CQC policies

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Post by Lesley Williams on Tue Oct 27, 2015 3:38 pm

1. 3rd party medical request protocol

A copy of the medical report submitted to the 3rd Party for employment or insurance purposes must be retained on file for a minimum of six months from the date it was supplied.

Do we do this?  Where do we keep these records? Do we destroy the copy after 6 months?
How do we check that this has been done?

Date stamp the correspondence and pass it to Alex Hennessy

I have never seen a date stamp on the reports I have filled out can we definitely ensure this is done. If CQC request to review these records we need to show that we are implementing our policies.

Answer: When ever any type of insurance form comes into practice, this will be dated by the admin/reception staff and passed to Alex. Alex will then log a copy of the insurance form on the computer system and pass it to one of the GP's or Admin to complete. Once completed this will be passed back to Alex who will update the computer log and take a spare copy which can be found in the Practice Managers Office, After 6 months this will be destroyed.

2. Access to occupational health protocol

In addition, all health care workers involved in direct patient care or body fluid sample handling will be required to submit a Work Health Assessment Form to the OHD for an assessment of their immunisation status and vaccination requirements.

I have never filled out a work health assessment form for the practice.  Do we need to update these and as a result I have never been reviewed by occupational health

all team has now completed this information with immunisation status updated
Immunisation Record adopted by the Practice which is completed for each Clinical Staff Member.

3.  Age discrimination

• We have ***Insert list of any other discrimination policies in operation e.g. an equality / anti harassment and disability policy*** which emphasises our commitment to reducing discrimination in the workplace.

This bit hasn’t been completed on the policy and needs looking at.  We need to insert our policy in here.


Answer: This will be updated by the end of the day 12/10/2015

Also just a thought will they look at our recruitment.  Have we got interviews for me, Rachel and Alex so it doesn’t look like we have just been given the job because we know each other.  Can we prove that we considered other candidates?  Do we need to show this?  Just a thought….

alex will chekc that Cv from other candidates are on file

4. Anaphylaxis

1. Emergency bag to be kept in the Treatment Room
• Resuscitation bag and mask
• Set of Geudel OP airways
• Pulse oximeter
• Oxygen plus trauma masks and tubing
• Emergency aspirator
• Nebuliser mask and tubing
• Scissors and gloves
• Syringes and needles
• IV cannulas, saline flushes, tegaderm dressings

• Adrenaline
• Salbutamol
• Chlorpheniramine
• Hydrocortisone

(Expiry date of drugs is checked monthly – Sian Irving has responsibility for checking the expiry dates)

• Kept in Treatment Room 1

Are all of the above in one place in the treatment room?  I don’t think tegaderm or scissors are in the box from memory. all present
We don’t have cannulas on site so this shouldn’t be in the protocol.  amended
Monitoring of the stock levels to show to CQC is imperative and to ensure these bags are regularly checked.  I think we should do a daily check of the resus bag to ensure all equipment is there and put a list on the front of the bag with it being signed off by the checker.  This could be done along with the daily fridge temp check.  

Do we charge up the defib to check it is working? This should be done at least weekly again with a signed checklist.  

Sian monitors all of this monthly and will order stock in if up for renewal the followiung month

a) Drugs given – details including time, mode of administration, batch number and expiry date to be recorded.

Hydrocortisone IM for anaphylaxis and chlorphenamine IM for this also couldn’t be found in sians room.  Alison is going to update anaphylaxis guidelines and make sure all drugs are there.  She will also leave copy of the anaphylaxis protocol in the emergency room.  

Drugs still on order
alison has updated guidline and is creating booklet for all emergencies

a) Equipment and oxygen - Lead Nurse Sian Irving

We need to put a second in command in here in case Sian is away.  Can this be added please.  Also can we add a weekly check to ensure the oxygen cylinder is full and masks present.  This needs to be added to the weekly check list

Alex is second in command
Sain will hceck oxygen weekly

I do have a list of all the medication in the emergency drug cupboard which I hold in the white file on top of my fridge and I currently do check them once per month- to ensure we have stock and check the expiry dates-for example on my last check I became aware that rectal diazepam was due to expiry end of October and therefore have ordered more in anticipation of this - the only drugs I do not have are Chlorpheniramine (which up to now I was not told was required ) and Hydrocortisone-which has been on order with Oakleys and Boots for several months now- perhaps we should cancel the order and try else where? (Alex is aware of this problem) . Once monthly I also check all the vaccines in the fridge and expiry dates and also all the equipment in my room such as defib,oxygen etc- again I have a check list in the white folder which I tick off and date/sign once done-which would hopefully be proof enough for CQC. Would you like this done more regularly?  We don't have an emergency aspirator or IV cannula's- is this something we need to look into purchasing?


we have created a poster to remind peple to log which drugs have been used on a drugs slip to be gievn to sian so stock can be re-ordered

5. Training

1 All clinical staff should receive an annual CPR update by an appropriately qualified trainer, and should be familiar with the use of available emergency equipment.
2 All staff who are AED trained must undertake an annual update with an authorised training provider .
3 Reception / office staff should be aware of the action to take in the event of an emergency occurring, and be able to assist where required.
Such assistance may include:
• Requesting emergency services via the 999 system;
• Assisting in resuscitation where CPR / Defibrillator trained;
• Providing privacy by screening the area if in a public part of the building;
• Caring for relatives.

Do we have this recorded in staff files to show to CQC that this has been done?  I know we have done the modules online but are we going to get someone in to show the use of the defib in reality and to use the resus dolls as it is different watching a video to actually implementing this?

All trainign completed and on file for recpetion

Answer: All staff are updated through training via BLUE STREAM E-LEARNING, which includes CPR training and Fire Safety.

]u]6. Reporting the Death of a Patient to the CQC[/u]

The Practice is required to notify the CQC without delay of the death of a patient when:

a) The death occurred whilst a regulated activity was actually being carried out (e.g. during a GP's home visit, or during the patient’s visit to your surgery),


b) The death occurred as a result of a regulated activity being carried out,
The Patient had seen their GP in the two weeks before the death,
The death was avoidable / related to inappropriate care and treatment.

There is a dedicated notification form to report such deaths – it is contained in the Outcome 18 document “Notification of Death - Outcome 18 Composite Statement and Form”.

Dr Thomas D Hennessy at the Practice is responsible for notifying the CQC immediately upon the death of a person who uses the Practice’s services.

Where the Registered Person is unavailable, for any reason, Dr Alison Williams will be responsible for reporting the death to the CQC.

I don’t understand which deaths need reporting? How do we do this? Is Alison aware she is a lead for this?

Answer: Dr.Hennessy Is the lead and Alison is deputy. I will create a list for each GP and Staff Member who each head lead is and deputy which I will give to you in due course. Most of the main leads will be Alex and Dr.Hennessy. In regards to what type of death needs reporting, is the following: A patient who passes away in the GP Practice on the premises or on a home visit where the GP is present.

Lead lsit now been created

7. Appraisal – Staff Feedback Survey (for 360⁰ appraisal)

The policy does not say who this should be targeted at.  Is the 360 degree survey for everyone including reception.  How often should it be done? Have we any evidence that this has been done in the practice and where is this kept?

All staff have completed and on their record

8. Regulated Activity and Adults At-Risk (formerly Vulnerable Adults)

We need to update our codes to say adults at risk not vulnerable adults.

we are keeping our code as vulnerable adults

Prevention of Instances of Abuse

SILVERDALE MED CTR_HENNESSY TD understands its responsibility and commitment to the prevention of abuse.
In this regard, the Practice has identified the following measures to assist in the prevention of incidents of abuse, including:
• Ensuring that there are robust polices and procedures in place which are meticulously followed and regularly reviewed, and that staff are sufficiently skilled and have an astute awareness of forms of abuse;
• An effective recruitment and selection process, involving CRB checks and employment reference checks;
• Ensuring that breaches of policies, procedures or systems are dealt with swiftly, proportionately and consistently;
• Maintaining positive and effective relations with other service providers for the protection of service users;
• Reporting cases of abuse to line-management and / or the appropriate authorities.

Shall we add to the policy here that all staff have completed e learning modules to show that they are informed on how to recognise abuse and alert the safeguarding lead? This is reviewed annually to ensure everyone up to date.
 Have we got all reference checks for our staff on file?

alex is going to look into reference checks

Consent of the Service User

Any actions in relation to the reporting of incidents of abuse, including referrals to Social Services and the Police, must be subject to the written consent of the service user (where they have capacity to make such a decision).

I think we should take out written consent here as I only take verbal consent.  Do the other GPs agree?

policy amended to verbal consent

Working Collaboratively with other Agencies

Multi-agency policies and procedures are in place throughout the NHS to ensure the continued protection of service users.

These collaborative partnerships exist so that reporting of alleged offences and subsequent action between Local Authorities, Police and those who provide a range of services to people can take place.

Adults who have been abused, or it is suspected have been victims of abuse will have a protection plan agreed collaboratively with all the multi-agencies involved. Each plan is tailored to the adult’s individual case.

All actions in relation to each case are recorded on the individual protection plan which is shared by all agencies involved to enable them to co-operate effectively, and reduce the risk of further abuse.

If there is either suspicion or clear evidence of abuse, the Practice Manager, in conjunction with the Practice Partners, must contact the relevant authority within 24 hours of a decision being taken to refer, in accordance with the relevant local multi-agency procedure. ***Insert Name & Position of Person*** is responsible for doing this.

The above persons name needs to be added in


Suspected Abuse – Action Required

Whenever abuse of a service user is suspected, staff members should inform the Practice Manager who should follow the procedure below:

Step 1
Alex Hennessy must contact the emergency services immediately if a
service user appears to be in immediate physical danger. Be aware of retaining forensic evidence.
If there is no immediate physical danger apparent, proceed directly to Step 2.

Notifying the CQC of Incidents reported to the Police or being investigated by the Police

The Practice is required to notify the CQC of any incident reported to, or investigated by the police that is associated with the delivery of the service and affects or may affect the health, safety and welfare of a person using the service, its staff, or anyone who visits the service.

There is a dedicated notification form to report such incidents – it is contained in the Outcome 20 document “Notification of Other Incidents - Outcome 20 Composite Statement and Forms.

Dr T Hennessyat the Practice is responsible for notifying the CQC of an occurrence of this type of incident.

Where the Registered Person is unavailable, for any reason, Alex Hennessy will be responsible for reporting this type of incident to the CQC.

Step 2
The Practice Manager should discuss the situation and courses of action available with the service user who has had abuse perpetrated upon them.
The Practice Manager should report the full facts and circumstances of the situation to the Practice Partners, and discuss available options and required action, having considered the following:
• If immediate referral to the Police and / or Social Services is required;
• If there is a need to contact any partner care / support agency;
• Review of relevant records, particularly similar incidents of the same kind;
• Consider the immediate health / welfare needs of the alleged victim or any other adult at risk who may be affected and methods for supporting the service user, including access to counselling services.
• The Practice Manager will consider with the Partners the appropriateness, or not, of notifying the alleged abuser of the allegation made against them prior to a referral to Social Services and / or the Police. Social Services and / or inter-agency input should be sought when making this decision.

Step 3
The Practice Manager, with input from the alleged victim and support from the Practice Partners, should complete an Incident Recording Form within 48 hours of the report / incident of abuse.
It is essential that the above form is signed and dated and completed in a manner that:
• Is clear and factual;
• Reflects the words and phrases used by the person making the disclosure;
• Describes the circumstances in which the disclosure arose (i.e. context, setting and persons present).
• Contains factual information only (opinions or third party information must be clearly identified as such).
An action plan outlining actions to be taken, when and by whom must be devised in consultation with the service user. This plan will be produced jointly by the Practice Manager and Practice Partners, and should be reviewed by those parties, along with the service user, at appropriate intervals to ensure it is being carried out.

A copy of the completed Adult Abuse Incident Recording Form and Action Plan, plus additional records pertaining to the incident should be kept in the service user’s file.

The issue of confidentiality should be considered, for example if the allegation involves a staff member, (i.e. will that staff member have access to the file in the course of their duties?)

Private and confidential information on staff should be kept separately from the case file and placed on the personnel file only.

I think the safeguarding lead should be the go to for the above ie me not Alex.  What do you think Alex as this is a lot to take on board and I have the training for this.  If we do change this you need to look through the whole document and remove your name or Dr T Hennessy as there has been a change of role

amended to include Dr L williams name

9. Being open Policy

• Make an accurate written record of the initial and any subsequent discussion and provide a copy to all the patient’s representatives.

Alex do you have all complaints on record upstairs with a copy of our verbal response?  This should be kept spate from the minutes of the meeting so they are easy to find if we need to show this to CQC.

Folder checked and updated from now on going to include reflection template for each complaint received - see file

Dr T D Hennessy at the Practice is responsible for notifying the CQC immediately upon the death of a person who uses the Practice’s services.

Where the Registered Person is unavailable, for any reason, Alex Hennessy  will be responsible for reporting the death to the CQC.

This need changing as in the last document Alison was second in command.


5. Going forward - reduce risk and improve systems
• After an incident has been identified and necessary short-term action taken to rectify the problem, the Practice should invoke its Significant Event Procedure (a problem solving tool that minimises the likelihood of repeat errors occurring, thereby improving patient safety). This will initially examine and facilitate understanding of the issues that caused the incident, then subsequently focus on recommending improving appropriate systems to ensure the risk of the incident recurring is prevented or minimised.

To help prove we do this can we keep a copy of the significant event attached to the complaint in the same file.  Alex can you check that all our complaint have been written up as significant events?

ALex is reviewing this

Bribery Prevention Policy

• Staff must record any gifts accepted in the central register (see pages 5 and 6) maintained by the Practice Manager. Any queries about the contents of the register should be directed to the Practice Manager.

Alex do you have this register?  The form for it is at the bottom of this policy.  I think we should record the lunches which the drug reps are doing each Wednesday. What do you think?

Register printed off - kerrie will record this informationa dn look back in diary and add in for last 12 months

Caldicott Policy

Training, Policies and Procedures

SILVERDALE MED CTR_HENNESSY TD takes their responsibilities for the security and protection of all patient-identifiable information very seriously.

All Practice staff have responsibility for compliance with the Caldicott standards. To this end the Practice has:
 Confidentiality clauses in each employee’s employment contract;
 Computer based training programmes (including a competency test);
 An Employee Handbook (outlining employee responsibilities);
 Policies, procedures and agreements to ensure any transfer of patient-identifiable information is compliant.

Alex could you check that everyone has a contract in their personal file, that it is signed and that it contains this confidentiality clause.

all staff have signed a confidentilaity clause

Is the competency test the blue stream learning? Have all staff completed this?  Could you check their certificate is in each of their folders.

all e learning up to date and in recpetion files

• The Caldicott Guardian will be expected to liaise and work with external bodies in the course of promoting the Caldicott principles, which may include attendance at various meetings as appropriate.

Has Tom attended any meetings with external bodies.  If so can we ensure that these are recorded as evidence if not can we try and organise this

Alex will look into meeting which Tom can attend to ensure this is being adhered to

]b]Call and recall policy[/b]


• On the 1st working day of each month, exception reports will be run to find patients within any of the above areas who are due for review appointments in the month that follows (e.g. patients due for a review appointment in June will be run in May).
• This list of patients will be mail-merged into pro-forma letters which also contain a tear-off portion enabling them to accept or decline the invitation.
There may be a few days’ delay before the letters can be sent out. So, before sending the letters, ***Insert Name of Person*** will check each patient record to ensure that they are still registered, not deceased (sometimes patients can be registered but deceased as there can be a delay before the patient is deducted by the PCT) and have not already been seen for their review / smear / immunisation / blood test.

Name need to be inserted into above.
Does our pro –forma letter have a tear off section enabling a patient to accept or decline review? yes
Our new computer recall system will show that this policy is being actioned maybe we could mention that in the policy?

Recall systemt will automatically send letters texts and emials to patient groups

Recall Time-Periods

Recall periods vary, depending on the reason / condition.

The following time-periods will be adhered to:
• Normal smear (patient aged between 25 and 49) - ***Insert Period e.g. every 3 years***;
• Normal smear (patient aged between 50 and 65) - ***Insert Period e.g. every 5 years***;
(Abnormal smears will vary depending on the result (see Cervical Smear Policy));
• Diabetic review - ***Insert Period e.g. every 3/6/12 months***;
• COPD review - ***Insert Period e.g. every 3/6/12 months***;
• Asthma review – ***Insert Period e.g. every 3/6/12 months***;
• Heart disease – ***Insert Period e.g. every 3/6/12 months***;
• Childhood immunisations will follow the national schedule.

All above need to be amended.  Ask one of use to go through it with you when you have it opened up.


Are we using the template letters from CQC? (At end of protocol)
no we have our own

Carers policy

The objective of this Protocol is to ensure that all Carers registered with the Practice are identified and referred to Adult Care Services

Are all our carers coded as being a carer? The likely number of carer according to our list size is 469 do our records reflect this?  Have they all been referred to adult care services?  
all being coded.  need to try and improve our detection rate for carers
Could we draft a letter to our carers detailing the support and referral to adult care services and if they want us to do this to contact the practice.

Letter drafted and will be sent out with with every letter to pateints to try and find this patient grop

The Practice will support Carers by:
• Identifying a “Carer’s Champion” to ensure that the support to Carers by the Practice is being undertaken and to be available to Carers as the first line of liaison.
• Providing relevant information and Local Authority resources and contact points
• Providing suitable appointment flexibility and understanding
• Providing care, health checks and advice to enable them to maximise their own health and needs.
• Undertaking a self-assessment, using the Checklist in the “Carers Toolkit” to track progress and be able to evidence the work conducted in line with good practice guidelines.

Who is our champion? Dr Winters
Can we create a folder with the contact details for local authority resources and contact points?
Can we ensure they are on the annual recall system for review. On recall
Have we done the self assessment for this year?


Notice Boards
The Practice displays a poster on existing notice boards requesting Carers to contact the Practice to provide details of their caring responsibilities. However, during appropriate seasonal times (e.g. Flu clinics) a notice board is dedicated to Carer information, for enhanced visibility.

Carer-referral Forms
Carer-referral Forms are displayed in reception to encourage Carers to complete and hand in to the Practice.

A message is attached to repeat prescriptions requesting appropriate patients to complete the Carer-referral Form.

New Patient Registration Forms
The Practice’s new patient registration form incorporates the following two questions:
• Do you look after someone?,
• Does someone look after you?

This information is used in the new patient screening appointment, tagging the patient’s notes and arranging referral to Care Services.

Can you ensure that we have a poster in reception, carer referral form on frint desk and that the new patient registration forms ask this question


Letter and Questionnaire to Patients
When the Practice writes to a patient, (e.g. during the flu vaccination campaign),  the communication incorporates a section on Carers, where if they are a carer but have not yet completed a Carer-referral Form, they are requested to contact the Practice and complete one. This may be part of the procedure for Disability Allowance forms.

A person who collects a prescription on behalf of someone else, may be passed a Carer-referral form.

Health Professional Identification
All Health Professionals in the surgery complete referral forms when they ascertain a patient is a Carer.

Can we discuss at a practice meeting what referral form to complete when a carer is identified and ensure that if we do write letters to patients that we include this in all communications to try and pick this up.  We could have it automatically appearing on the letter templates to patients

When carer is identified reception send details in post if consented by patient to be place on carers register with wired and reception also call social services for carers assessment if the pt wishes this also.  Heather then codes.  On all referral templates received reception should fill out their roles and tick to say completed

Upon identification of a Carer the Practice will take the following steps:
• The Medical Record of the Carer should be edited to insert the ‘Carer’ Read Code of 918A and entered as an alert.
• The Role of Carer should be marked as an ‘Active Problem’ so that it can be easily visible to the Clinician when accessing the Medical Record of the Carer.
• An ‘Alert Message’ should be added to the Carer’s Record on the Front desk to alert Receptionists in order that they may prioritise booking appointments where necessary.
• The medical record (EMIS) of the person receiving care will be allocated a read code of 918F (“has a carer”) and cross reference the carers details in the text box
• Chronic Disease Templates used by Nurses and Doctors when consulting Patients include data entry spaces for inserting Carer’s name and contact details.

Are we using this read code?
Are we putting alerts on the screen also? yes heather is doing this and ticking the box to say this has been completed
Are we read coding has a carer on patient notes who is receiving the care with the carer details being on their record? heather is actioning
Do our templates have carers name and contact details on? Can we add to the templates whether patient has a carer to ensure we are asking

Hiya Rachel,

I was wondering how you would feel about being the practice lead for carers.  I was reading one of the practice policies, the carer policy, and we should have a carers champion.  Would you be happy to take on this role?  If dont mind if could you have a read of the practice policy and see what it entails and see if you would be happy to take this on.

I have tasked Alex to ensure that we have coded our carers on emis correctly and for them all to have screen alerts.  I have asked Alex to run a search because it is expected that we should have about 467 carers for our practice population.  Once they are all identified I have asked Alex to put them on recall for a yearly healthcheck and flu vaccination. I have asked that the new patient forms have the question, are you a carer or does someone care for you, on it to try and identify more carers.  I have also asked that this question is on all letters sent to patients so thay can reply and alert us to the fact they are carers.  I have asked for there to be a poster in reception and that the referral form for support are freely available at the front desk. (Alex this is all detailed in the policies folder on the desk top in Lesley folder).

There is a meeting for advocates detailed below.  I dont think it would be nescessary to go twice a month but maybe once every 3 months to show we are trying to keep up to date.   Let me know what you think

Lesley x

yes am more than happy

will check policy tomorrow


Last edited by Lesley Williams on Tue Nov 10, 2015 7:52 pm; edited 5 times in total

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Post by Alison Williams on Tue Oct 27, 2015 4:23 pm


This section outlines the procedures that should be taken following any spillage, large or small.

Please note that only clinical staff should be involved in the clean-up of any spilled biological substance. Administrative and secretarial staff should inform one of the clinical team if they become aware of a spillage of this nature.

Alex- are reception aware they are to ask a clinical member of staff. Should we advise that they should initially present to the infection control lead- ?Sian, should we also have a second in command in case Sian is away

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Post by Alison Williams on Tue Oct 27, 2015 4:29 pm

Infection Control Biological Substances Incident Protocol

Sorry above also applies to this policy

A Practice Blood Spillage Kit containing the necessary items is to be found Practice Nurses Room

Do we have this?

Small spills on hard surfaces, objects or equipment – should be wiped using a paper towel soaked with sodium hypochlorite 10,000 ppm (1%) solution. Suitable hand PPE (not necessarily sterile) should be worn, and the PPE and towels should be discarded into a yellow clinical waste bag for incineration.

A Practice Blood Spillage Kit containing the necessary items is to be found Practice Nurses Room

Hypochlorite solutions are corrosive, so treat the affected surface (post-cleaning) by rinsing with clean water, then drying thoroughly.

Large spills on hard surfaces, objects or equipment – should be treated with absorbent, chlorine-releasing granules (e.g. Sodium Dichloroisocyanurate). This treatment ensures that the active disinfecting agent is in contact with any present micro-organisms in the entire spill, and also limits the spread of the blood to a smaller area.

Do we have this? Has our infection control read these policies?

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Post by Alison Williams on Tue Oct 27, 2015 4:58 pm

Infection Control Inspection Checklist

1. The Practice can provide evidence of arrangements for management of education and training on infection control.

Do we have this?

2. The Practice has a fully trained and nominated lead for infection control.

[color=#990099]Have they read the protocols. I think we also need a second lead.

3. The Practice provides training in infection control for non-clinical and clinical staff at induction and has an ongoing program of training in place.

Can we make this part of the induction handbook-think it would look good if we had an induction handbook

4. Records are kept for all Practice staff on infection control education programmes and evidence of relevant continuing professional development (CPD).

5. The Practice can produce evidence of audit in relation to specific infection control policies and procedures.

Have we done any audits?

6. All Practice polices and procedures for infection control are clearly marked with a review date.

Do we have review dates for this policy?

If you have a look at the policy there are areas where we need to write lessons, actions and actions, has this been done?

Hand Hygiene Review

This is supposed to be part of induction. Have we got certificates to say all staff have had this training. Has the form been completed for this on the policy

Do we have latex free gloves? We did have some ordered in, I think we should have latex free gloves in all clinical areas, as its not just the user but the patient may have a latex allergy. Can all clinicians only use them if necessary as they are expensive

Sterile and non-sterile (powder-free) gloves with latex-free alternatives available are worn as single-use items for each clinical procedure.

Tom do you have your own supply of sterile gloves for when you do joint injections.

Single-use facemasks and eye protection are worn by staff members where there is a risk of splashing of bodily fluids.

Do we think we do anything that would warrant needing the above?

All needlestick / sharps / splash incidents are recorded on an incident form and also reported according to Practice policy.

Do we have an incident book? If so where is it kept?

All sharps containers in use are labelled with date first used, location within the Practice, and signed by the assembler.

Have they got the location on them? Have they been assigned by assembler?

. Sharps containers are stored safely away from patient, out of reach of children and elevated from the floor.

Where are we going to put them? I don't have one in my room? Can we make sure all clinical rooms have a sharps box, is labelled correctly with above?

1. The Practice has a comprehensive protocol for specimen handling.

Do we have a protocol?

2. All Practice staff handling specimens are trained in management of spillages, hand washing, PPE, use of spillage kits.

Are reception staff trained in this as patients will often drop in samples to reception?

3. Gloves are worn by any member of staff that handles clinical specimens – including reception staff.

Reception need to be made aware that they must wear gloves if handling any container with bodily fluids, we need to make sure gloves are therefore also kept in reception

5. Patients are provided with appropriate specimen containers if required to produce specimens at home.

Can we all give out the appropriate containers with the WROCS form rather than asking reception to do this

6. Specimens are sealed in designated plastic transit bags and kept in a designated area.

Our samples aren't kept in bags but the box in reception can we ensure we have the relevant bags in reception with a more appropriate area for these to be stored.

The Practice can produce evidence of using a decontamination Process Assessment Tool(PAT).

Can we provide this evidence? If so where is it kept?

The Practice keeps a record of all staff training undertaken for the decontamination of medical devices.

We need to ensure we have a record of above

Relevant staff members are familiar with the COSHH regulations 2002.

Can we all be given a copy of the COSHH regulations, can we keep a copy of this with ths policy so we can re-refer to it if required

10. Staff members understand and are encouraged to use the protocol for reporting incidents involving medical devices to the MHRA.

Can we all be shown a copy of the protocol used to report incidents, can we then keep a copy with this policy

All Practice staff have attended a training session on the safe management of waste.

Can we have a training session. I would suggest Sian, as infection control lead, be asked to do a short power point presentation on this and present to all staff. We then need to document that we have all attended this

9. There is a dedicated area for the safe storage of clinical (hazardous) waste which is in a secure room, inaccessible to the public.

Where is this within our practice? Are we doing this?

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Post by Alison Williams on Tue Oct 27, 2015 5:14 pm

Infection Control Policy

In the policy Dr Hennessy is the lead GP in infection control-just to highlight this to all GP's. Having just spoke to Alex, Sian is the Lead within the practice, and Nicky is second in command? Do we need all these people, will it confuse things?

• A daily, weekly, monthly and 6 monthly cleaning specification will apply and will be followed by the cleaning staff.

Have we got documented evidence of this? Is this happening, if not how can we address this?

• Infection Control training will take place for all staff on an annual basis and will include training on hand decontamination, hand washing procedures, sterilisation procedures the use of Personal Protective Equipment (PPE) and the safe used and disposal of sharps

Have we got documented evidence of this occurring annually?

• Infection Control Training will take place for all new recruits within 4 weeks of start.

This further illustrates how an induction handbook would ensure all new staff are having the appropriate training when starting at the practice.

• A random and unannounced Inspection Control Inspection by the above named staff (Using the Infection Control Inspection Checklist) should take place on at least a bi-monthly basis and the findings will be reported to the partners’ meeting for (any) remedial action.

Can we ask Sian to take on this role.

• The Practice will also seek to educate patients and carers regarding effective hand decontamination and hand washing techniques.

Can we put a sign in the waiting room. Can we put on our web page information for patients/carers how to clean hands, we need to make it appealing eg the NHS campaign about covering your nose when sneezing to prevent the spread of diseases. Any ideas?

Do we have these protocols?

Do we have the following protocols? I think we should have a folder with the following in. We need to make all staff aware what is in the folder

• Access to Occupational Health Protocol

What is this?

• Cleaning Plan;
• Clinical Waste Protocol;
• Contagious Illness Policy;
• Control of Substances Hazardous to Health (COSHH) Policy & Risk Assessments;
• Decontamination of Re-usable Instruments Policy;
• Decontamination Training Policy and Register;
• Disposable (Single Use) Instrument Policy;
• Hand Hygiene Policy and Audit;
• Hepatitis B Policy;
• Infection Control Biological Substances Incident Protocol;
• Infection Control Inspection Checklist;
• Infection Control Policy;
• Laundering of Linen, other Fabric Materials and Uniforms Policy;
• Local Laboratory Accreditation Statement – Outcome 8 – Criterion 8;
• Needlestick Injuries Policy;
• Patient Isolation Protocol;
• Personal Protective Equipment (PPE) Policy;
• Specimen Handling Protocol;
• Staff Screening and Immunisation Policy;


The Practice has a policy of conducting a thorough programme of training on infection control as part of the staff induction process. This is led by the Practice Infection Control Team in association with other, carefully chosen, external bodies, including: ***Insert External Training Bodies***.

Need to insert all members of infection control team? Need to have induction handbook

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Post by Alison Williams on Tue Oct 27, 2015 5:30 pm

Information Governance - Staff Reference Sheets

ALWAYS keep confidential papers locked away Do you have a clear desk policy?

Can we all clear our desks

Disposal policy/procedure for confidential information

Do we have this?

* Confidentiality contracts with third parties
e.g. archiving companies, cleaners, temporary staff, outside contractors

Do we have we the above for Liz?

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Post by Alison Williams on Tue Oct 27, 2015 5:37 pm

Information Governance Factsheet for Staff

Information Governance is a term used to describe how confidential information is recorded, stored, accessed and transferred.

Thought this was a good summary of information governance in case we are asked

Information sent by e-mail MUST be sent using the ‘NHS.net’ domain identifier.

Can we ensure we only send emails though our NHS accounts

Is it accurate and up-to-date? with regard to patient records

We need to tidy up patient summaries, can we all please make an effort to do this

Guidance for Sharing Confidential Information by Fax/telephone

I have printed the above guidance out. I will ask Alex to ask all reception to read it, and a copy to be kept above the fax machine as a reminder.

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Post by Alison Williams on Tue Oct 27, 2015 5:48 pm

Information Governance Policy

• The Practice will undertake or commission annual assessments and audits of its policies and arrangements for openness.

Do we do this?

• The Practice will have clear procedures and arrangements for liaison with the press and broadcasting media.

Do we have this?

• The Practice will undertake or commission annual assessments and audits of its compliance with legal requirements.

do we do this?

• The Practice regards all identifiable personal information relating to staff as confidential except where national policy on accountability and openness requires otherwise.

I have discussed this with Alex, and he is going to put all information currently on the walls into each individual persons folder

• The Practice will undertake or commission annual assessments and audits of its information and IT security arrangements.

are we doing this? I have asked Alex to make sure we all have a key for our room. We should all lock our rooms when going on home visits, as well as our computer.

• The Practice will establish and maintain incident reporting procedures and will monitor and investigate all reported instances of actual or potential breaches of confidentiality and security.

Alex have you got documented evidence that you have spoken to reception staff about the above. You have recently addressed this with them following a complaint from a patient after they had overheard information about a friend.

• The Practice will undertake or commission annual assessments and audits of its information quality and records management arrangements.

are we doing this? We could use the example of patients summary not being concise, we could audit this again in 12 mths to see if for example 50 patietns chosen randomly now have a more concise summary record. What do you think?


It is the role of (Enter the names of the Senior Partners in the Practice Setup screen) in the Practice to define the Practice’s policy in respect of Information Governance, taking into account legal and NHS requirements.

Whose responsibility is this?

Thomas Hennessy is the designated Information Governance Lead in the Practice and is responsible for: INFORMATION ONLY

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Post by Lesley Williams on Mon Nov 02, 2015 9:58 pm

Carers Supporting Evidence

Can we send the letter out to all patients who are being sent a letter by the practice whether it is for long term condition of medication review to try and pick up our incidence rates.  
carers letter is being sent out to all patients who are getting letter form practice and also being attached to all prescriptiond
Can we also put page 9 up on the notice board to try and identify more carers notice board been updated
Page 10 of the policy - can we send this to all patients identified as receiving care so that we have their written permission on record for what part of the record can be viewed and ensure this is easily accesible for all to see reception are sending these letter put when patient call up saying they have permission to see records
Can we put the carers line telephone number up on the notice boards for support Info on designated carers board
We need to put a carers referral box in reception no box instead we have asked patient to pass directly to reception
For those for respond and identify themselves as a carer can we then send a second letter advising about the carer support group at the pratice
letter has been created and being sent out carers forum to be held at heswall coffee house arranged for 2nd Dec

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Post by Lesley Williams on Mon Nov 02, 2015 10:01 pm

Carers Toolkit

Can we try and complete this toolkit and discuss at next practice meeting - the form is included in the policy

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Post by Lesley Williams on Mon Nov 02, 2015 10:08 pm

Changes in service Policy

• Conducting return-to-work interviews after absences

Alex are we now conducting these?  Are they in the staff files with a note to say how we can facilitate / help prevent sickness agaiin eg if back paion is a problem have we offered a desk assessment

this is being done and is in reception files

• Monitoring and investigating the causes of absence

Do we have on record how many days someone has taken off sick and the reasons for this?  Where is this info kept?
all kept on reception files

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Post by Lesley Williams on Mon Nov 02, 2015 10:27 pm

Chaperone Policy

The Chaperone Policy is clearly advertised through patient information leaflets, website (when available) and can be read at the Practice upon request. A Poster is also displayed in the Practice Waiting Area (See example in Annex A).

Have we got an information leaflet with this on? alex will get leaflet
Could we add it to the website alex will put on websit
Is there a poster in reception?
poster in recpetion

All trained chaperones understand their role and responsibilities and are competent to perform that role.

Who are our trained chaperones and what extra training should they have?

all staff have completed e learning on this

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Post by Lesley Williams on Mon Nov 02, 2015 10:37 pm

Cleaning Plan

Please return the completed record to:

Alex Hennessy

at the end of each week

There is a tick chart for Liz to complete which you have said needs to be handed to you at the end of each week
Is Liz completing these as it needs to be documented when she is doing each separate room
Where are these forms kept?

Liz keeps a chart of whats been cleaned for the week and it is kept on the inside door of the cleaning cupboard with her signature to prove it has been done

Premises Spot-Check Cleaning Template

Who is doing the spot checks?
There is a cobweb in the corner of my room that has been there for 4 weeks has this been noted on the spot check
Have we got documented any outcomes from the spot checks and any areas for improvement?
There was an incident with the male cleaned not cleaning the toilet correctly and you contacted his superior has this been documented on a spot check form with outcome of this?

alex is doing a monthly spot check

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Post by Lesley Williams on Mon Nov 02, 2015 11:20 pm

Clinical Governance Policy

2.   Patient experience.  

We will discuss feedback received from patients and publicise both suggestions and the practice response. Whenever an identifiable patient makes a suggestion, the Practice will ensure s/he will receive a personal response.

Where do we publicise the changes we are making?
Can you on the website the outcomes from the patient participation group to show how the practice is responding
Can we publicise participation in patient forum on notice boards and website

alex will publicise this on the website and on the newsletter for the practice

We operate an open system of Significant Event Reporting which ensures we review, obtain and provide feedback and learn from such incidents. Each Significant Event is discussed in detail and agreed action documented in a Significant Event Review / Clinical Policy Review Meeting.

Can we ensure that we have reviewed the significant events from last 6months to ensure change has been implemented and if not then make another plan to ensure it is done.  Can this be a priority at next practice meeting to review

this is done monthly

4.   Clinical Audit.  

Are all our audits in one place?  can you show me the audits from the last 12 months so we can ensure audit cycles been done
As a separate note to this Alex have you got the data for the diabetes audit cycles which we discussed last week and can you give me the names for patient prescribed cefalexin and ciprofloxacin over the last 2motnhs to complete this audit cycle please

all audits are on file and the appropriate audits kept together to show an audit cycle

Our administrative procedures are also audited on a regular basis to ensure they are operating effectively.

Have we got any evidence that our administrative procedures are being audited?  One example of this is GPs signing their letters could you present this as an audit please showing that the use of the stamp has improved quality

alex is going to audit the letters to ensure that we are signing and documenting the outcomes

5.   Evidence-based medical treatment.  

The Practice will develop, refine and maintain an awareness of the latest developments, research results and advances in medical treatment and assess the impact of this information on our established and proven methods of working.

To encourage discussion and learning, we will ensure that expertise and opinion is shared both within the Practice and between clinicians.

Can we start ensuring that if GPs attend meetings that the outcomes are presented to the rest of the team and this kept on record.   For instance I shared my learning of from the safeguarding update via email this can be presented at next meeting.  Could we therefore add to the minutes of each meeting that if a GP has attended a course or meeting that at the next practice they present this to the team with a slideshow of the information given out.

alex is going to keep this information in a folder
each person who attends a talk or presentation needs to present this to the group
Alex will be emailed the presentation and it will kept on computer and a hard copy

7.   Staff and staff management.

To encourage team working throughout the Practice, we will operate “no-blame” learning culture which will provide all Staff with an open and equal working relationship.

Can we set up the forums for all staff to post their comments and to encourage everyone to share ideas for improvement

8.   Education, Training and Continuing Professional Development (CPD).  (See separate “Continuing Professional Development (CPD) Policy” for full details).

All Practice Staff, Clinical and Non-clinical take part in an annual appraisal system which links into their personal development programme.

Are all our staff appraisals up to date?  Who does the appraisal and where is this info kept?  How do we know when they are due review? Are the nurse appraised via an external body like GPs?

all appraisals done in Feb by managers alex is going to find where this info is and they will be redone in feb

The Practice closes for no hours each month to allow all staff to take part in protected learning sessions, including updates on basic life support, health and safety, appraisal skills, team building and information governance

Are we going to look at closing the practice for one afternoon every month for training?  Every practice I have worked at always does this on a monthly basis with OOH covering phones

9.  Strategic approach.  

We will operate a five year strategic plan based on projected patient needs, being mindful of both the current and projected National and Local healthcare situation.

We will actively participate in the Clinical Commissioning Group and focus on activity which creates resources to help achieve both immediate and longer term patient clinical needs.

How do we prove that silverdale is actively participating in the clnical commissioning group? Are there regular meeting for this?

Dr Hennessy goes to the CCG meeting every meetings

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Post by Lesley Williams on Mon Nov 02, 2015 11:32 pm

Communication Policy

Staff members will consider the following points when receiving, writing or sending any letter:
• Letters received by the Practice must be logged and forwarded to the relevant person immediately (Reception Staff  is responsible for receipt, logging and distribution of all letters at the Practice.  

How does the practice log letters received?

when a letter received we date stamp the letter, put it immediately into the GPs trays for review that day with GP action stamp on this. Heather immediately scans letters on for that day and ensures only letters that are dated and actioned and signed by gp are put on the system

• When sending a fax, use a cover sheet with a confidentiality statement

Do we do this?

this is done

• On completion, retain the printed record of transmission as confirmation the fax was successful (this may need to be requested if not automatic). Include the record on file along with a copy of the cover sheet as proof of sending

DO we save to the patients file the confimraiton that the fax has been sent?

we don't save the confirmation but the reception code that fax has been fax has been sent and confirmation received on care history
any 2 week referrals are noted in the 2 week referral file the girls signs to have they ave sent and wait for confirmation and then sign for this again to show confirmation recived

• Display details of the online prescriptions request service (minimum of 48 hours notice) which is available for all registered users. All information given by patients is through a secure connection;
• The Practice Charter will be clearly signposted on the website;
• Details of out-of-hours services (including timings) will be provided;
• The most up-to-date newsletter will always be featured;
• Signpost details of additional relevant services offered by other NHS providers

[color=#ff0000]Is the online prescriptions on website with 48 hours notice on there? [color=#006600]yesolor]
Is the practice charter on the website?
Are out of hours details on the website and the new 111 service? [color=#006600]yesolor]
Is the newsletter on the website? yeslor]
Have we updated the website with additional info for families and children, teenagers, mental health, elderly, carers, palliative care?
[color=#006600]in progress

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Post by Lesley Williams on Mon Nov 02, 2015 11:36 pm

Complaints and comments leaflet

Are these leaflets printed out in the reception area for the reception staff to give to the patient if they wish too make a complaint?

yes there is a leaflet and it is on website

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Post by Lesley Williams on Mon Nov 02, 2015 11:54 pm

Complaints and Comments procedure

Complaint initiated on Practice Premises
• In the event that a Practice staff member notices that a patient appears to be distressed / upset on the Practice Premises, they should immediately contact Alex Hennessy, who will attempt to identify and resolve the problem personally at that time.
• In the event of a Practice staff member being advised that a patient wishes to make a complaint, the patient should be passed a copy of the current Practice Complaints and Comments Patient Information Leaflet.
• The patient should be asked if they intend to complete the form in this leaflet there and then, or do they intend to complete it later.
 If they intend to complete it later, the Practice staff member should provide them with an envelope.
 If they intend to complete it there and then, the Practice staff member ask if they require assistance in completing it – if so, Alex Hennessy should be contacted to provide such assistance.
• Whichever option is chosen, the patient will be assured that their complaint will be acknowledged within 3 working days from receipt of the form

Do we have the practice complaints and comments leaflet to have with an pre=addressed envelope if they wish to send it back to the practice at a later time?
we are creating a complaints folder which will have leaflet adn acknowledgement letter within to give or send to aptient
Do we acknowledge receipt of the complaints? yes as above

• All complaints, whether written or verbal will be recorded by Alex Hennessy in the dedicated complaints record

Where do we keep this record? yes all in folder upstairs in order

Initial action upon receipt of a complaint
• All complaints, whether verbal or in writing must be forwarded immediately to the Alex Hennessy, the Practice Complaints Manager or, if unavailable to Dr T Hennessy, the Practice Responsible Person.
• Where the complaint is made verbally, a written record will be made of the complaint and a copy of this will be provided to the complainant.

Do we send a copis to the patients?
we have been writing it down but will now send to patient

• As much of the following information as possible will be obtained at this initial meeting, to enable their concerns to be assessed correctly, resolved quickly if possible and build a good ongoing relationship with them:
 Ascertain they would like to be addressed – as Mr, Mrs, Ms or by their first name.
 Ascertain how they wish to be kept informed about how their complaint is being dealt with – by phone, letter, email or through a third party such as an advocacy or support service.
If it’s by phone, ascertain the times when it is convenient to call and verify that they are happy for messages to be left on their answerphone.
If it’s by post, make sure that they are happy to receive correspondence at the address given
 Check if consent is needed to access someone’s personal records
 Check if they have any disabilities or circumstances that need to be taken account of.
 Ensure they are aware that they can request an advocate to support them throughout the complaints process, including at the first meeting.
 Systematically go through the reasons for the complaint so that there is a clear understanding why they are dissatisfied.
 Ascertain what they would like to happen as a result of the complaint (for example, an apology, new appointment, reimbursement for costs or loss of personal belongings or an explanation).
 Advise them at the outset if their expectations are not feasible or realistic.
 Formulate and agree a plan of action, including when and how the complainant will hear back from the Practice.

Shall we create a checklist so this data is captured when dealing with a complaint? It would be easy to forget this info.  Have we any evidence that we have done this with previous complaints?

goign to creat checklist

• After the investigation is completed, the Practice will compile a written report which incorporates:
 A summary of each element of the complaint
 Details of policies or guidelines followed
 A summary of the investigation
 Details of key issues or facts identified by an investigation
 Conclusions of the investigation: was there an error, omission or shortfall by your organisation? Did this disadvantage the complainant, and if so, how?
 What needs to be done to put things right
 An apology, if one is needed
 An explanation of what will happens next (e.g. what will be done, who will do it, and when)
 Information on what the person complaining should do if they are still unhappy and wish to escalate the complaint, including full contact information on the Health Service Ombudsman.
• The Practice will send the complainant a response within the 6 months “relevant period”, signed by Dr T D Hennessy , the Practice Responsible Person. The response will incorporate:
 The written report
 Confirmation as to whether the Practice is satisfied that any necessary action has been taken or is proposed to be taken;
 A statement of the complainant’s right to take their complaint to the Parliamentary and Health Service Ombudsman.

do we have any evidence on record to show that patients are given a written response from the practice about their complaint with details of how to escalate if they are still not happy?

at present not doing this but alex is now compling checklist to be compeletd today to ensure any future complaints are delat with this way
Complaints Register
To ensure the Practice monitors, handles and reviews complaints in a logical and timely manner, and to keep an audit trail of steps taken and decisions reached, the Practice records all complaints received on a dedicated complaints register (see Appendix A

Where is our complaints register?

complaints reguster is upstairs

Annual Review of Complaints
• In line with National Guidance, the Practice will supply the following information to the PCT:
 The number of complaints received;
 The issues that these complaints raised;
 Whether complaints have been upheld;
 The number of cases referred to the Ombudsman.

Have we done this?  When was this info last given?
we are going to review our complaints as a pratcie meeting

There is a format for how the complaints register format should be at the end of this policy.  Is this the data we keep?

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Post by Lesley Williams on Tue Nov 03, 2015 12:22 am

Confidentiality code of practice

Dr T Hennessy at the Practice is responsible for notifying the CQC without delay about allegations of abuse including:
• Any suspicion, concern or allegation from any source that a person using the service has been or is being abused, or is abusing another person (of any age), including:
a) Details of the possible victim(s), where this is known, including:
b) A unique identifier or code for the person.
c) The date they were or will be admitted to the service.
d) Their date of birth.
e) Their gender.
f) Their ethnicity.
g) Any disability.
h) Any religion or belief.
i) Their sexual orientation.
j) All relevant dates and circumstances, using unique identifiers and codes where relevant.
k) Anything you have already done about the incident.

Does this mean that all cases of abuse need to be reported eg a patient who is a victim of domestic violence would they come under this remit?

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Post by Lesley Williams on Tue Nov 03, 2015 12:28 am

Confidentiality policy for practice staff

Staff Confidentiality Agreement

I understand that all information about patients held by SILVERDALE MED CTR_HENNESSY TD is strictly confidential.

Have all our staff memebr signed this document and is it in their folders?

all signed

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Post by Lesley Williams on Tue Nov 03, 2015 12:39 am

Consent Policy and consent

Obtaining Consent

• Consent (Implied or Expressed) will be obtained prior to the procedure, and prior to any form of sedation.
• The clinician will ensure that the patient is competent to provide a consent (16 years or over) or has “Gillick Competence” if under 16 years.
Further information about Gillick Competence and obtaining consent for children is set out below.

Can we add a gillick competent tick box to the contraceptive template
this will be added to all templates


Informed consent must be obtained prior to giving an immunisation. Although there is no legal requirement for consent to immunisation to be in writing, a signature on a consent form is not conclusive proof that consent has been given, but serves to record the decision and discussions that have taken place with the patient, or the person giving consent on a child’s behalf.

Should we do written consent forms?
nurses document verbal consent

Patient Consent Form
for another person to access their medical records

We need to ensure that written consent is gained for relatives to have access to patients record as shown on this form. Verbal consent wont suffice
this is being collected

Reception Staff

Upon arrival at the Practice for the consultation, or during the booking of the appointment, the receptionist will explain to you that the doctor / nurse that will be seeing you will also have a medical student or observer sitting in with them and would like your help in providing this service.

The receptionist will also explain that if you are prepared to see or have a medical student or other observer sitting in on your consultation, that the practice will need to obtain your consent.

An information leaflet will be provided for your reference and should answer any questions you may have. If this leaflet does not answer all of your concerns, please do not hesitate to raise these with the receptionist who will be only too happy to answer them.

The practice is grateful for your help in enabling us to provide this teaching service, however this is entirely voluntary.

No one will mind if you would rather not see a student, or if you change your mind or want the student to leave at any time.

You can also refuse to see particular students, such as those of a different sex or those you have met outside the surgery.

Of course, the care provided to you by the Practice will not be affected in any way.

consent form will be done from now on with recpeiton writing next to patient name if have consent of not


Patient’s Consent Form to Observer Policy

This states that written consent has to be obtained from patients to allow medical students to even observe the consultation.  We are currently not doing this

will now be implemented

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Post by Lesley Williams on Tue Nov 03, 2015 12:48 am

Contagious illness policy

Newly employed staff will, during the first week of their induction process, be made familiar with the Practice’s various infection control policies. Refresher training will also be mandatory for all staff on an annual basis and / or when new practices / methods become available.

Is this covered in blue stream learning?
on blue stream learning

Occupational Health Arrangements

The Practice has arrangements in place for occupational health support and advice, together with appropriate policies for the protection of staff from infection through immunisation, the avoidance and management of incidents, and training and compliance with health and safety legislation.

Each new member of staff must complete a pre-employment health questionnaire and provide information about previous immunisation against relevant infections. Patients and other staff also need to be protected from staff infected with a communicable disease.

The Practice’s occupational health policies set out the responsibilities of staff members to report episodes of their own illness, (e.g. vomiting, diarrhoea), to the Practice manager.

Have this health questionnaires been completed with immunisation status all present? Are staff aware if they have D&V to call in and let you know and they shoudl be free 48 hours of this before returning to work?

WHA completed

Infectious Diseases in Staff

Staff members who are suffering from any sickness, diarrhoea or have a heavy cold or flu symptoms should not attend the Practice for work. This also applies to any staff members who may be suffering from septic skin conditions.

The member of staff should notify their Practice Manager as soon as possible before they are due to start work if they are suffering from any of the above conditions.

The Practice Manager must then assess the situation and make sure the appropriate action is taken (e.g. excluding the staff member from work if necessary).

Staff members who are ill must be symptom-free for 48 hours before returning to work to ensure that any infection is not passed to other staff members and patients

Is everyone aware of this?
all staff aware

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Post by Lesley Williams on Tue Nov 03, 2015 12:52 am

Continuous quality improvement statement

• Patient Demand / Staff Capacity Audits

From the list this is the only thing I dont think we have done.  Could we try and conduct a patient demand audit and then we can show that we have changed our appointment times to try and reflect this

we are going to complete these audits and have it planned

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Post by Lesley Williams on Tue Nov 03, 2015 12:55 am

Contract of employment

Issuing and Retaining the Contract

Two copies of this document should be produced and issued

• One for the Employee to sign and retain;
• The other for the employee to sign and then be filed in the Employee's File, as a permanent record of their terms and conditions of employment.

Does everyone have a signed contract that we have a copy of and they also do?
all have this and on their file

Last edited by Lesley Williams on Fri Nov 13, 2015 2:08 pm; edited 1 time in total

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Post by Lesley Williams on Tue Nov 03, 2015 1:12 am

COSHH Policy and risk assessment

Alex Hennessy is responsible for arranging the assessments.

Risk assessments will be reviewed regularly and Alex Hennessy is responsible for arranging these. Alex Hennessy is responsible for retaining the records of assessments.

Do we have any hazardous materials on site and have risk assessments been carried out?

each room has a risk and helath assessment form

Recording Hazardous to Health Substances

An index will be kept of all substances hazardous to health within the workplace. Alex Hennessy  is responsible for maintaining this. (See Appendix G – COSHH – List of Hazardous Substances in use).

This index shall also contain the manufacturers’ health and safety data sheets (See Appendix F for a Safety Data Sheet Index Template).

Do we have an index?
alex will look into this

A copy of the Safety Data Sheet which specifies emergency treatment will be held for each substance:
• In the central health and safety file.
• In the possession of the cleaning staff.
• Adjacent to the storage location of the substance.

Do we have a copy of any of these safety sheets?e
Alex will review today

Personal Protective Equipment (PPE)
PPE will only be used by employees as a last resort or as a back-up measure during testing or modification of other controls. The type and use of PPE will be carefully assessed and PPE will be maintained according to the manufacturers’ instructions.

Alex Hennessy is responsible for the issue of PPE and retaining records of its issue.

All changes of PPE will be properly assessed.

What PPE is kept on site?  Do we have goggles and facemasks to utilise if needed? If not we should order some
ALex will order some goggles and facemasks

• Audit COSHH items at least on an annual basis as part of the annual Health & Safety joint inspection –

Do we have any items that may be needed to be included in an audit? If so has this been done?
start audit from Jan 2016


The Practice will monitor and control all substances in the Practice with the potential to cause harm to ensure the safe usage and storage of these items, and that staff are aware of them, and trained in their use See Appendix D – COSHH – Hazardous Substance Risk Assessment Record

These procedures will include, but will not be limited to:
• Clinical substances
• Clinical Waste
• Cleaning materials
• Chemicals
• Gases
• All substances with a hazard identification symbol

The oxygen would be classed as this.  Do we store this correctly and is the safety information close to hand and on file and is it audited?

Do we lock our yellow bind to prevent community member going into the bin
locked already outside
Do we audit the correct storage of cleaning material and is the cleaning cupboard kept locked? locked and cleainng subastans have COSHH report

Step 7. Prepare an emergency plan.
The Practice will draw up plans to deal with emergencies such as spillages etc.

do we have emergency plans eg spillages of blood and how to deal with it? If CQC asked reception would they know what to do? I am not sure only that the agent is in sians room if she wasn't in what would we do? Is the information on how to deal with it safely kept with it?  Is the correct PPE by it to utilise if needed?
sian will do a talk

Have we completed any COSHH activity/situation risk assessment record? being completed for each room

COSHH – Hazardous Substance Risk Assessment Record

Do any substance fall into this category and has this form been completed?

COSHH – Record of Audit

Have we completed a COSHH audit?

COSHH Index of Safety Data Sheets

DO we have an index of the safety data sheets?

COSHH – List of Hazardous Substances in use

Do we have these listed?

alex will review above today

Last edited by Lesley Williams on Fri Nov 13, 2015 2:22 pm; edited 1 time in total

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Post by Lesley Williams on Tue Nov 03, 2015 1:15 am

Co-operating with other providers policy

The Practice must work side-by-side with many other providers, such as those which provide:

• District Nursing Services;
• Out-of-Hours Care Services;
• Social Care Services;
• Secondary Care Services;
• Safeguarding of Children Services;
• Health Visitors Services

Have we sent an email asking if we can try and organise a monthly meetings with the district nurses and community matron?  Is there a social worker assigned to our practice i think the answer to the latter is no

helath visitor will attend monthly. District nurses ahve been sent a letter of invite but have not been able to make any meetings

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