CQC policies

Notifications of Death or Unauthorised Absence under the Mental Health Act 1983 – Outcome 19 Composite Statements and Forms
Dr T Hennessy at the Practice is responsible for notifying the CQC within three working days upon the death of a person detained or liable to be detained under the Mental Health Act 1983.

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

Do we think it would be better to have a GP rather than Alex as second to Tom?

Notify CQC of Absence & Return from Absence of a Registered Individual for 28 or more consecutive Days – Outcome 27 - Statements & Forms

Where an absence of 28 or more consecutive days by the Registered Person who is in day-to-day charge of the Service is planned more than 28 days before the absence begins, Dr T Hennessy is responsible for advising the CQC of this planned absence a minimum of 28 days before the absence begins.

Where an absence of 28 or more consecutive days by the Registered Person who is in day-to-day charge of the Service is planned less than 28 days before the absence begins, Dr Lesley Williams is responsible for advising the CQC of this planned absence without delay before the absence begins.

Where a likely absence of 28 or more consecutive days by the Registered Person who is in day-to-day charge of the Service occurs as a result of an emergency, Alex Hennessy will inform the CQC of the absence within 5 working days after the absence began.

Should any of these three situations arise, and Dr T Hennessy is unable to advise the CQC, Alex Hennessy will be delegated this task.

Should any of these three situations arise, Dr Lesley Williams will manage the continued operation of the regulated activity during the Registered Person’s absence.

Is Lesley aware of this?

Notify CQC of changes affecting the Provider/Manager of a regulated activity – Outcome 28 - Statements & Forms

In the event that the Practice initiates plans for a person other than the current Registered Person (Provider or Manager) to carry on or manage the service, Dr T Hennessy is responsible for advising the CQC of these plans as soon as possible before they do so.

In the event that a person other than the current Registered Person (Provider or Manager)begins to carry on or manage the service, and it has not been possible to advise the CQC of this situation in advance, Dr T Hennessy is responsible for advising the CQC of this situation without delay.

Does Tom need to inform CQC that Alex is our temporary PM, in this case should Alex be given all these responsibilities on the protocols?

In the event that Practice appoints a NEW Registered Person (Provider or Manager), Dr T Hennessy is responsible for advising the CQC of the appointment as soon as possible.

In the event that the above change cannot be notified to the CQC before it takes place, Dr T Hennessy is responsible for advising the CQC of the change without delay afterwards.

Should either of these two situations arise and Dr T Hennessy is unable to advise the CQC, Alex Hennessy will be delegated this task.

Has this taken place?

5. Practice Statement –When the Practice is an Organisation, notify the CQC of any changes to the following:
• The Organisation’s Name
• The Organisation’s Business Address
• The Organisation’s Officers (e.g. directors / secretary)
• The Organisation’s Nominated Individual

In the event that the Practice is an Organisation, ***Insert Name of the Registered Person*** is responsible for advising the CQC of any of the following changes as soon as possible:
• The Organisation’s Name
• The Organisation’s Business Address
• The Organisation’s Officers (e.g. directors / secretary)
• The Organisation’s Nominated Individual

In the event that any of the above changes cannot be notified to the CQC before they take place, ***Insert Name of the Registered Person*** is responsible for advising the CQC of the changes without delay afterwards.

Should any of these situations arise and ***Insert Name of the Registered Person*** is unable to advise the CQC, ***Insert Name of Person*** will be delegated this task.

We need to appoint someone for the above

Notifying CQC of Legal Actions taken against the Service – Practice Statement

SILVERDALE MED CTR_HENNESSY TD confirms that it is also fully aware of its obligations to notify the CQC of any personal insolvency of a member of the Partnership.

Was this done when the other partners left?

Nutritional Needs Policy

SILVERDALE MED CTR_HENNESSY TD does not provide food or drink in the course of the provision of its services.

Need to remove the water or change the policy

• Patients and their carers will be provided with written guidance and advice on maintaining nutrition and hydration during periods of ill-health, where required;

I don't think we are doing this, but would be important for our insulin dependant diabetics and those with Addison's.

Obesity Policy

DM 2 The percentage of patients with diabetes whose notes record BMI in the preceding 15 months.
Mental Health
MH 12 The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of BMI in the preceding 15 months
Obesity
OB 1 The practice can produce a register of patients aged 16 years and over with a BMI greater than or equal to 30 in the preceding 15 months.

Can we make sure that the above patients have their weight assessed annually. Alex can this be added to their care plans please

Patients identified with a BMI equal to, or greater then 30 will be invited to the Practice to discuss an action plan.

Can we please make the nurses aware of this as they will be the main clinicians in managing this we will support. This is were live well will play a big part. Alex when are they coming in, need all nurses to be present.

The best course of treatment will be identified by the patient’s GP or the Practice Nursing Team, who will aim to provide the following:
• Leaflets and information on how to reduce the amount of calories in their diet;
• Advice on which type, how, when and how frequently they should exercise (incl. possibly referring the patient to exercise on prescription).
• Information on the type of diet that will benefit the patient best and how to follow this safely.


Alex can we make sure the live well team have given us information leaflets.

Palliative Care Policy & Protocol

Although QOF Indicator PC2 requires that multi-disciplinary case review meetings are held regularly and at least on a 3 monthly basis, the Practice has adopted a policy hold such reviews at least monthly, as it is considered that a 3-monthly gap between meetings is too great for optimum patient care.

The aims of the multi-disciplinary case review meetings are to:
• Improve the flow of information between teams in relation to these patients and in particular to Out-of-hours providers.
• To ensure that each patient on the register has a personal management plan, and that decisions are taken and acted upon by the most appropriate person.
• To ensure that each personal management plan clearly details a preference for the patient’s chosen place of care.
• To ensure that carers’ needs are discussed and addressed where possible.


We need to ask the palliative care nurse tci for monthly review as per policy. Lesley is now lead for this area. We need to ensure they all have care plans and the carers needs are also assessed. We should also be looking at their nutritional assessment as per the nutrition policy and referring to dieticians as required.

• These meetings will be held as item 1 of Practice Meeting on 2 weekly basis
• Attendees will include (but will not be restricted to):
• All Practice GPs
• Practice Palliative Care Co-ordinator
• Practice Nurse Representative
• Community Matron
• District Nurse
• Other community staff as appropriate
• Administrator – to write up minutes

This conflicts with the above, I think we should stick to monthly reviews, Alex can we try to tie in asking the DN and community matron and palliative care nurses and have a monthly meetings solely to review our palliative care pt's hope everyone is in agreement with this.

• The administrator will issue the agenda prior to the meeting.
• The Palliative Care Register itself will form the basis of the agenda and the discussions at the meeting in the absence of further items.
• Prior to the meeting, the Palliative Care Co-ordinator will:
• Prepare the updated Register
• Update the personal management plans with any known actions;
• Identify and carry out necessary preparatory work for any special points for discussion in relation to individual patients.
• Each individual patient on the Palliative Care Register will be the subject of a specific note in the minutes, even where the meeting agrees that no new action is required – the minutes will reflect this stable situation.

This is an area we need to work on. Alex, when we do the minutes as stated above we need the pt's unique NHS number and an action plan, even if there is none. We could prepare this document in advance to show CQC and try to have a meeting prior to their visit so they can see our intentions for the future care of these patients.

At each and every meeting, each Patient’s Palliative Care Record Sheet is reviewed with the following topics being discussing and recorded:
• Patient Name;
• Carer Name;
• Diagnosis;
• GP / District Nurse initials;
• Problems / concerns discussed;
• Anticipated needs;
• Information given / Carer issues;
• Date of completing Form DS1500;
• Macmillan Nurses – names etc.;
• Hospice / SPC details;
• Date OOH Hand-over form sent;
• Statement and date of preferred place of care;
• Actual place and date of death;
• Bereavement Care;
• Crisis events / Notes.

This is a good template of what we need to cover for each pt so Alex if we can draw up a document to cover the above. We can put a copy in each pt's care plan also.

Panic Alarm Protocol

Static – Intruder System Reception Desk Turn deactivation key and ring the Control Centre at ADT,

Computer Screen Software (button) All screens when logged on Administrator to reset

Alex can you show us were this is in reception. Can we all make sure we know were our panic button is on our computer. I think we should put this on front desk as at present it isn't easily accessible.

Parental Rights and Responsibilities

for info only

Patient Access to Medical Records Policy and Request Form

A request for your medical health records held at SILVERDALE MED CTR_HENNESSY TD should be made in writing (e-mails also accepted) to the data controller who is ***Insert Name & Position of Person*** (please contact the Practice for alternative methods of obtaining access if you are unable to make a request in writing).

We need to appoint someone, likely PM.

Patient Consent Form
for another person to access their medical records


Alex can we please print out a copy of this form, reception to use this if a patient wishes others to be able to view/access their records.

Patient Dignity and Respect Policy

• A notice will be displayed in reception stating that guide dogs are permitted in all parts of the building.
• A hearing loop must be installed and operational at all times, and staff members trained in its use.


Can we ensure we have a poster/sign to say guide dogs allowed. Can we make sure everyone knows how to use the hearing loop.

• The area used for dressing / undressing will be equipped with clothes hangers or pegs and will have a chair with arms at a suitable height and design for the patient to use.

Can we put some hooks on the walls, and one on the back of the door for our coats.

Patient Emergency Handling - Patient in Distress Desk Aid

Can we please print out the flow chart for each room.

Patient Information Statement

• The Aims, objectives and purpose of the service;
• The facilities that are available for their care, treatment and support;
• How their care, treatment and support is reviewed;
• The cost of the services, where charges are applied;
• How to raise a concern or complaint about the service, and how it will be dealt with
• How to raise a concern if they or another person are being abused or suspect abuse
• Health promotion to encourage patients to change lifestyle behaviours that are placing their health at risk, so they can make informed choices about whether they wish to lead a healthier lifestyle
• How to make a suggestion
• Local advocacy services, e.g. PALS, ICAS

Alex have we got the paper and pen for the suggestion box? Do patients know how to make a complaints? Maybe we should have a sign in reception with regard to this.

Patient Participation DES - Local Participation Report Template

Alex has this been completed and filed?

Patient Participation Policy & Example Survey Questions

The outcomes of the engagement and the views of patients are to be published on the practice website.

Have we done this?

Are we using their documents?

This policy has a lot of questionnaires for patient feedback. We could print out and give to CQC on their visit, it ouwld be good to show the views of our patients.

Patient Participation DES – Supporting Documents

Can we ensure we have the poster in the waiting area. Can we ensure this is on our webpage

Patient Population Needs & Practice Staff Capacity Analysis

Alex has this been completed?