Be Inspection-Ready any time

About Websites

This is your public facinginformation for any visitor, your Service Users and stakeholders. So it is important that this is kept accurate and up to date.

CQC inspectors have been know to issue improvement notices where website information has been deemed 'out of date'.

Legal Requirements

Why? – Because the inspector’s job is to see if what you say you are doing, actually happens. Their main objective is to find out whether patients are looked after properly and their safety and rights protected.
For an inspector, the best way to do this is:-

1. Interview your patients to see if they are  happy with the service and whether they are kept informed about their treatment.
2. Interview your staff to see if they really do know what to do in particular circumstances.
3. Interview the Registered Manager to see whether they have a good handle on their duties
4. Look for evidence that you are monitoring activities, reviewing outcomes, and have regular quality assurance and clinical meetings to discuss and take action

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Why? – Because for the last 20 years, PCTs and their predecessors have concentrated on policies.

All you had to do to get through a PCT inspection:-

1. Make sure all your policies have a current reviewed date
2. If anything's missing, just say "I'm planning to do it"

 Essentially a quick search and replace in Word got you through a PCT inspection.

Inexperienced CQC inspectors added to this problem by doing exactly the same thing in the early days, making everyone focus on policies.

This will not get you through an inspection

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Why? – Because getting things like training, implementation, and monitoring take far longer than what it sounds like on paper. Examples of practical problems that affect a manager’s time:-

1. Part time staff not being available at the right time
2. Some staff being slower at learning than others
3. Staff unwilling to take responsibility
4. Constantly running to keep on top of processes and paperwork
5. Everything is referred to the practice manager

All of these add up to a significant chunk of a manager’s time. Whether true or not, most managers will agree with the feeling that they spend more time shifting paperwork than actual management. So don’t underestimate the amount of effort and where your focus should be.

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CQC Inspectors are taking a targeted approach to selecting providers for inspection visits.

The CQC has confirmed that their primary targets will be:-

1. Providers judged as “Requires improvement” (Especially if weaknesses in SAFE and WELL-LED)
2. Intelligence that shows underperformance or at risk (e.g. Insight Reports for GPs)
3. Information CQC has received e.g. whistleblowing, complaints, other reports
4. Recent changes in management e.g. Registered Manager
5. Recent changes in provider services
6. Where CQC have received notices of concern from the public or other sources

Additional targets

CQC are focused on patterns of poor performance in connected or related organisations.
If you are part of a Corporate Group; Provider Group; Federation; Out of Hours member; GP Group then the following will flag you up for a potential visit:-

1. Others in your group show poor performance
2. Others in your geographical area show cause for concern

Annual Provider information collection

Practices rated Good or Outstanding will need to provide annual information and data on overall performance; confirm how regulations are being met and declare any changes since the last inspection. (This information will need to be submitted via an online form.)

Practices with an overall rating of inadequate or requires improvement will continue to complete the provider information request before their inspection. PIR is a requests for specific information that will support your inspection.

Best Practice

• Up to date list of key officers and contacts
• Opening times where applicable
• Contact us/Location details
• Service User and/or PPG Groups and how to be involved
• Details of services
• How to get appointment(s)
• How to make a complaint/Suggestions/Comments & compliments

Optional

• New Registrations process

Additional content for GPs and Clinics

• Catchment area
• Friends and family test
• Extended hours
• Ordering repeat prescriptions
• Patient signposting and self-care information
• Referral Advice
• Types of consultations (GP, Nurse Led, telephone, etc.)
• How to change contact details
• Out of hours facilities
• Patient information leaflet which should include
• Chaperone Policy
• Patient Surveys/Results
• Sickness certificates
• Details of any chargeable services

Medical Records - Optional for GPs

Viewing of personal medical information in their GP records, where requested by the patient and where GPSoC approved systems are available.

This should be subject to appropriate safeguards which are summarised in the British Medical Association’s (BMA) guidance

For GP Practices: Mean earnings for all GPs

From1 April 2015, it has been a contractual requirement for practices to publish on their website the mean earning relating to the previous financial year for all their GPs and this needs to be completed by the end of the current financial year (ie 31 March 201X).

All earning reported should be before tax, National Insurance and employee pension contribution.

For GP partners, the figures should be net of any practice expenses incurred.

The BMA guidance has details of what income and expenditure to include and exclude when calculating the earnings for partners.

The rules around this are fairly detailed and partners may need their accountants to undertake the necessary calculations.

To find out more CLICK HERE.

CQC is very much outcomes focused, meaning that the regulator is looking to learn:-

1. What you have in place to achieve positive and consistent outcomes
2. Whether you actually achieve them
3. What do you do when you don't
4. How do you monitor all this
5. How do you ensure this is managed at higher levels

From a practical point of view, you have to be compliant all the time not just March as most practices tend to do and all your staff must understand why they do what they do, always keeping proper evidence of compliance.

Compliance is about managing Quality Assurance on a daily basis. This includes tasks like daily safety checks, monitoring, and supervision.
A well run and managed system should ensure a high level of safety and quality at all times, and will automatically keep the organisation inspection-ready anytime.