CQC Transitional Monitoring Approach Guidance Dental

CQC Transitional Monitoring Approach Guidance – Dental

1 t: 0333 405 33 33 e: [email protected] w: www.qcs.co.uk

The CQC has evolved its approach to regulating as the risks from the coronavirus pandemic change, by using a transitional approach to monitoring services.

The focus is on:

• Safety

• How effectively a service is led

• How easily people can access the service

The new approach includes:

• A strengthened approach to monitoring, based on specific existing key lines of

enquiry (KLOEs) so that risk in a service can be monitored

• Using technology and local relationships to better direct contact with people who

are using services, their families and staff working in the service

• Targeting inspection activity where there are concerns

Once the CQC have reviewed information about your service, you will have a conversation online or via telephone. This is not an inspection and you will not be rated from this. It will help decide if further regulatory action is needed.

Information considered about a service

The CQC will consider:

• Previous inspection reports and ratings

• Monitoring information collected through usual data sources and an inspector’s knowledge of the services

• Views of people who have used the service from online feedback, such as google

reviews, practice website, social media platforms plus enquiries and

information from other agencies

Where more information is required, the CQC will contact you for further information.

Monitoring

A call will be arranged with you and can take an hour or two, but some may be shorter. Microsoft Teams will be used where possible, if not a telephone call will be arranged.

The call will be around the specific KLOEs for your type of service and the inspector will note details around the discussion you have, noting any risk areas identified and examples of good practice and improvements to the service.

The inspector may also request evidence during the call and will allow screen sharing or attachments to be sent on an encrypted or protected email. If evidence cannot be sent on the call it must be sent to the inspector within 24 hours of the call. This will only be done where

necessary.

Audio recordings will not be taken unless your consent is gained. An overall monitoring

summary of findings will be prepared after the call.

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The monitoring summary record is not an inspection report, and no ratings are given, as such the factual accuracy process does not apply. Monitoring summary records will not be published on the CQC website and should not be shared publicly.

Monitoring Outcome

Where an inspection or other regulatory action is not needed, a copy of the monitoring summary record will be sent.

Where risks are identified to the safety of people using the service, further regulatory action may be taken, including help to find additional sources of support for the service, an inspection to be carried out or enforcement processes. A monitoring summary record will not be sent in such cases and the necessary action will be taken.

Monitoring Questions for Providers

During the inspector’s call they will focus on the specific key lines of enquiry below. The types of detail asked within each KLOE is also recorded with some guidance from QCS on potential examples, policies and documents to refer to for evidence of these:

SAFE

S1: How do systems, processes and practices keep people safe and safeguarded from abuse? Potential Evidence

How do you ensure staff

recognise safeguarding issues

for adults, children, and other

vulnerable people, and that they

take appropriate action?

• Safeguarding notifications and records

• Feedback from Local Authority/Safeguarding teams

• Safeguarding Policy and Procedure

• Safeguarding Children and Child Protection Policy

• Mental Capacity Act (MCA) 2005 Policy and

Procedure

• Protecting Vulnerable People from

Radicalization Policy and Procedure

• Appropriate level of training for individual staff

members – as a standard level 2 is expected

How do you ensure that the

management of any

safeguarding concerns does

not discriminate people, and

that their human rights are

protected?

• Equality and Human Rights Policy and

Procedure

• Consent Policy and Procedure

• Update staff training in Safeguarding, FGM,

Radicalisation, Domestic Violence

• Document regular Safeguarding staff meetings

• Check for regular updates on local Safeguarding

board websites

• Display Safeguarding flow chart and safeguarding

lead details for all staff to see

• Patient feedback







What are your arrangements to

respond to medical

emergencies?

• First Aid and Medical Emergency Policy and

Procedure

• Management of Medical Devices Policy and

Procedure

• Accident and Incident Reporting Policy and

Procedure

• Demonstrate staff training in BLS updated

annually or ALS if offering sedation services

(both clinician and assisting nurse)

• Use of panic button on dental software to alert

other staff members to an emergency

• Evidence regular meetings discussing medical

emergency arrangements and role

play/scenario- based training on how to respond

to a medical emergency

• Check lists and regular spot checks on

equipment and emergency drugs

• Handover forms for Ambulance service –

detailing the event, staff present, materials used,

medication used – batch numbers and expiry

dates

Where you have moved to remote

consultations (telephone and

video consultations)? How do you

identify vulnerable people or

people who might be digitally

excluded because of

communication barriers (for

example, because of a disability or

poverty)?

• Video Consultations Policy and Procedure

• Antimicrobial Prescribing Policy and Procedure

• Refer to the GOV.UK Guidance on shielding and

protecting people who are clinically extremely

vulnerable from COVID-19

• Equality and Diversity Policy and Procedure

• Equality and Human Rights Policy and Procedure

• Update and maintain staff training as and when

guidance changes and update SOP to reflect this

• Follow SOP in regard to appropriate triaging

procedures

• Evidence practices meetings

• Dental Care Communication and Information

Policy and Procedure

• Communication Policy and Procedure

• Patients with Communication Difficulties Policy

and Procedure








S2: How are risks to people assessed, and their safety monitored and managed, so they are supported to stay safe?

Infection Control Potential Evidence

What changes have you made

to infection control

arrangements to protect staff

and patients using the service?

• How have you made the Practice COVID secure?

E.g. screens, revised cleaning schedules, break

areas, social distancing with work areas

• Created a Standard Operating procedure and

shared with all staff

• Adequate training of staff to demonstrate

enhanced cross infection procedures after an

AGP

• Introduction of Fallow time or reduction of Fallow

time using certified Extraction fans with >10-12

ACH

• *Sessional mopping of the floors

• Enhanced PPE – including FFP3 masks, full face

visors, gowns and aprons

• Controlled waiting room – monitoring how many

patients are in the waiting room at any one time

• Infection Control and Decontamination Policy and

Procedure

• Personal Protective Equipment (PPE) Policy and

Procedure

• Assessing and Reducing Risk to Workforce

(COVID-19) Policy and Procedure

• Coronavirus Policy and Procedure

• Pandemic Policy and Procedure

• Staff Immunisations Policy and Procedure

• Premises Cleaning Policy and Procedure

• Hand Hygiene Audit Tool

• Signage (internal and external)

• Patient notices about social distancing, face

coverings and hand washing/sanitising

• Risk Assessments e.g. Risk of Showing

Symptoms of Coronavirus (COVID-19), Risk

Assessment for Staff (Including Vulnerable

Groups During COVID-19), Staff Immunisations

• Encouraging staff to have the vaccine, and

directing them via the correct pathway

• The Practice website and social media have been

updated with appointment, prescription collection

and visiting information







• Locked door policy

• Updated patient journey

• Paperless interaction such as signing forms on

patients' behalf etc.

How do you ensure that staff have

the appropriate time for

donning/doffing and cleaning

between seeing patients?

• Personal Protective Equipment (PPE) Policy and

Procedure

• The procedures you have in place to allow

additional time e.g. longer

• appointment times, zoning of appointment book

• Staff input and feedback

When was your last audit of

IPC/PPE/the environment and

facilities? What did it tell you and

what actions have you taken?

• Infection Control and Decontamination Policy

and Procedure

• Audit Policy and Procedure

• Clinical Waste Disposal Policy and Procedure

• An IPC audit has been carried out in the last 6

months

• Any IPC actions are documented and with

target and completion dates

• Updated training and CPD

Safety systems and risks to people Potential Evidence

What actions have you taken in

the last six months as a result of

learning from serious incidents to

ensure that people are kept safe?

• Serious Incident Notification Policy and

Procedure

• Hazard Reporting Policy and Procedure

• Significant Event Policy and Procedure

• Accident and Incident Reporting Policy and

Procedure

• Quality Meetings Policy and Procedure

• Management Meetings Policy and Procedure

• COVID-19 Secure Workplace

• Risk Assessments e.g. Pandemic Threats by

Infectious Diseases Risk Assessments

• COVID–19 Practice Management Policy and

Procedure

• Health and Safety Policy and Procedure

• Health and Safety Training Policy and Procedure

• In-house training documenting relevant changes

to procedures

• All documented actions discussed at relevant in-

house meetings





CQC Transitional Monitoring Approach Guidance – Dental Last update: 17.05.21

t: 0333 405 33 33 e: [email protected] w: www.qcs.co.uk 6

How are patients who need

urgent care and treatment

identified, prioritised, and protected

from discrimination?


• Referral Policy and Procedure

• Appropriate triaging procedures

• Training evidence for staff

• Describe and provide evidence of your processes

for treating patients who need urgent care

• Referral to Urgent Dental Care Hubs- following

referral criteria

• Tracking, monitoring and following up on

referrals

How do you recognise and

manage the deteriorating

patient?


and Procedure

• Patient Involvement Policy and Procedure

• Management of Oral cancer and implementing

the Two Week Wait urgent referral form


• Appropriate triaging procedures to recognise

dental trauma or life-threatening dental

swellings

• Evidence of staff training on when to seek

secondary care in a dental emergency

• Describe how you maintain your list of

vulnerable, or clinically Vulnerable patients and

how they are prioritised in the diary – such as

vulnerable clinics first thing in the morning

How do you ensure appropriate

staffing levels and skill mix to

cope with demand? (For example,

weekends, bank holidays, seasonal

pressures, epidemics)

• Staff rota Policy and Procedure

• Recruitment Policy and Procedure

• Training Policy and Procedure

• Agency Staff Policy and Procedure

• Business Continuity Policy and Procedure

• Annual Holiday Policy and Procedure

• Unable to Attend Workplace Policy and

Procedure

• Outbreak Management Policy and Procedure

• Sickness Absence Policy and Procedure

• Absenteeism Policy and Procedure

• Furlough Policy and Procedure

• Training records and CPD logs

• Staff Attendance Record

• Rota Management





• Details of how the team was managed - i.e.

teams were split into two groups or split shifts

to avoid transmission within the team

• Advise staff to turn off track and trace app while

in work

• If there was a transmission within the workplace,

how did you handle this? What procedures did

you follow?

Do you provide conscious

sedation? If yes, how do you

ensure that risks are assessed,

monitored and managed so that

sedation is delivered in a safe

and effective way, in line with

published standards?

• Refer to the Sedation Policy and Procedure

• Ensure that staff are appropriately trained in

sedation and hold current qualification and

indemnity to perform the regulated activity


Procedure

• Management of Medical Devices Policy and

Procedure

• Risk Management Policy and Procedure

• Both Clinician and assisting nurse must be

trained to ALS

• Follow SAAD guidelines

• Ensure that two oxygen cylinders are on site at

all times

• Ensure that all appropriate safety checks and

logs are carried out and audited appropriately

How do you identify and manage

patients who need a face-to-face

appointment?


• Appointment Book Management Policy and

Procedure

• Treatment Policy and Procedure



• COVID-19 Practice Management policy and

Procedure

• Describe how patients are triaged and assessed

for a face-to-face appointment

• Evidence how you pre–screen patients prior to

appointments for signs and symptoms of

COVID-19

• Discuss Patient Journey and SOP

How are you managing clinical

capacity to provide safe oral

health treatment and support?


• Appointment Book Management Policy and

Procedure

• Treatment Policy and Procedure






• Zoning diaries to include appropriate clinics

• Fallow time calculator

• Maintain records of who is triaged, referred and

seen face to face and then how you follow up

these patients

• How do you Manage the staff rota to fill

available surgeries and facilitate fallow time?

• Maintain good training records

What are your systems to support

staff to work remotely where this is

appropriate and required?

• Home Working Policy and Procedure

• Data Protection and Confidentiality Policy and

Procedure

• Confidentiality and Data Protection checklist

• Display Screen Equipment Policy and Procedure

• Employee Welfare Checklist

• Flexible Working Policy and Procedure

• Emergency Communication Policy and

Procedure

• Daily Communication Policy and Procedure

• Stress and Mental Health in the Workplace


• Assessing and Reducing Risk to the Workforce

(COVID-19) Policy and Procedure

• Discuss how you support staff and manage

their workload throughout the day





S3: Do staff have all the information they need to deliver safe care and treatment to people?

Potential Evidence

How do you manage clinical

records to ensure safe care and

treatment?

• Record Keeping Policy and Procedure

• Archiving, Disposal and Storing of Records


• Obtaining Medical Reports Policy and Procedure

• Clinical Record keeping Audit – every 12 months


• Treatment Plan Policy and Procedure

• Treatment Plan Audit tool

• Data Security and Data Retention Policy and

Procedure

• Training of staff on accurate record keeping

• How have you included triaging notes? Did you

create a template?

• Staff meeting minutes

How do you manage referrals to

and from other providers?


• Referral to Urgent Dental Care Hubs - following

referral criteria

• Tracking, monitoring and following up on

referrals

• Computer, Email and Internet Usage Policy and

Procedure

• Data Protection and Confidentiality Policy and

Procedure

• Breach Notification Policy and Procedure





S4: How does the provider ensure the proper and safe use of medicines, where the service is

responsible?

Potential Evidence

Have you made any changes to your

approach to medicines

management? (For example, in

relation to repeat prescribing,

ongoing monitoring requirements for

high-risk medicines)

• Antimicrobial Prescribing Policy and

Procedure


Procedure

• Prescription Security and Management Policy

and Procedure

• Prescription Security and Management Policy

and Procedure

• Antimicrobial Prescribing Policy and

Procedure

• Describe and evidence AAA prescribing and

safe electronic security of sending scanned

prescriptions - i.e. NHS.net email address

• Auditing Prescriptions

• Logging and monitoring Prescriptions

• How do you follow up on these prescriptions?

Did it result in a UDC referral?

If so, what, and how has this affected

care?

• Discuss antibiotic resistance in over

prescribing

• Discuss increase in loss of teeth due to lack

of face-to-face treatment in first lockdown

• Discuss link to prescribing and UDC referrals

• Discuss how it impacted root canal vs

extraction ratios

• Discuss the changes in your pre-COVID

audits to your most recent audit

How are people’s medicines

reconciled, in line with current national

guidance, when transferring between

locations or changing levels of care?

• NICE Guidelines

Have you made any changes to

antimicrobial prescribing? If so, how

has this affected care?

• Describe and evidence any changes you

have made and how this has affected care






EFFECTIVE

E1: Are people's needs assessed and care and treatment delivered in line with current legislation,

standards, and evidence-based guidance to achieve effective outcomes?

Potential Evidence

How are you identifying, cascading

and keeping up to date with changes

in clinical guidance?

• Primary Care Bulletins

• CDO updates

• QCS Resource Centre and Updates

• CQC Updates

• NHS England website

• FGDP updates

• SDCEP updates

• PHE Website

• LDC emails/newsletters

• BDA website

• NHS Digital Website

• NICE website


• Management Meetings Policy and

Procedure

• Regular COVID staff meetings

• Staff are provided with regular training and

instruction as guidance changes

What are your oversight arrangements

for clinical care provided by clinical

and non-clinical staff?

• Supervision Policy and Procedure

To people in care homes • Only applicable to Residential Care

• Feedback from patients

To vulnerable people in their own

homes

• Only applicable to Domiciliary Care

• Feedback from patients





E3: How does the service make sure that staff have the skills, knowledge and experience to

deliver effective care, support and treatment?

Potential Evidence

How do you ensure that all staff (clinical and

non-clinical), including those being flexibly

re-deployed, have the skills and knowledge to

carry out their roles and responsibilities

effectively?

• Recruitment Policy and Procedure

• References Policy and Procedure

• Development Appraisal Policy and

Procedure


• COVID-19 Testing Policy and

Procedure


Procedure

• Contingency Plans

• Evidence of Practice training days

• Evidence of Fit testing

• Evidence of COVID-19 vaccination

• Lateral flow testing logs

• Practice Reporting arrangements

• Discuss how you have kept staff

updated throughout

• Meetings around transition back to

face-to-face dentistry





E5: How are people supported to live healthier lives and, where the service is responsible,

how does it improve the health of its population?

Potential Evidence

How do you ensure that people

who are affected by health

inequalities are receiving the care

they need?


• Quality Assurance Policy and Procedure


Procedure

• Equality and Diversity Policy and Procedure

• Transgender Policy and Procedure

• Dental Care Communication and Information



and Procedure



• Displaying important patient information on

social media platforms/website and in Practice

telephone messages

• Ensuring that patients have access to expert

advice and a robust referral process

• Operating out of hours services in line with

contractual arrangements

• Evidence that all patient contacts are

• followed up

How are you promoting good

health/targeted approaches in

response to coronavirus

(COVID-19) and people at risk?

• Information available on the Practice website

and social media

• Continuing with health screening programmes

such as Oral cancer awareness week, World Oral

Health Day, Mental Health week and smoking

cessation campaigns

• Staying updated via:

• Primary Care Bulletins

• CDO updates

• QCS Resource Centre and Updates

• CQC Updates

• NHS England website

• FGDP updates

• SDCEP updates





• PHE Website

• LDC emails/newsletters

• BDA website

• NHS Digital Website

• NICE website



Procedure

• Regular COVID staff meetings

• Staff are provided with regular training

and instruction as guidance changes

How is your service working with other

practices, and sectors, to promote

access to good oral health and deal

with any missed appointments?

• Appointment Book Management Policy

and Procedure


• Staying updated on guidance from the

BDA website and LDC newsletters

• Evidence of local arrangements with a

buddy practice

• Business Continuity Plan Policy and

Procedure

• Dental Neglect training with staff





CARING

C1: How does the service ensure that people are treated with kindness, respect and compassion,

and that they are given emotional support when needed?

Potential Evidence

How have you adapted how you

support and engage with patients and

their families/loved ones (for example,

in the context of more remote working)?


• Feedback from patients and their relatives

and carers via email

• Google reviews

• Friends and Family Test

• Staff feedback questionnaires

• Dedicated email domain for patient advice

• Discuss how you have responded to

patient feedback and if you took any

action – give examples

• Triaging clinic daily

• Staff rota to reflect delegation of triaging

responsibilities

• Implementation of remote prescribing and

working with local Pharmacies





C2: How does the service support people to express their views and be actively involved in

making decisions about their care, support and treatment as far as possible?

Potential Evidence

How do you support people to express their

views and actively involve them to make

decisions as far as possible?



• Complaints, Suggestions and

Compliments Policy and Procedure

• Patient Involvement Policy and

Procedure

• Treatment Plan Policy and Procedure

• Give examples of how you have

responded to feedback or how you

de- escalated a complaint

• Discuss how you share this

information with the wider team

• Evidence of meeting minutes

• Evidence of staff training in

Complaints handling and ethics

• Complaints poster displayed in the

Practice and on social media/website

platforms

• Complaints leaflets available

• Details of Complaints Officer/Lead

• Discuss how complaints are logged

manually or electronically

• Examples of how you share any

actions taken from a

complaint/feedback to the patient





RESPONSIVE

R1: How do people receive personalised care that is responsive to their needs?

Potential Evidence

How do you take into account patient

choice about how, when, where they

want to be seen?



• Accessible Information Standards Policy and

Procedure

• Patients with Communication Difficulties



• Mental Capacity Act (MCA) 2005 Policy and

Procedure

• When and how would you implement Gillick

Competency checks?

• Discuss the procedure on providing patients

with their treatment options, how is this

documented in the patient records?

• Describe and evidence the communication

methods to show how patients can make

decisions about their care and treatment

• Are information leaflets or videos available

to the patients? Do you direct them to online

resources?

• Are patients given ample time to think about

their options and discuss these with friends

and family?

• How do you document their final decision?

How do you ensure that people with

information and communication

needs are able to access

appointments and services in ways

that meet their needs?

• Dental Care Communication and

Information Policy and Procedure

• Access to Information Policy and Procedure

• Patients with Communication Difficulties


• Describe how you help patients with a

Learning Disability to access appointments

• Provide examples of any adjustments made

for patients





• Do you have a hearing loop? Braille leaflets?

Translation or interpreter services

available?

• Is there wheelchair access? A stairlift?

Disabled access WC? Ramps?

• Is the reception desk at a reasonable height

for wheelchair users and people with

dwarfism, what reasonable adjustments

have you made to accommodate less

able-bodied patients?

• Do you have appropriate lighting throughout

the premise for those with poor or limited

eyesight?

• Discuss how you would book a patient with

diabetes or severe dental phobia?

• Give an example of when you went above

and beyond to accommodate a patient with

additional needs?

• How would you accommodate a patient

who arrives to the practice and informs you

they are Transgender and wish to change

their name and pronouns on their records?

• Evidence staff training Evidence Practice

meeting minutes

Have you identified any barriers to

care provision, particularly for

patients with protected

characteristics? For example,

disabled or older people. If yes, what

actions have been taken to combat

them?

• Provide examples of issues you have

come across and how you have addressed

them

• Risk Assessment Policy and Procedure

• Individual Risk Assessments

• Black and Asian minority risk assessments

• Disability Access Audit

• How have you managed shielded patients

who have required urgent dental treatment?

• Referrals to UDCs

• Triaging procedures

• Referrals to Community Dental Services

• Management of urgent cancer referrals

• What adjustments have you made to how

you manage these patients?

• Discuss any training you have provided your

staff to recognize these patients





R3: Can people access care and treatment in a timely way

Potential Evidence

How are you managing access to

services?

Do you have backlogs of activity and

long waiting times as a result of

coronavirus? How are you managing

this? What are your recovery plans?

• Appointment data from your clinical

system

• Waiting lists for patients part way

through treatment

• Running reports to reflect incomplete

course of treatment

• Cancellation code to reflect

COVID-19 as reason for cancelled

appointment for auditing purposes

• Prioritising outstanding treatments

based on need, urgency and patients

shielded status

• How will you work through any existing

blog?

• Provide examples of how you have

managed this thus far

• What hurdles have you overcome?

How are you ensuring that

high-risk/vulnerable patients and

pathways are being identified and

prioritised appropriately?

• Describe how you triage patients before

arranging face to face appointments to

ensure it is an essential journey and in line

with the patient pathways

• Describe how you have zoned your

diaries to allow for emergency clinics,

vulnerable or shielded patients to attend

• Describe how you ensure that staff are

aware of the appropriate pathways for

patients e.g. GOV.UK Guidance on

Shielding and Protecting People Who are

Clinically Extremely Vulnerable from

COVID-19 and COVID-19 infection

prevention and control guidance.

• Discuss how you have managed fallow time

or what provisions you have put in place to

mitigate the risk or reduce fallow time via

mechanical extraction

• Evidence staff training





What are your arrangements to

follow-up and support patients whose

care and treatment was delayed due to

coronavirus? For example, patients with

non-coronavirus related issues.

• Describe how you manage waiting lists

for patients whose appointments were

postponed during the pandemic

• Describe your recovery plans

• Discuss the impact the coronavirus has

had on your practice and how you have

been managing appointments, with

60-minute fallow time, reduced surgeries

and staffing rota issues due to

self-isolation or infection

How are you ensuring equitable access

to appointments when they are needed,

especially for people with protected

characteristics and vulnerable groups?

For example, Trans people, people who

are housebound, people at the end of

their life (not relevant to online services)

• Appointment Book Management


• Dental Care Communication and

Information Policy and Procedure

• Transgender Policy and Procedure

• Describe how these patients access

appointments


Procedure

• Do you run a Domiciliary service? If so,

discuss arrangements in place

• FGDP Dementia friendly dentistry good

practice guidelines


• Updated Safeguarding training

• Mental Capacity assessments – give

examples

• Robust referral system in place to log,

track and follow up

How do you ensure that patients are

receiving appropriate types of

appointments to meet their needs?

• Appointment Book Management



How do you ensure that people are able to

register with the practice? For example,

refugees, asylum seekers, migrants and

homeless people

• Equality and Diversity Policy and

Procedure


Procedure

• Refer to GOV.UK Dental Health: Migrant

health Guide





How is the service working with

partners to maintain and improve

access? (For example, third-party

providers, carer services, local

services such as ambulance service

etc.)



Procedure

• Describe how you are providing NHS 111

appointments and liaising with the UDCs,

GPs and other dental professionals in your

field

• Give an example of when you may have

organised treatment via another allied

healthcare professional





WELL LED

W3: Is there a culture of high-quality, sustainable care?

Potential Evidence

What actions are you taking to protect

and support the health, safety, and

wellbeing of staff, particularly those who

are high-risk for example, coronavirus

testing?

• Risk Assessments – e.g. for staff

(including Vulnerable Groups during

COVID-19) and Risk of Showing

Symptoms of Coronavirus

• Give examples of any reasonable

adjustments you have put in place

• Black and Asian Minority Groups risk

assessments

• Fit testing of FFP2/3 masks and RPE

• Lateral Flow tests – twice weekly

• Level 2 PPE

• On-going training as Government advice

and the science changes

• Updated Cross Infection and Prevention

guidelines

• Access to vaccination (voluntary)

• Furlough – high risk staff

• Discuss what your arrangements were and

how you accommodated your staffing

needs during the initial lockdown

How do you promote equality and diversity,

and check that staff feel supported,

respected, and valued?

• Equality and Diversity Policy and

Procedure

• Staff Retention Policy and Procedure



Procedure

• Staff feedback from surveys, appraisals,

one-to-one meetings, and opportunistic

discussions

• PDP meetings

• Regular 1-2-1 catchups with staff






What training and support is available for

staff using new technology to deliver

care? (Not relevant to online services)



• Mock Inspections

• Maintain open communication and

review staff needs – training analysis

• Describe how staff are using and

adapting to different ways of using

technology to deliver care

How are you supporting staff who work

remotely and how are you assessing

them?



• Describe how you keep in touch with

staff working from home

W5: Are there clear and effective processes for managing risks, issues, and performance?

Potential Evidence

Has your business/operating model

changed since the pandemic? If so, how,

and what has been the impact on staff

and people who use your services?


• Quality audits

• Evidence of good governance i.e. meetings,

action plans and lessons learnt

How do you assure yourself that you are

providing a safe service? For example,

regular audits and increased supervision

etc.

• Clinical Governance Policy and

Procedure

• Audit Policy and Procedure


• Evidence actions and learning from any

audits and meetings, with examples of how

this has driven improvement in the service

How are you monitoring business risks

and issues, and what actions are you

taking to respond to them?

• Risk Management Policy and Procedure

• Business Continuity Policy and

Procedure

• Following advice from NHS England CDO,

FGDP, BDA etc. and updating SOP to

reflect the changes

• Implementing changes and providing

staff with adequate training to carry out

any new roles and responsibilities

• Staff and patient feedback

• Regular management and practice

meetings





What are the arrangements for

business continuity? For example,

arrangements for diverting calls,

contingency planning for staff

shortages/outbreak onsite, changes

made in light of coronavirus. How are

you flexing the service/models of

care to adapt to changing

circumstances, including second

wave of coronavirus?

• Business Continuity Policy and

Procedure

• Describe how you have reviewed your

Business Continuity Plan, what

adjustments you have made and what

lessons you have learned to put things in

place for any further waves of the

pandemic

How are you working with partners to

review and update local pathways?

• Describe how you are working with the

CDO, NHSE, BDA, FGDP, SDCEP, local

Practices and other care providers

How do you ensure oversight and

governance of care provided by external

staff who are working with your patients?

For example, Agency or locum staff

• Clinical Governance Policy and

Procedure

• Locum Policy and Procedure

• Agency Staff Policy and Procedure

• Supervision Policy and Procedure

What are your arrangements for X-ray

equipment at the Practice and radiation

protection?

• HSE registration evidence

• RPA arrangements in place

• Regular audits – evidence available

• Dosimeter badges

• Radiography and Radiation Protection


• What are your new procedures for taking

and developing X-rays during an AGP

procedure?

• Do you have a runner or buddy staff

member processing X-rays?

• Have they been adequately trained? Is

this documented?

• How have you maintained equipment

and servicing during this time?

• Dental Equipment Maintenance Policy

and Procedure





W8: Are there robust systems and processes for learning, continuous improvement, and

innovation?

Potential Evidence

What systems are in place to support

people (staff/people who use your services

and their families/carers) to speak up and

raise concerns?

• Complaints, Suggestions and

Compliments Policy and

Procedure

• Whistleblowing Policy and Procedure

• Duty of Candour Policy and Procedure

• GDC Policy and Procedure

• Posters on display

• What information is available to patients

and how are they made aware of this?

• Staff training – evidence on how to

handle complaints and feedback

• Encourage open door policy for staff to

raise concerns

• Who do staff raise concerns with?

• Give an example...

• Regular staff meetings – meeting

minutes

How do you support people to provide

feedback?

• Staff surveys

• Patient surveys

• Patient Participation Group

• Friends and Family Test

• Online feedback via the Practice website

• Google review

• Social media reviews

• Encourage honest feedback – and share

changes implemented as a result of

feedback back to patients on a regular

basis

• Maintain open communication with

patients and staff



CQC Transitional Monitoring Approach Guidance Dental

Documents

Transcript of CQC Transitional Monitoring Approach Guidance Dental