AGENDA

TIME TOPIC SPEAKER         09.00 - 09.15 Registration and Welcome All    09.15 - 10.00 CQC Inspection - Further Hints and Tips Lisa Soultana Chief

Operating Officer  

 10.00 - 10.45 GP’s CQC Experience and Nigel Sparrows’

Myth-bustersNwando Umeh  Business and Liaison Officer

 10.45 - 11.30 What’s Next: After the Inspections Emma Bravery   Bravery

Consultancy  

 

11.30 - 12.00 General Q&A/Close All    

CQC InspectionsFurther Hints and Tips

Lisa Soultana Chief Operating OfficerDerby and Derbyshire

LMC

Basic CQC Administration

Who is your CQC Registered Manager?

Is the Registered Manager recorded on your CQC e-registration account and is your e-registration account up to date with all critical information, as required by CQC?

Have you encountered any recent partnership changes and have you informed CQC and carried out a validated (via Post office) DBS check and submitted to CQC?

Be up to date with information on the CQC website for GP providers.

Gathering information from the GP practice 5 working days before inspection (1/2)

Before CQC begin inspecting in a CCG area they will write (usually email to Registered Manager in the first instance) to GP practices and ask them for some information.

GP practices and will have five working days to respond to their request.

CQC will make clear what information to send, where to send information and who to contact with any queries or questions

The following list is not exhaustive and CQC may ask for further information depending on the information available to them.

Copies of letters and further information and guidance on this matter can be found on the LMC website

The information CQC will request is likely to include:

An action plan that addresses the findings from any patient survey carried out.

A summary of any complaints received in the last 12 months, any action taken and how learning was implemented.

A summary of any serious adverse events for the last 12 months, any action taken and how learning was implemented.

Evidence to show that the quality of treatment and services has been monitored. This includes evidence of two completed clinical audit cycles carried out in the last 12 months, and evidence of any other audits, with evidence of actions or outcomes taken as a result.

Recruitment and training policies and procedures (for example, how staff are recruited and vetted before commencing work, arrangements for European Economic Area (EEA) and foreign doctors and what induction they receive).

Number of staff by role (whole time equivalent) and their professional qualifications and any training provided in the last 3 years.

A copy of the current Statement of Purpose.

Evidence and examples of the quality of care provided for the six population groups maximum 1,000 words.

Gathering information from the GP practice 5 working days before inspection (2/2)

30 minute presentation

There is no specific format or media for the 30-minute presentation; the GP practice can choose whatever format suits them.

Practices may choose to involve patients, staff (to include attached staff) that helps evidence compliance with the regulations.

Practices should be open and share their views with CQC. CQC inspectors want to get to the HEART of people's experience of care, so the focus of their inspections is on the quality and safety of services, based on the things that matter to people.

CQC Inspectors corroborate evidence during the inspection, so the presentation is one of the best opportunities to set the scene and tell the story of the practice and to evidence quality services and safe care against the five key questions and the six population groups.

It is vital to ‘SELL’ and ‘MARKET’ the care and services provided and try and demonstrate ‘outstanding’ examples and what the practice is doing to improve in those areas you know are not so good. The patient view is a very powerful medium to include in the presentation.

A well thought out presentation will help the practice establish the best possible rating.

Further guidance on a 30 minute presentation can be found on the LMC website

How KLOEs and evidence build towards ratings

Key lines of enquiry (KLOE)To direct the focus of CQC inspections, the CQC inspection teams use a standard set of key lines of enquiry (KLOEs) that directly relate to the five key questions they ask of all services in relation to the six population groups.

Having a standard set of KLOEs ensures consistency of what CQC look at under each of the five key questions and that they focus on those areas that matter most.

CQC argue this is vital for reaching a credible and comparable rating.

To enable CQC inspection teams to reach a rating, they gather and record evidence in order to answer each KLOE.

CQC Inspection Teams will use evidence from four main sources to answer the KLOEs.

For a copy of the KLOE read Please note: there are some differences in the prompts for GP practices and GP out-of-hours services, which are clearly marked with the KLOE document.

It’s critical for GP practices to use the KLOEs as an in house tool to review its operational systems and to start collating evidence for their CQC inspection.

How KLOEs and evidence build towards ratings

Gathering the views of GP practice staff and the importance of marketing

The inspection team will speak to staff. On all inspections, they are likely to speak to the following people:

GP partners. Other GPs employed, including locums and trainee GPs. Practice managers/managers of out-of-hours services. Practice nurses. Healthcare assistants. Administrative staff.

Although, this may feel informal and the inspection team are friendly, they are asking you questions to gather evidence about the compliance of the GP practice.

Critical for all the GP practice workforce to be on your guard.

The importance of Regulation 17: Good governance (1/5)

The intention of this regulation is to make sure that providers/GP practices have systems and processes that ensure that they are able to meet other requirements in this part of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Regulations 4 to 20A).

To meet this regulation; providers must have effective governance, including assurance and auditing systems or processes.

These must assess, monitor and drive improvement in the quality and safety of the services provided, including the quality of the experience for people using the service.

The systems and processes must also assess, monitor and mitigate any risks relating the health, safety and welfare of people using services and others.

Providers must continually evaluate and seek to improve their governance and auditing practice.

Regulation 17 compliance (2/5)A GP practice might use or refer to some of the following examples:   The systems in place for risk management and clinical governance and any

evidence of any change in practice as a result.

Having a mechanism for patient feedback/comments.

Having a publicised and robust complaints procedure for handling complaints from patients, this should comply with the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009.

Conducting clinical audits (at least 2 years’ worth that follows the audit cycle and evidences change)

Conducting regular significant event reviews and analysis.

Conducting risk assessments as and when appropriate and undertake all reasonable actions.

In addition, providers must securely maintain accurate, complete and detailed records in respect of each person using the service and records relating the employment of staff and the overall management of the regulated activity.

As part of their governance, providers must seek and act on feedback from people using the service, those acting on their behalf, staff and other stakeholders, so that they can continually evaluate the service and drive improvement.

Evaluating changes to ensure improvements have been achieved.

Incident reporting related to controlled drugs and other medicines and any evidence of learning/action taken.

  Any external accreditation process.

Reviewing and updating process for the workforce to read relevant policies/protocols/procedures.

Relevant local or national guidance having been taken into account.

Records of training and development and information related to misconduct investigations for ALL staff.

The importance of Regulation 17: Good governance (4/5)

Regulation 17 compliance (5/5) Reviewing of all information gathered about the safety and quality of the

services GP practices provide. From these reviews GP practices can identify any risks and the action to be taken to address them; and pinpoint ways to improve the service to patients.

Discussing key information collected at practice team meetings so that learning and development points/changes to working practice are identified if necessary. However, it should be the case that the GP practice workforce feels able to raise concerns about risks to patients/staff in a confidential manner at any time (Whistleblowing Policy).

Showing data about the quality of the GP practice in some form, within the public areas of the GP practice reception and/or on GP practice website. For example, results of a practice survey or a summary of patient feedback received via a suggestion box. Similarly, for the safety of patients, display health and safety information (including information about own responsibilities for contributing to health and safety) in the GP practice reception.

Circulating and acting on clinical guidance, medical alerts and safety alerts and any other relevant local or national reports, so that staff can change their working practices, if necessary, for the benefit of patients.

For further information about Regulation 17: Good Governance read

Regulation 17 compliance (6/6)

Start now…

Gather appropriate information and data to evidence compliance with CQC and Regulations

and present on day of your CQC inspection

CQC's New Approach to Inspecting Practices and What This Means for You Linda Hirst, Inspection Manager, Primary Medical Services and Integrated Care Directorate, Care Quality Commission, Central RegionThe CQC's New Inspection Regime from 1 October 2014 Dr John Byrne, CQC GP Regional Advisor We've Been Inspected - Hear About Our Experience Nicola Bromirski, Practice Manager and Melissa Smith, Trainer, Darley Dale Medical Practice - see the video presentation -  here Top Hints, Tips and Prompts - Preparing the GP Practice for a Scheduled Comprehensive CQC Inspection Lisa Soultana, Chief Operating Officer, Derby and Derbyshire LMCHints and Tips for Answering Questions During an Inspection Lisa SoultanaPreparing a 30-minute presentation for a GP Practice Scheduled Comprehensive CQC Inspection Guidance Lisa Soultana CQC's New Style Inspections - What to Expect When we Inspect Non-clinical GP workforce - The types of questions a CQC inspector may ask themA Greater Understanding of the CQC GP Scheduled Inspection and my Role and ResponsibilityFor the non-clinical workforce excluding managementCQC adapted copies of letters, emails and templates CQC will require information prior to the GP Practice inspection. GP Practices will receive a letter and template asking for this information to be submitted 5 working days prior to the inspection date.

Further information and additional resources available on the Derby and Derbyshire LMC website

Thank you for listening

Any questions?