentation (New) Recommendation: The Practice will be expected to make a presentation lasting around half an hour to the CQC Inspectors the content of which will be predefined. This is an opportunity to ‘blow your own trumpet’ and promote your practice in the best light. Tell the CQC about your practice, what it does and where it is going. The Presentation should be supplemented by a handout.


7. Business Plan (Amended) Recommendation: The Practice should have a Business Plan setting out its aims and objectives looking ahead at least five years, and demonstrating ‘leadership’ by the members of the Practice and its Manager(s). The Business Plan should demonstrate how the Practice might deal with succession planning, practice vacancies, premises development and clinical and financial management. It may refer to involvement with the CCG and any locally formed Federation.Question: How frequently is a Business Plan prepared and when is it reviewed?

Kingfisher PM Copyright – Robert Campbell – Revised August 2017



10. Practice Agreements (Amended)

Recommendation: A copy of the Partnership Agreement, the NHS Contract (GMS/PMS) Agreement, along with DES/LES agreements and any Company Registration documentation should be available. The documentation might include the contracts of Salaried Doctors and Locum Doctors, which should be available in their personal files. Question:

What type of ‘service contract’ does the Practice have with NHS England?

Is the Practice VAT registered? Is the Practice a registered company? Have employment contracts been issued to Salaried GPs &

Registrars?Date Checked: Lead Manager’s Name and Initials:

PERSONNEL CONTRACTS13. Criminal Record Bureaux

(CRB) / Disclosure and Debarring Service (DBS) (Amended)

Recommendation: The Practice should have a clearly defined policy of carrying out CRB/DBS criminal record checks. Copies of reports should be available for Inspectors to see. The Practice should be clear about which staff require a CRB/DBS Report including a Risk Assessment to justify any staff excluded. NHS England’s advice points to nursing and reception staff but opinions vary to all staff except cleaners! Be clear too about whether new employees can start work and on what duties if a DBS Report is not available.

Questions: Do new staff start work before or after a DBS report is sought? What steps are taken to check the annual professional registration

of clinicians (GMC etc), that qualifications are formally documented and evidence of inclusion in the Performers List is obtained.


16. Staff Recruitment (Amended)

Recommendation: A Vacancy file should be kept recording the process of recruitment for each post, which should include a copy of the advert, job description, personnel specification, criteria for shortlisting, and selection of candidates for interview. Staff files should include the original application, interview notes, details of any scoring system and at least two formal written references along with evidence of checks to ensure entitlement to work in UK and where appropriate confirmation of qualifications and annual professional membership registration. Questions:

Are staff aware of a clear chain of command – who is in charge? Are there regular staff meetings and arrangements in place to

communicate ‘change’ to all employees and clinicians? What are the arrangements for advertising vacant posts,

shortlisting, and selecting candidates?




19. Staff Contracts (Amended) Recommendation: Staff Personnel files should be available for inspection. The Practice Manager may be asked to select a given number. Files should contain a signed copy of the staff contract and be tidy and in date order. A copy of DBS reports along with evidence of annual registration should also be apparent. The CQC Inspectors may ask to look at appraisal documentation, sickness and absence records and training records, although these records may be kept elsewhere.


21. Staff Terms and Conditions of Service (Amended)

Recommendation: Staff contracts and Personnel Manuals/Handbooks should set out the pay arrangements, and the terms and conditions of service under which staff are employed. It should cover such areas as annual leave (minimum 28 days p.a.), employers sick pay (if any) maternity and paternity leave, study leave, compassionate leave, jury service, etc. It might also cover travelling expenses. The CQC Inspectors may ask to be a copy of the Disciplinary and Grievance Procedures, a Whistleblowing Policy, Recruitment and Staffing Policies. Date Checked: Lead Manager’s Name and Initials:

Questions: Has the Practice adopted NHS Agenda for Change? Does the Practice still use uprated NHS Whitley Council pay scales

or use its own local pay scales? Are all staff paid at least the National Living Wage and entitled to

the statutory 28 days annual leave? 24. Employers and Medical

Indemnity Cover (Amended)

Recommendation: The Practice should be able to demonstrate that the professional indemnity cover of each GP is updated annually. Evidence of professional indemnity (insurance) cover in the form of annual certificates should be available along with the Employers Indemnity Certificate. Evidence of sickness absence insurance cover might also be requested.Questions:

What are the arrangements for GP membership of the MDU, MPS or other defence organisations offering professional indemnity.

In addition, what indemnity cover is provided for other professional staff, such as Pharmacy Advisers, Dispensers, Health Care Assistants.

Is the annual Employers Liability Insurance Certificate on display? Date Checked: Lead Manager’s Name and Initials:

27. Staff Appraisals (Amended)

Recommendation: Records of staff appraisals should be available to view, including any 360 questionnaires or agreed assessment forms, along with any mutually agreed reports. A central file of documents should be kept. The Inspectors may look for evidence of records of achievement or non-achievement of objectives and any subsequent follow up if necessary.Questions:

How frequently are staff appraisals carried out and by whom?



At what intervals are appraisal reviews carried out? Date Checked: Lead Manager’s Name and Initials:

PRACTICE and PERSONNEL POLICIES

NOTE: All Policies should show the name of the Lead Manager, the date written and the date of Review. Keep a printed version as well as a computer version that is easy to find. Maybe have a copy of all documents on a memory stick with an interactive menu.

30. Confidentiality Policy(Privacy and Dignity)

Recommendation: The Practice should have a clearly defined Confidentiality Policy with which all staff should be familiar. A requirement to maintain confidentiality should be incorporated into the Staff Contract. A Policy Manual could be prepared and signed by staff when read. The Practice should have a named Caldicott Guardian. Staff should also be aware of the need to afford patient’s privacy and respect their dignity. Reception staff may be observed when dealing with patients. (See Privacy below)Date Checked: Lead Manager’s Name and Initials:

32. Access to Records Policy (Amended)

Recommendation: Practice Staff should be aware of the procedure involved in allowing access to records, including the arrangements for access by third parties and to clinicians working at the Practice.

Data Protection Act Registration: The Practice should be able to provide evidence of annual registration with the Information Commissioner under the Data Protection Act.Question: What are the arrangements for allowing access by patients to their own manual and online computer held records? Date Checked: Lead Manager’s Name and Initials:

35. Disciplinary and Grievance Procedures (Amended)

Recommendation: As part of a raft of personnel policies the Practice should include these Disciplinary and Grievance procedures in its personnel manual which should be available to staff. Examples of personnel policies are available on www.practiceindex.co.uk . The BMA and ACAS web sites are sources of model policy documents too. Date Checked: Lead Manager’s Name and Initials:

37. Privacy (Amended) Recommendation: The Practice should ensure that reception and waiting room areas allow for patients to wait not within earshot of the reception counter and for a separate room or area to be provided to talk to staff in confidence. Similarly, telephone conversations with patients should not be taken at reception locations within earshot of waiting patients. The CQC Inspectors may observer activities in the Reception and Waiting areas and talk to patients.Question: What arrangements are made for patients who wish to talk privately to practice reception staff?


40. Equal Opportunities Policy Recommendation: An Equal Opportunities Policy should be included in its personnel manual which should be available to staff.


http://www.practiceindex.co.uk/



42. Bullying and Harassment Policy (Amended)

Recommendation: The Bullying and Harassment Policy should cover violence, threatening behaviour, verbal abuse, as well as emphasising that the Practice supports a culture with no bullying and harassment of employees. Copies of the policy should be available to staff.


44. Equality Policy (Amended) Recommendation: The Staff Equality policy should set out the employer’s approach to equality of employees no matter gender, age, sexual orientation and religious beliefs. Equality would cover equality of pay across the genders as well as pay equality for staff holding the same or similar jobs. The policy should be available to staff.

Date Checked: Lead Manager’s Name and Initials

Question: Are facilities at the surgery provided for daily religious observance by doctors and staff?

47. Trade Union Membership (New)

Trade Union Membership: Staff should not be prohibited from joining or be inhibited in any way due to trade union membership. Doctors may be members of the BMA and Nurses members of the RCN.

48. Working Hours Policy (Amended)

Recommendation: A Staff Working Hours Policy should set out a duty of care toward employees to monitor their mental and physical health (including stress) in relation to extended weekday and weekend working hours, not exceeding 48 hours per week. Both employers and staff should be aware of the obligations. The GP Employer should be aware of any staff working exceptionally long hours.

Questions: Is a record kept of the hours worked by all practice staff, including

overtime and additional hours? What arrangements are made to ensure the safety of staff working

alone?

Date Checked: Lead Manager’s Name and Initials

51. Whistleblowing Policy Recommendation: Staff should have no fear of reporting irregularities, such as fraud or concerns about inappropriate activities of any type or by any person during their employment. Staff should be aware of the Whistleblowing Policy and may be asked by CQC Inspectors about its existence.

Question: To whom should practice staff report if concerned about any aspect of the performance, ‘activities undertaken’ or the ‘associations of personnel’ working at the surgery.




PERSONNEL RECORDS54. GP & Nurse Professional

Registration (Amended) Recommendation: A central file might be kept demonstrating that the national registration of GPs (GMC) and Nurses (RCN) has been checked annually. In addition, GPs should be included in NHS England’s Performers List. NHS England carry out CRB checks on GPs only when admitted to the Performers List. Questions:

Are any GPs members of the British Medical Association? Does the Practice pay the Voluntary Local Medical Committee levy?


57. Staff Training Records (Amended)

Recommendation: The Practice Manager should be able to explain the type and extent of training that is available for Practice Staff. Personnel records should show the internal and external training certificate(s) of attendance records for each member of staff.

Questions: What training sessions have been arranged by the Practice in the

last 12 months? Does ‘training’ include Life Savings skills, and Safeguarding

Vulnerable Patients? (Amended August 2017)

Date Checked: Lead Manager’s Names and Initials:

60. Practice Staff Training Recommendation: The Practice has a duty to ensure that professional clinical staff are permitted to keep up with postgraduate training. For all staff, records of attendance for Safeguarding Vulnerable Adults and Children, Resuscitation and Anaphylaxis training should be available. Practices may also provide training on Confidentiality, Call Handling, Complaints, and Practice Administration.

Questions: Does the Practice have a defibrillator and if not has a risk

assessment been carried out? Has training on using the defibrillator been provided?


63. Training Needs Assessments (Amended)

Recommendation: Evidence of training needs assessments, Personal Development Plans or Learning Plans should be available, particularly for clinical/nursing staff. Assessments might cover the use of new technology and computers.




65. Staff Name Badges and Visitors Book (Amended)

Recommendation: The Inspectors may ask to speak to any member of staff and as such a name badge would be very useful. The badge might show at least the forename and designation. Staff will be expected to have read and be signed up to practice policy documents and may be asked questions by the CQC Inspectors. (Beware of staff with loose tongues).

The Practice should consider introducing a Visitors Book and issue Security Badges to visitors, including CQC Inspectors, who enter the non-public areas of the Practice Premises.

Question: What are the arrangements for recording the identity of visitors to the Practice?


68. Staffing (Manpower) (Amended)

Recommendation: The Practice should have a Staffing Policy setting out how it intends to maintain adequate staffing levels at all times, particularly where the need to employ locum doctors arises. The CQC needs to be satisfied that the Practice is run safely. Practices should understand the relationship between the number of sessions provided and the number of appointments demanded. It may also look at the financial management of the Practice.

Questions: What are the ‘core’ staffing levels needed to maintain a ‘safe’ and

‘quality’ service? How many GP Sessions and how many appointments are required

per week to run a ‘safe’ practice?


71. Staff Induction and Training Handbook

Recommendation: The Practice might provide the following Employee Handbooks:

An Induction Handbook for new clinical and practice staff is highly recommended.

A Handbook for Salaried and Trainee GPs Registrars is also recommended.

An additional Training Handbook setting out basic instructions for staff working at Reception might also be prepared.

Question: What training documents, procedures, crib sheets, policies and procedures are given to new staff?


INFECTION CONTROL74. Infection Control Lead Recommendation: The Practice should ensure that it has nominated an

Infection Control Lead and that person is available to meet the CQC Inspectors.




76. Cleanliness and Infection Control Inspection

Recommendation: Practice Managers should make sure that the most recent Infection Control report carried out independently is available and that evidence of any necessary action taken arising from the report is apparent.


78. Cleanliness and Infection Control Policy (Amended)

Recommendation: The Practice should have a Cleanliness and Infection Control Policy document and provide evidence of its review. A Cleaning Schedule should be available and a system of reporting on cleaning quality or lack of it.

Questions: What evidence exits that the quality of cleaning services provided

has been checked. Does the Practice engage Contract Cleaners or employ its own

cleaning staff? Is there a COSHH Manual including Data Hazard sheets for all

materials and substances used in the Practice?


81. Decontamination Policy (Amended)

Recommendation: The Practice should have a Decontamination Policy document setting out the arrangements for cleaning, disinfection and sterilisation. The Practice should be to provide evidence of its review.

Questions: What type of sterilisation process or system is used? Are pre-packed surgical instruments used for minor surgery? How are used pre-packed instruments disposed of?


84. Vaccine Refrigerator and Out of Date Drugs (Amended)

Recommendation: The Practice should have kept regular records of temperatures found in the vaccine fridge. The ‘datedness’ of vaccines should also be checked regularly.

Question: Is a Lead person responsible for checking fridge temperatures? Is a lead person appointed to check the datedness of vaccines and

drugs kept in the refrigerator and drugs cupboard?


34. Legionella Testing (Amended)

Recommendation: The Practice should be able to provide evidence of undertaking a risk assessment in relation to legionella or have carried testing at least every two years of taps, showers and water sources. Advice can be sought from the Health and Safety Executive.




RISK ASSESSMENTS – GENERAL35. Risk Assessments (New) The Care Quality Commission has during inspections sought evidence of

differing risk assessments. Here are some examples:Surgery Premises:

Asbestos in building and roofing materials Automatic closing devices on entrance door and door appliances Changing Electric light bulbs and fluorescent tubes Disabled Access to Car Park, and Premises (Patients and Staff) Fire Precautions, Equipment and Alarm, Fire Evacuation, Fire Doors

(self-closing) Drill Testing, Bomb Alerts Evacuation Legionella Testing Power failure, loss of electricity, gas, water Maintenance of Building, lifts, stairwells, uneven flooring, re-wiring Erection of Art Work, Notice Boards Safety during building maintenance and building works

Staffing Issues: Bullying/ and Harassment Chaperone/Receptionist – DBS Checking First Aid Requirements (Lack of First Aider), First Aid Box Inclement Weather Precautions, use of salt, snow clearance Incident Reporting, Accident Book, Significant Events Lone Working – Reception staff (extended hours) Maternity Care – expectant staff, time off and ‘safe’ working Protected Learning Time; Staff remaining at ‘open’ surgery Right to Work in UK Youth Workers – Health and Safety issues (Work Experience) Whistle-blowing Zero Tolerance, threats, violence, bad language

Office and Cleaning Equipment and Materials: Use and Storage of Cleaning Equipment Use of Office Equipment, photocopier, scanner, laminator Control of Substances Hazardous to Health - COSHH Ergonomics, suitability of furniture, position of seating Manual Handling, Use of Ladders, Step ladders Display Screen Equipment, seating position, time used, eye tests Portable Appliance Testing (PAT) Window Cleaning, Man-safe, Window Restrictors

Medical Equipment: Clinical Negligence Claim (needle stick injury, infection control) Delivery, Handling, Storage and Use of Liquid Nitrogen Ear Irrigation, Use of Cautery, Sharps Disposal, Needle Stick Injury Storage and Use of Oxygen Equipment and Cylinders

Practice Management (Finance): Risk of theft, fraud, bribery, and chasing bad debts Handling of Cash Staff - Attachment of Earnings (handling of cash) Storage of Blank Prescriptions and FP10’s awaiting patient

collection



See www.practiceindex.co.uk – threads on risk assessmentsHEALTH AND SAFETY

36. Health and Safety Policy (Amended)

Recommendation: The Practice is legally required to have a Health & Safety Policy document setting out the Practice’s commitment to the protection of health and safety of all employees and the patients, including the public at large. The Health and Safety Executive provide guidance material. Question:

Is the Health and Safety Executive’s poster on display? Is the Employer’s Liability Insurance Certificate on display?


37. Health and Safety (Hazard) Risk Assessment

Recommendation: The Practice should have arrangements in place for the routine inspection of the surgery premises. Records should be available setting out the results of a Health and Safety Risk Assessment carried out within the Practice (at all surgery locations). Evidence should be available of what action if any was taken as a result of any hazards found or negative findings?


Question: What arrangements are made for the safe storage and use of Liquid Nitrogen?

38. Waste Disposal Recommendation: The Practice should have in place a Waste Disposal Policy for disposing of Business Waste and Clinical Waste including ‘sharps’. Evidence of regular collection of Clinical waste should be kept. Date Checked: Lead Manager’s Name and Initials:

Question: What arrangements are in place to dispose of sharps bins presented by patients for disposal?

39. COSHH – Control of Substances Hazardous to Health (Amended)

Recommendation: The Practice should have a COSHH Policy document and provide evidence of its review. Hazardous substances should be marked or labelled. If an independent cleaning service is used the Practice should ensure that legislation is complied with and that reference ‘manuals’ are available.

Question: Is there a Manual of Data Hazard Sheets?


40. RIDDOR(Reporting of Injuries, Disease, Dangerous Occurrences Regulations)

Recommendation: The Accident Book should be available for inspection along with any evidence of action taken if any entries occur. Questions:

Where is the Accident Book kept? Is the name of a certified first aider on display, along with any

training certification?





41. Fire Precautions and Evacuation Procedure (Amended)

Recommendation: Inspectors may ‘walk around’ both inside and outside the surgery and check for fire extinguishers, alarm points and exit signs. Ensure that fire exits are not blocked and surfaces are clear. Wheelchair users should be able to move around the building and exit it with ease. If exit routes require keys the keys should be clearly available.

Question: How frequently are fire alarms tested and when was the last

evacuation drill/rehearsal? Is there a separate procedure for evacuation if a suspect package is

found? Are there designated Fire Wardens and a Fire Officer?


42. Equipment Maintenance (Amended)

Recommendation: Ensure that records of equipment maintenance and PAT testing of electrical equipment are available. Equipment might include scales, ECG machine, and spirometry machines and also include kettles, refrigerators, televisions, telephone systems and all computer equipment (including VDUs’, keyboards, computer units, booking in systems, scanners and printers). The Defibrillator should be charged and ready to use. Question: How frequently is PAT Testing carried out on electrical appliances?


43. Medical Alerts Policy Recommendation: There should be a Medical Alerts policy/system in place for the dissemination of medical, drugs and equipment safety alerts. This may include having a single point of contact for incoming alerts and then evidence of circulation.


Question: Who is the lead recipient (and is there a deputy) of medical alerts and how are ‘alerts’ and ‘hazard warnings’ disseminated to members of the Practice?

PRACTICE ARRANGEMENTS44. Registration of New

Patients Policy (Open and Closed List) (Amended)

Recommendation: A New Patient Registration Policy should describe whether the practice has an Open List or Closed List, the extent of the practice area and the approach toward temporary and out of area patients.

Question: What evidence of identity is requested when patients register? What steps are taken to deal with patients requesting registration if

the list is Closed?Date Checked: Lead Manager’s Name and Initials:

45. Violent and Abusive Recommendation: The Practice should have an in-house alert system in



Patients Policy – Zero Tolerance (Amended)

place for disseminating information about patients reported to be violent of abusing drugs. The Practice should have on display posters stating a Zero Tolerance approach to abuse of staff or threatening or violet behaviour. A Panic Alarm system should be evident. The Zero Tolerance Policy should state what action will be taken should an incident occur including reporting to the Police and removing the patient from the practice list.


46. Appointments System (Amended)

Recommendation: Practice Staff should be able to give a clear explanation of how the appointments system operates. The CQC Inspectors will look for evidence of safe practice. Any ‘examination’ of the appointments system would be expected to reveal that same day and immediate appointments are available, that continuity of care is feasible and that there is not an undue wait for regular appointments with a named doctor. Such transparency should be equally matched with the online booking service offered to patients. Practices may also be asked to clarify arrangements for the timing of appointments slots of 10 or 15 minutes and indicate whether patients can ask for double appointments.

Questions: In addition to when the next available appointments are, Staff may

be asked what action is taken if a doctor is absent. Are appointments cancelled or reorganised when a doctor is

absent?Date Checked: Lead Manager’s Name and Initials:

47. Telephone Services (Amended)

Recommendation: The Practice should be accessible via a local geographical telephone number so that patients do not incur higher call charges and that such number should be clearly ‘advertised’ to patients. Staff should be familiar with the ‘messages’ contained on any answering service. Staff may be asked whether call back facilities are offered. Practices should ensure that there are sufficient telephone lines and staff manning the lines to deal with the demand faced by the Practice.

Question: What steps has the Practice taken to ensure that patient telephone

numbers (home and mobile) are up to date? Can you explain how the Call Management system works, if one is

used?


48. Texting/Messaging Services

Recommendation: The Practice may have introduced texting services to remind patients of booked appointments and to seek health data from patients.


49. Home Visits Recommendation: The Practice should maintain records of requests for



home visits either by computer or in diaries and ensure that patient records are updated. The Inspectors may ask what arrangements are made if patients require regular or follow up home visits particularly if a doctor is absent.


50. GP On Call Arrangements (Amended)

Recommendation: Practice Staff should be able to explain the daily GP on-call arrangements within the surgery. There may be a notice board displaying the names of duty clinicians and duty manager. Contingency Plans to cover absences should be known to the Staff. .


51. Out of Hours Services (New)

Recommendation: Members of the Practice should be able to explain the arrangements for GP Services to be continued outside the contracted ‘core hours’. This may involve transferring calls to another service, such as ‘111’. Staff should be aware of the system for reporting out of hours care to the Practice. The Out of Hours contact arrangements should be clearly displayed outside the surgery entrance and in the Practice Leaflet and on the Practice Web Site.

Date Checked Lead Manager’s Name and Initials

52. Extended Hours Services (New)

Recommendation: The Practice Staff should be able to explain what the arrangements are to provide Extended Hours Services beyond the normal ‘core hours’. Information should be posted on Notices in the surgery, the practice leaflet and web site. Patients should also be aware of the ‘111’ service or the local alternative. If Extended Hours services are provided at a different location or surgery this should be clearly stated. Patients should also be made aware that access to their medical records will be available at the extended hours appointment held at another surgery. The inappropriate use of A & E services should be highlighted and attention drawn to the location of Minor Injury Units or Walk-In Centres.

Question: How are patients made aware of how to contact out of hour’s services and when extended hours are available (and where)?


53. Absence Records Recommendation: The Practice should keep a ‘business diary’ setting out records of absence and cover provided for all clinical staff. It should record holidays, sickness and training absences. It should also record internal and external meetings (e.g. CCG) and who attended. The evidence may be required to support evidence in litigation.


PATIENT SERVICES AND INFORMATION



54. Practice Leaflets (Amended)

Recommendation: The Practice is required to have an up to date Practice Leaflet and copies should be available for the Inspectors. A Safeguarding Leaflet/Poster should be available for patients. The Leaflet displays should be kept in a tidy condition. The Practice should also provide a Complaints Leaflet. Date Checked: Lead Manager’s Name and Initials:

55. Practice Web Site (Amended)

Recommendation: The Practice Web Site should mirror the Practice Leaflet and offer contact points for making complaints, making appointments, ordering prescriptions and allowing access to medical records. Practices should make sure that the Practice Web Site also matches the content of the NHS Choices web site. Additionally, the web site should include information about the activities of the Patient Participation Group.

Question: Does the Practice web site provide an email address for patients to contact the Practice Manager? If not, is a generic email address offered?


56. NHS Choices Web Site Recommendation: The NHS Choices web site should be kept up to date at all times (often forgotten!). Ideally, the content should mirror the Practice Web Site and reflect hours of availability of GPs correctly. The Inspectors may have been prompted to visit the Practice by and be aware of any adverse comments from patients contained on NHS Choices.

Question: What steps are taken to comment on any adverse comments about the Practice that might appear on the NHS Choices web site?


57. Consent for Treatment Procedure

Recommendation: The procedure for seeking consent to treatment in the Practice should be set out in a Consent Policy along with sample consent documents. Patient’s clinical records should show evidence of consent sought and consent given, where appropriate. A patient’s consent will be needed where a Carer acts for a patient.


58. Consent to Video Consultation (New)

Recommendation: Practice Staff should be aware of the need to seek the consent of patients to video or record audio of any consultation. Date Checked Lead Manager’s Name and Initials

56. Chaperone Policy Recommendation: The Practice policy/procedure for arranging a chaperone should be visible in the practice reception/waiting room and the offer and use and name of a chaperone recorded in the patients notes. Question: Have staffing acting as Chaperones received any certified training?


59. Identification of Minors – Consultations with lone

Recommendation: The Practice should have a procedure in place to identify patients who are minors and a clear policy about at what age, if at all



children (Amended) doctors and nurses will be see children under the age of 16 without a parent or guardian present. The Practice may be asked to explain the circumstances whereby a child would be seen by a doctor without parental involvement or permission. Staff may be asked if they are aware of Gillick and Fraser Competence, which looks at whether a child is mature enough to deal with their own medical matters.


60. Choose and Book Management of NHS E-Referrals (Amended)

Recommendation: Information should be available to patients about the Choose and Book system. Patient’s clinical records should show evidence of treatment referrals offered. The Practice may be asked to explain how promptly the individual doctors action referrals under Choose and Book system, now known as NHS E-Referrals. .Question: What steps are taken and by whom to manage the take up of referrals by patients booking appointments?


61. Palliative Care (Amended) Recommendation: The Practice should keep a Palliative Care Register and ensure that out of hours’ service providers are notified of new patients added to the register. The Practice may be asked to explain the arrangements for meetings of the Multi-Disciplinary Care Team and be able to produce minutes of meetings.


62. Safeguarding Vulnerable Patients

Recommendation: The Practice should have clearly defined policies for dealing with vulnerable patients (children and adults). Staff should have had certified Safeguarding Training and be aware of the name of the Practice Lead and to whom to report any concerns.


COMPUTING SERVICES63. Computer Security Policy Recommendation: The Computer Security Policy should deal with the and

setting of passwords and access rights to software as well as emergency reinstatement of the system. It should specify the arrangements for issuing and managing Smart Cards.


64. Computer Housekeeping (Internal)

Recommendation: There should be evidence of a technical support system in place for all computer hardware and software used in the Practice whether it be provided internally or externally. Practice Staff should be



aware of the Help Lines for Software Support for the Clinical System.


65. Use of Social Media Policy (Amended)

Recommendation: The Social Media Policy should set out rules about the use or non-use of social medical such as Facebook and Twitter whilst at work and in relation to colleagues, patients and practice business. The policy may also extend to the use or non-use of mobile phones and texting whilst on duty.

Questions: Are mobile phones switched off whilst at work? Are all staff clearly aware of the need to be careful about the use of

social media in relation to work colleagues and practice issues?


66. Patient Access to Online Services Policy

Recommendation: The Access Online Policy sets out arrangements for patient access to online prescriptions, appointments, access to medical records and contact with the surgery. The arrangements for issuing ‘usernames’ and ‘passwords’ should be set out, including provisions for access by children. Practice Staff should be familiar with the registration process for online services.

Questions: Can patients contact the surgery by email or text to a named

person? Does the Practice offer text reminders for appointments?


67. NHS Smart Card Policy Recommendation: This Policy sets out the arrangements for issuing Smart Cards to NHS Staff, and for authorising and managing their use in the Practice. The Practice should nominate a lead person authorised to deal with Smart Card applications and reactivate Smart cards.


PRESCRIBING PRACTICE68. Repeat Prescribing Policy Recommendation: The Repeat Prescribing Policy sets out the procedures for

issuing and monitoring and reviewing repeat prescriptions.

Question: What period of time is the maximum patients need to wait for a routine repeat prescription and an urgent prescription to be issued?


69. Prescribing Policy Recommendation: The Prescribing Policy sets out arrangements for issuing prescriptions such as the period of supply, the period of review and any restrictions or limitations on drugs prescribed.


Robert Campbell, 30/11/15, RESOLVED



70. Drug Formulary Recommendation: The Practice may have set up arrangements for a practice drug formulary including personal GP, Nurse or practice based formularies and have arrangements for monitoring, review and updating.


71. Controlled Drugs Policy Recommendation: The Practice should have a clearly defined Controlled Drugs Policy and evidence of a system of checking and updating the content of Doctor’s Bags. It is now unusual for controlled drugs to be kept in a surgery unless it has a dispensary.


72. Dispensing Policy Recommendation: A Dispensing Practice may need to provide an explanation of the dispensing service provided.


MEDICAL RECORDS73. Record Keeping Recommendation: The Record Keeping Policy sets out the arrangements for

ensuring the quality of medical record is maintained. Records should be timely and accurate. There should be evidence of regular case review. (e.g. Minutes of Practice Meetings) Records should demonstrate that patient choice of referral hospital has been offered.


74. Summarising Records Recommendation: The Practice should have a system in place to summarise all records kept in the practice including those newly received by clinical staff or doctors. Manual Records may need ‘clipping and tagging’, placing in chronological order. Care should be taken not to destroy significant content. It must not be assumed that records received from other practices have been kept properly.

Question: Who is responsible for summarising records and how is the process carried out?


75. Allergy Recording Protocol

Recommendation: The Practice should have an Allergy Protocol which sets out the procedure for ensuring the allergies are recorded in patient’s computer records and that any allergies shown on the front of manual records are transferred to the computer record.




76. Clinical and Reports Procedure – Scanning and Data Input (Amended)

Recommendation: The Practice has in place a procedure to deal with the receipt of clinical letters, and reports to ensure that the documents are read promptly and action is taken when and where appropriate. The procedure should provide for deputies to act in the absence of the patients own doctor. The procedure should cover both manual and computer reports and clarify at what stage documents should be scanned and the period retained before shredding (e.g. 6 months). The procedure should also cover correspondence marked as urgent and that received by fax. The arrangements for data input (coding) and validity audit checking should also be explained. Date Checked: Lead Manager’s Name and Initials:

77. Quality Outcomes Framework, (QOF/CQRS) (Amended)

Recommendation: The Quality Outcomes Framework (QOF) policy sets out the arrangements for maintaining, updating and reviewing the QOF/CQRS records. QOF is amended annually and Practices will need to review and monitor changes and decide how and who will record any necessary data. The Practice may have appointed one or more clinicians with a lead responsibility for QOF Domain Management and these persons should be available to meet the QOF Inspectors, if necessary.


Question: What is the current and last year’s achievement level under the Quality Outcomes Framework (points)? CQC Inspectors may ask for access to the Practice’s Clinical Computer system.

78. Clinical Audit Recommendation: The Practice should be able to provide evidence of regular Clinical Audit and in particular Case Reviews of patient notes, particularly of cancer referrals? (e.g. Minutes of Practice Meetings). Clinicians may be asked to provide reports of any audits carried out in the last 12 months. Date Checked: Lead Manager’s Name and Initials:

79. Death Reporting Recommendation: The Practice should have a Death Reporting Protocol setting out how and to whom deaths should be reported in the Practice. A death occurring in the practice premises will need to be reported to the CQC. A sudden death should be reported to HM Coroner. The protocol should set out whom in the primary care team and in secondary care should be informed that a patient has died to avoid unnecessary correspondence being sent to relatives.


80. Transfer of Medical Records (Amended)

Recommendation: This policy sets out the arrangements for ensuring the medical records are transferred when patients leave or join the Practice List using the GP2GP transfer system where and when available and to chase up the receipt of records for newly registered patients when missing. Staff



should be familiar with the arrangements to chase up the receipt of records for new patients required urgently.


CLINICAL MANAGEMENT81. Continuity of Care – Out

of Hours ServiceRecommendation: The Continuity of Care protocol should include the arrangements for deputies and for dealing with out of hours’ reports. Care should be taken to ensure that patients receive the same standard of care and attention no matter which doctor in the Practice they see.

Question: How do doctors become aware of the provision of Out of Hours Services and how is action taken where reports require a follow up?


82. NHS E-Referral / Choose and Book – Medical Records (Amended)

Recommendation: The CQC Inspector may look at the arrangements for processing referrals under the NHS E-Referral/Choose and Book Service.

Question: Can the Practice demonstrate via notation in patient records that choice is offered and that checks are carried out to ensure that appointments have been made?


83. Referral Letters – Quality and Timeliness (Amended)

Recommendation: The Practice should make sure that adequate steps are taken to ensure that the standard and quality of referral letters is maintained and that sufficient information is provided in the letter to enable an efficient, effective and appropriate referral to be made. The Practice should make prompt referrals and there should be no undue delay in making ‘Urgent’ referrals, dictating, typing and despatching letters. The CQC Inspectors may review the clinical notes of a number of patients.


84. Health Checks Recommendation: The Practice should have in place procedures to offer health checks to newly registered patients and patients aged 40 and over. Arrangements should also be in hand for a named doctor to take responsibility for patients aged 75+.

Question: Has the Practice appointed a named doctor for elderly patients?


85. Medical Emergency Plan Recommendation: The Practice should have set down in a policy document the procedure for dealing with a major medical emergency such as an epidemic. (e.g. Ebola, Asian Flu etc.)




86. Lifestyle Information Protocol

Recommendation: The Practice should set out its policy on providing lifestyle information for patients and managing their care.


87. Patient Group Directives (New)

Patient Group Directives should be kept centrally in the Practices and evidence should be available that new PGD have been ‘read’ by appropriate nursing staff and that the documents have been formally signed off by a lead clinician, normally a doctor.


QUALITY AND PERFORMANCE88. Complaints Procedure

(Amended)Recommendation: The Practice has a practice based Complaints Procedure (Local Resolution) and the options to make complaints are clearly explained in the practice leaflet and on the practice web site.

The procedure should clarify the mode of complaint (verbal, in person or in writing) time limits, consent and rights of appeal. Complainants should be made aware of the right to raise a matter with the NHS Ombudsman.

It should be clear to whom complaints relating to health professionals not employed by the practice but who might have been working in the surgery should be made.


89. Complaints Lead Manager Recommendation: The Practice has appointed a lead person to manage the complaints process.

Question: Are staff familiar with the procedure for making complaints?


90. Annual Complaints Review

Recommendation: There should be evidence available of an annual complaints review, an analysis of complaints outcomes and action or learning points if any.


91. Significant / Critical Events (Amended)

Recommendation: The Practice should keep records of any Significant Events that has taken place. Records should show events recorded over at least the past year including action taken, review and learning outcomes – if any. The CQC Inspectors are likely to request sight of reports.

Question: Are all staff aware of the arrangements for reporting a significant event?




92. Patient Survey Recommendation: The Inspectors may wish to see the results of any Patient Survey carried along with a report of any action taken. Remember information is already available to Inspectors online. The Inspectors may also have viewed entries on the NHS Choices web site and their visit may have been prompted by a complaint.


93. Friends and Family Test Recommendation: The Practice should be able to show what steps are being taken to carry out the Friends and Family Test and produce the results so far.


94. Patient Participation Group

Recommendation: The CQC Inspectors will ask to speak to members of the PPG. Keep a list of contact names available. Have copies of minutes and reports available. These should be online on the practice web site. The Practice should be able to provide evidence of Patient Survey reports. Ensure that an invitation to join the PPG is on display.


Question: When are PPG meetings held and what is the frequency of meetings or is the group managed by email (virtual group on line forum)

FINANCIAL MANAGEMENT 95. Standing Financial

Instructions (Amended)Recommendation: The Practice should have a set of Financial Instructions setting out how the finances of the practice are managed. It should include information about existing and setting up new bank accounts, and the arrangements to sign off payments. It should indicate whether the Practice is VAT registered. It will show the selection process for appointing the Practice Accountants. It should explain the arrangements for setting and reviewing drawings and determining partnerships shares. The Instructions should also cover the arrangements for handling cash and dealing with private income. It should also set out the spending powers of the Practice Manager, if authorised to sign off payments. The CQC expect practices to demonstrate that there are financially viable and able to provide the services they are contracted to provide.


96. Payroll Management Recommendation: The procedure for undertaking the payroll operation and recording NHS Superannuation payments should be set down in a policy, such as Standing Financial Instructions. The method of calculating pay and dealing with pensions should be explained along with any software used or any agency employed.

Question: Are annual pension returns issued to staff and are staff offered

pension estimates?



Added to that are staff only being offered a Workplace or NHS Pension on employment?


97. Premises Management Recommendation: The Practice Management should ensure that the premises are clean and tidy in readiness for a CQC inspection. Corridors should be clear of blockages. Notice Boards should be well organised and any notices or posters should be readable. The Inspectors will in effect start their inspection before walking in through the main entrance in the car park. They may comment on outside signs, on the privacy of the reception counter, and whether it is disability ‘friendly. They may look for a ‘hearing loop’ and large typeface signing.

Pre-Inspection Premises Tips: - first impressions count!

Is there any part of the surgery that needs a touch of paint? Are there any unmarked trip hazards – mind your head? Are the toilets facilities well stocked and checked regularly? Are fire extinguishers ‘checked’ annually? Are all light bulbs, including fluorescent lights functioning? Is the waiting room tidy, including toys, books, magazines, leaflets,

and positioning of chairs. Are there any trailing electric cables? Are computer screens left on unattended, smart cards still

connected? Are there any worn carpets that need replacement? Are exit routes clearly signed and rooms named? Does any Branch Surgery meet the same standards?


98. Practice Accounts Management

Recommendation: The procedure for managing the practice accounts should be set out in Standing Financial Instructions, which should define who has authority to approve payments, open bank accounts, and keep financial records. The Instructions should specify the software used for payroll and practice accounts. A copy of the most recent annual accounts should be available. (The Inspectors may ask!)


99. Petty Cash Control Recommendation: The procedure for handling petty cash in the practice should be documented and staff should be aware of such procedures. The Practice may be asked about steps taken to record the receipt of cash and cheques in order to avoid fraud and theft. Practices may also have introduced card machines for receiving payments.


100.Private Fees and Charges Recommendation: The Practice should have a clear and visible policy on



charging patients for private non-NHS Services. A poster setting out private fees charged by the Practice should be on display in the surgery waiting room or at the reception counter.


BUSINESS MANAGEMENT101.Disaster Recovery Plan Recommendation: The Practice should have in place a Business Continuity,

Disaster and Recovery plan to activate should there be a major disaster such as a fire or maybe the sudden loss of a senior member of the practice, such as a partner or practice manager. It does happen!


Question: What arrangements are in place to deal with a computer ‘crash’ and how will consultations continue?

PRACTICE PREMISES102.Ownership or Tenancy Recommendation: The Practice should be able to provide information about

the ownership of the premises. If leased a copy of the lease should be available along any evidence of building maintenance that is required to be provided under such a lease.


103.Disability Access Recommendation: The Practice should be able to demonstrate that access to the premises for disabled people has been provided along with suitable ambulant toilet facilities and accessible (sign-posted) treatment and consulting rooms.


104.Nursing Mothers Recommendation: The Practice should provide facilities for nursing mothers who wish to breast feed.


NOTE – The Inspectors may be looking for specific information on waiting room notice boards. This may include the location of breast feeding facilities, how to make a complaint or make a suggestion and how to join the Patient Participation Group.

NHS CONTRACTING105.Clinical Commissioning

GroupRecommendation: There should be evidence of involvement and interaction with the local Commissioning Group (and local Federation or Alliance if one exists) and with NHS England’s Area Team.


Robert Campbell, 02/12/15,



106.Directed and Locally Enhanced Services (Amended)

Recommendation: The Practice should be able to provide copies of any current agreements to provide enhanced services along with evidence of activity and claims submitted. The Inspectors may also ask for an explanation about each Enhanced Service that is currently provided by the Practice.

Question: Inspectors may ask to see signed agreements and check how clams are made and checked. Is there an audit trail?


NOTES

Please be aware that this list is not exhaustive. The checklist has been updated and extensively amended to take account of developments in general practice and the content of reports issued by the Care Quality Commission. If you have any comments or want to suggest additional items or area to cover, please contact Robert Campbell – [email protected]

All policy documents, procedures and protocols should be dated and show a review date. They should also name a lead person responsible and a deputy. Sample documents may be found on the following sites:www.practiceindex.co.ukwww.gpsurgerymanager.co.uk If there are any documents, you would like help with please do not hesitate to contact me.

Robert Campbell - 2nd Edition August 2017, 1st Edition December 2015


http://www.gpsurgerymanager.co.uk/


care quality commission ‘100+’ inspection checklist...

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