The CQC strategy for the five-year period (2016-21) sets out a new approach due to the vast majority of GP practices being rated as either good or outstanding (as far as ratings go, past month's numbers show that there are 51 "Outstanding", 908 "Good", 344 "Requires improvement" and 101 "Inadequate" practices nationwide). Having this level of quality within primary healthcare has resulted in the CQC adapting how they regulate general practice.
This does not mean that the previous formal visiting inspections will cease completely. On the contrary, the CQC will still inspect practices on site every five years but they will also now carry out the less intimidating, although still formal, Annual Regulatory Review (ARR) of the information that they hold on each practice.
It is expected that this process will result in less site visits as each year an inspector will formally review all the information that the CQC holds on practices and consider whether the quality of care has changed since the last inspection.
This approach will help the CQC prioritise their inspections where there has been most change, either deterioration or improvement. They will focus where risk is greatest whilst also supporting practices to improve. It will also enable the CQC to move to more focused inspections that concentrate on those areas of significant change.
To facilitate the ARR, each year a CQC inspector will contact practices to arrange a telephone call. This triggers a period of four weeks where the practice needs to obtain the information needed to respond to the set questions. The questions are designed to ask about any changes since the last inspection (or Annual Regulatory Review) and the answers given form the Provider Information Collection or PIC. Whilst the questions asked are straightforward, preparation is key to achieving a positive outcome.
Upon notice of the ARR, practices should consider the questions as part of the multi-disciplinary team discussions. This collaborative approach will assist in the preparation of all responses to the questions. The CQC will then consider all the information that has been offered to enable the outcome decision.
Important to remember is that the Annual Regulatory Review is not an inspection. It is simply a conversation about any changes at the practice. It also gives the practice the opportunity to add context to the information that the CQC already has about the practice that has been provided by stakeholders and national data collections. The calls are designed to help to strengthen the relationship between the practice and the CQC inspector.
So what happens if following the ARR there is an indication that the quality of care may have improved or deteriorated since the last rating?
The answer is that the CQC will then choose between either going ahead with an inspection visit to the practice (if they think for example that the level of care has deteriorated) or they may just ask for clarification of any information.
If the CQC decides to inspect, they will either formally write to the practice to advise of an inspection within the next six months or send the normal two-weeks' notice of the date of the inspection. Where the CQC makes the decision to inspect a practice rated good or outstanding, in most cases this will be a focused inspection. A focused inspection may not always consider all five key key points, although the CQC will always inspect the effective and well-led key questions as a minimum. Any decision to inspect other key questions will be based on the information that is held, identified on any inspection or assessed as part of the ARR. If it decides not to take any further action, the CQC will advise that they have carried out the review and that no further action is needed at this stage. It will then publish a note of this on the practice's profile page on the CQC website.
Whilst it is important for practices to know and understand the changes in how the CQC inspects and assesses, more crucial however is for primary care providers nationwide to be well prepared which translates into ensuring they are delivering high level of care to their patients based on the five key questions asked by the CQC during their inspections. Let's look into the first question asked which is: How safe is your practice?
Under this key question, all primary care providers are expected to manage patients who are critically ill or at risk of deterioration or in cardiac or respiratory arrest. This involves nominating a resuscitation lead who will ensure that all staff have access to resuscitation advice, training and practice, quality standards are maintained and that the emergency equipment is checked regularly. Emergency medicines bag should carry the drugs required to deal with an on-site emergency and for acute situations when on home visits. The contents of the emergency drugs bag should be checked regularly to ensure they do not expire or deteriorate whilst being kept in stock. As for equipment, practices are expected to have available for immediate use the following:
- Automated External Defibrillator (AED)
- adhesive defibrillator pads Ã¢Â" spare set also recommended
- oxygen, including cylinder with key and tubing where necessary
- pocket mask (adult) with oxygen port - this may be used inverted in infants
- protective equipment - gloves, aprons, eye protection
- absorbent towel Ã¢Â" to dry chest if necessary
- razor Ã¢Â" to shave chest to apply pads if necessary
- Pulse oximeters can be clearly beneficial for managing a deteriorating patient as well as for chronic respiratory disease.
All significant events should be documented and discussed internally to enable learning from mistakes made and also to share the learning/outcomes amongst the multidisciplinary teams in the practice. DBS (Disclosure Barring Service) checks should be in place for all staff (not just clinical) and ideally the practice should have a policy on how these checks apply to both new and existing staff members.
Cleanliness is one of the key aspects of safety in general practice and on that note, practices should have adequate hand washing facilities available and easily accessible to all staff. Carpets should not be used in treatment and minor surgery rooms however carpets can be used in areas where the risk of spillage is lower, such as consulting rooms, waiting area, dispensing areas and administrative, storage and meeting rooms. Where carpets are used in a GP practice, there should be consideration to needs such as having appropriate maintenance and cleaning programmes in place.
Still on the topic of cleanliness, more exactly to do with infection prevention and control, practices should carry a risk assessment for the prevention of legionella as any water system that has the right environmental conditions could potentially be a source for legionella bacteria growth.
Another recommendation/point of inspection by the CQC is that practices must be aware of sepsis and be able to demonstrate how an acutely unwell or deteriorating patient is managed before and during an appointment, including any ongoing referral or care. Although practices providing in-hours services are not likely to encounter sepsis frequently but early detection is vital.
Every practice should have a chaperone policy in place and staff should be adequately trained on how to chaperone to prevent unpleasant and unnecessary distress to patients whilst in consultation.
Did you know that vaccines cost the NHS around Ã'Â£200 million a year?! Storing and transporting vaccines inappropriately causes wastage and unnecessary costs. It is therefore paramount that vaccines are stored and managed properly so immunisations are done safely, efficiently and effectively. GP practices should also have systems in place to ensure the safe management of controlled drugs and respond to information they receive that might have an impact on the safety of patients. This means that every practice should keep a log of alerts received and document action taken in response to alerts such as Medicines and Healthcare products Regulatory Agency (MHRA) alerts, Central Alerting System (CAS) alerts, Local or national clinical guidance, National and local formularies, etc. Likewise, there should be clinical oversight of the process.
As for safeguarding adults at risk and children, each practice should have a nominated lead for each (can be the same staff member leading on both) and doctors and all other practice staff should be capable of demonstrating their competence in safeguarding their most vulnerable patients.
Portable appliance testing and calibrating medical equipment should be carried out periodically and the appropriate records of such actions should be kept as you will be asked by the inspectors to produce evidence of this.
There are a few other items that fall under the category of Ã¢ÂÂsafeÃ¢ÂÂ and I would definitely recommend a visit to the CQC website for more in detail info and guidance. Remember, not only it is important to be compliant for the safety and welfare of patients but at the same time you are usually only given two week's notice prior to an inspection so you definitely do not want to leave it for the last minute to get things right!
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Jorge Goncalves (NHS Practice Manager)