CQC policies

Fraud Policy

Practice Debit Card

Accountability
The accountable person for the Practice’s dedicated debit card is the person named on the card. This person is Dr T Hennessy.

The debit card was approved by all the signatories on the current Practice account and a mandate was completed and signed by all the signatories.

The conditions for the use of the debit card are as follows:
• Only the named person on the debit card will be able to utilise this card for purchasing;
• The purchase remittance will then be presented to the Designated Partner and Dr T Hennessy will obtain a signed signature from them to sign this purchase as authorised and to provide a complete audit trial;
• The remittance will be filed in the expenditure file;
• Alex Hennessy will record the purchase on the accounts package and highlight this as a debit card purchase.

Before the cheque is sent to the supplier, a copy will be taken, along with a copy of the invoice, and filed in the Donation Account folder (this is kept in ***Insert Location***).
Do we have a donation account folder? If so can we put in,location on policy as none there.
Is Dr H and one other partner looking at all debit card purchases before being filed?

Bank Accounts

The main Practice bank accounts is accessible online.

There are 3 Practice account(s) called Silverdale Practice Ac,  Drs Hennessy, Pickles and Nelson and Abbey National Ac
These are operable with one signatory.  

Are all the partners aware that there are 3 accounts. It would be useful if at least quarterly these accounts are looked at by the partners. Should these need 2 signatures to prevent fraud?

Freedom of Information Act – Compliance Guidance and Model Publication Scheme Pre-formatted Template

The ICO requires that, in the event that a Practice is currently using a Publication Scheme created before 1 January 2009, this is out-of-date and should be replaced using the current ICO Model Publication Scheme.

Just checking re above
No other problems identified

Gillick Competency Assessment

POINTS FOR CONSIDERATION

• Has the young person explicitly requested that their parents/carers are not made aware of this assessment, or any other services they are receiving?
• Have you clearly documented the young persons’ reason why they do not want you to inform their parent/carer?
• Can they clearly explain their reasons for this decision?
• Is this a rational decision based on their own value system, or religious belief?
• Can they understand the advice / information that has been given, and understand what the implications are, and what is involved?
• Are you confident that the young person is not being coerced into making a decision?
• Would the young persons’ physical or emotional wellbeing be likely to suffer without this service(s) or advice?
• Would it be in the young persons’ best interests to carry out the assessment and identify services and/or support and provide this without parental consent?

You should be able to answer ‘Yes’ to these questions if you believe that the young person is competent enough to make their own decisions about giving consent to have treatment, receive services, and to share information with them, without parental consent.

I am sure we all do the above when seeing a patient < 16 years old. Make sure everyone is documenting gillick competent and also document why they don’t want to inform parent/carer.

Good Practice Guidelines

General Medical Council - Regulating Doctors to ensuring good medical practice:

http://www.gmc-uk.org/guidance/good_medical_practice.asp
As a doctor we all work within these guidelines. Can all doctors make sure they have read these recently so we are aware of the updated principles.


Grievance Policy, Procedure & Supporting Template

Our Rules And Procedures Ensure:

• Any grievance you may have, formal or informal, will be dealt with fairly and consistently.
• Provision will be made for setting out a formal grievance in writing, if you are unable to formulate one yourself due to a disability, or for some other justifiable reason (i.e. illiteracy or where English is not your first language).
• You will be invited in writing to attend a meeting to discuss your grievance.
• You have the right to be accompanied by a companion during your grievance / Appeal meeting.
• You will receive written notification of the outcome of the Grievance meeting.
• You have the right to appeal if you feel the grievance has not been resolved to your satisfaction.
• You will be invited to attend an Appeal meeting in the event that you exercise your right to appeal.
• You will receive written notification of the final decision.


Know this is all in the employers handbook but just so we are all aware of the policy and how a grievance should be dealt with. I wonder if CQC will ask about Alice and was all above steps followed?

Hand Hygiene Policy and AuditAudit

To ascertain the awareness and knowledge of infection control processes and procedures of Practice Staff, the practice will undertake an audit every ***Insert period***, to identify the effectiveness of effective hand preparation and hand decontamination of all staff within the Practice to minimise the risk of transmission of infection.

The audit will also provide an opportunity to evaluate the effectiveness of training in hand hygiene procedures, plus an opportunity for staff to reflect on their own hand hygiene practices, improving their technique where required.

The policy states re audit of handwashing do we do this? Can we update policy to say how often. Who is in charge of this audit SI or NH?

First Aid and Reporting Accidents at Work

First aid boxes are located in Practice Nurse’s Room. All employees will be shown the location of the nearest first aid box to their regular work station and will be given the names of designated first aid personnel.
Are all staff aware where this is

Manual Handling

The Practice is committed to educating staff on the prevention of long-term musculo-skeletal health problems by promoting an “each-and-every-time” protocol for safe lifting.

Have all staff completed bluestream this had manual handling on?
The rest of this policy we have covered elsewhere such as fire safety

Health and Social Care Act 2008 - Practice Statement

All relevant staff members carrying-on, managing or working for the purposes of regulated activity at SILVERDALE MED CTR_HENNESSY TD have been subject to the necessary checks as described in Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, so that the Practice is assured that these staff members are suitable for their roles.

SILVERDALE MED CTR_HENNESSY TD confirms that it is fully aware of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 (Part 3 and Part 4) and understands the consequences of failing to take action on set requirements.

Alex can we look at these regulations and see that we are following them . we can have a look together

Health and Wellbeing Policy for
‘Looked After’ Children and Young Persons

The lead health professional will:
• Ensure the health assessments are undertaken (working with the designated health professionals for looked after children, depending on local arrangements);
• Work with the child’s social worker to co-ordinate the health care plan and ensure actions are tracked;
• Act as a key conduit and contact point between the child or young person and their carer, where they have difficulties accessing health services;
• Act as a key health contact for the child’s social worker;
• Work with the designated health professionals for looked after children, coordinate the individual health reviews.

Do we have any looked after children I dont think we do

Heart Attack Action Plan – Desk Aid for Reception

Heart Attack Action Plan - Desk Aid for Reception

If a patient, relative or carer calls the Practice in distress, stating that the patient has any of the following symptoms:

Central chest pain which is severe or crushing
or
Chest pain which has lasted for 15 minutes or more
or
Chest pain and a past history of heart problems
or
The patient has other symptoms similar to a previous heart attack















THE FOLLOWING ACTION IS NEEDED URGENTLY AND QUICKLY:

1. Ask the caller for the patient’s name, address (including postcode) and telephone number (or current location details if not at home).
2. Inform the caller that you are going to telephone 999, then if possible, pass the caller to another receptionist to try and keep them calm.
3. If you have already ascertained that the patient is unconscious, during the 999 call, ask the ambulance control to telephone the caller to provide cardiopulmonary resuscitation (CPR) instructions, then tell the caller to hang up immediately so that the ambulance control centre can call them.
4. Immediately following the 999 call, contact the duty doctor and inform them of the situation, the location of the patient and that an ambulance as been called.
5. Record the details of the incident on the patient’s computer records

Do we have anything like this for reception staff

Help with NHS Costs – Patient Poster

HAVE WE GOT ONE OF THESE UP ANYWHERE SEE POLICY FOR POSTER

Hepatitis B Policy

Staff at Risk
All staff in regular contact with patients, blood, blood products and tissues contaminated with blood are at risk of infection.

All staff undertaking Exposure Prone Procedures, (EPPs), (mainly doctors, nurses, health-care assistants and phlebotomists), are also at risk of transmitting infection.

3 Aims

The aims of the Surgery are to ensure procedures are in place to:

• Identify staff that are not immune to HBV and provide immunisation to protect them against infection, which could be acquired during their work.
• Identify any infected worker whose work involves EPPs who may pose a risk to patients and take appropriate action.

4 Pre-Employment Screening

Pre-employment screening of clinical staff should seek to prevent those with chronic skin lesions on their hands working in high-risk areas.

Health care workers who have or develop such conditions should not undertake invasive procedures and will be referred to the Occupational Health Department.

Compliance with this policy is a condition of service for new staff that will participate in EPPs.

Any offer of employment involving EPP will be made "Subject to medical clearance including Hepatitis B".

Appropriate documentation from previous places of employment or training may be sufficient to demonstrate compliance and should be presented to Alex Hennessy.

Alex has already asked me for my hep B imms schedule can all other drs nurses give them your hep B screening and booster information. This is definitely something CQC will ask about

All health care workers undertaking EPPs should be immunised against Hepatitis B. Priority must be given to doctors, nurses, health-care assistants and phlebotomists.

Other staff at risk include Receptionists (e.g. when handling samples or cleaning up spillage of bodily fluids) and the Practice Cleaning staff.

Where immunisation has not taken place or is not complete, tests of current infection (HBsAg) should be carried out as soon as practicable and before the health care worker performs EPPs.

Health care workers whose Hepatitis B carrier status is unknown should not perform EPPs.

How We Use Your Health Records - Patient Leaflet & Posters


we have this leaflet if a patient wants to know about how we use their health records
This could always be put on website will chat to Alex about it


HR Policy Statement

HR Policy Statement

SILVERDALE MED CTR_HENNESSY TD is committed to providing an efficient and comprehensive service, achieving positive Outcomes for all patients on its Practice list through the skill, aptitude and commitment of its staff members.

The Practice accepts its ethical responsibilities and recognises its obligation to conduct its activities in full knowledge of, and compliance with, the requirements of relevant legislation, governing bodies and approved Codes of Practice.

The Practice achieves this by adopting a policy of best practice in staff recruitment, training and management.

The principal objectives of the Practice’s comprehensive suite of HR-related policies, protocols and systems are to ensure that:

• All employees are selected and recruited based upon their attitude, skill, competency, and aptitude;
• The philosophy and management style of the partners and senior management staff members are such as to promote and encourage motivation and retention of the best employees;
• Professional relationships between staff members are based on mutual trust, fairness and equality of opportunity for all;
• The dignity of all employees is respected by the management team and fellow employees;
• No employee is subjected to discrimination or bullying of any kind;
• All employees are trained to carry out their role competently, in compliance with relevant legislation, guidance and regulatory bodies, including promoting and adopting best practice, and are supported to advance their continued professional development;
• Communications between the senior management team and other employees, along with their union representatives, are mutually accepted as open and honest;
• Alex Hennessy is the HR contact at SILVERDALE MED CTR_HENNESSY TD. This person is available to provide professional advice, guidance and practical support to all employees in matters relating to their employment at the Practice;
• Line managers are responsible for ensuring that the contents of this HR Policy Statement are employed within their own departments. The Practice’s HR contact must always be consulted before any action is taken in relation to any employee and their employment at the Practice. This person is available to be contacted to answer any queries relating to the application or interpretation of this statement and the policies, protocols and systems it represents.
• This HR Policy Statement will be reviewed on a regular basis, where the Practice reserves the right to alter any provisions previously set-out from time-to-time, as required.

I think we do all of above. Alex do you have regular meetings with staff so they can discuss any concerns. Do you think we should come to some of them so staff can talk to us also.

Identifying Patient Needs Protocol +
New Patient Registration Policy & Form

The New Patient Registration Form has a section where patients can alert the practice to any specific needs they may have.

Specific needs include:

• Sensory impairment, i.e. speech, hearing, sight
• Physical disability
• Mental disability
• Religious or cultural needs
• Translation/interpretation
• Allergies and sensitivities
• Has or is a carer
• Access to premises
• Assistance dog
• Advocacy
• Phobias

Alex can I have a look over the patient registration form with you. Think it covers most of the areas.

Implementation Record - Implementation Record Default

This is an example of how to record anything new implemented

An integral part of proving any policy, procedure or system is fully operational, is ensuring that a record / audit trail exists using a timeline to detail its implementation history and action taken. This can provide evidence that:
• You have an appropriate procedure, policy or system in place and all relevant staff fully understand it and use it correctly;
• You have effective systems in place for reporting and learning from incidents;
• Your policies are up-to-date and are regularly monitored and reviewed for effectiveness.

Anything we now implement which is new maybe we should have a record and then review how its going in a set time period?


Incident Management Procedures

This policy goes through every possible incident such as breach of confidentiality, inadequate disposal of confidential waste, theft, computer misuse etc

4. Managing incidents

The Practice has assigned the role of Incident Manager to Alex Hennessy.

The Incident Reporting Form in Appendix A of this document will be used to report the details on all actual and potential incidents that affect the confidentiality and security of Patient information.

After initial completion, it will be passed to the Incident Manager for further action.

[color=#ff9933] Alex have we got any recent incidents we can show CQC and show that we have got incident form and how each one was dealt with[/colo

6. Lessons learned

The Practice maintains a register of all incidents occurring within the organisation. This register of incidents and the resulting actions taken are likely to impact upon other policies and procedures within the Practice.

All registered incidents are re-evaluated after a 6 month period to assess the effectiveness of the implemented actions, in ensuring that either the type of incident is no longer being reported or the volume of those types of incidents has reduced.

Have we got a register of incidents and do we re-evaluate these

Induction policy

Alex and I will go through this policy as goes through everything each staff member should have had when joining know Alex gave me a folder with lots in it.


Infection Control Biological Substances Incident Protocol

Definition

For the purposes of this protocol, the term biological substances relates to any fluid generated by the body. For example:
• Blood;
• Vomit;
• Sputum / saliva;
• Urine;
• Breast milk;
• Wound drainage;
• Faecal matter.

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.

Blood

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

Have we got spillage kit and where exactly is it?

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.

Have we got these granules

in the spillage kit have we got instructions

Multi-disciplinary Protocol

Where multi-disciplinary care is required, the patient will have a medical record that is kept at their home.

A lead clinician will be identified and noted in the record.

All team member contact details will form part of the record.


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),

OR

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

Information only. Dr H is responsible for informing CQC and Alex if he isn't in

Are we doing this? I think if we see a palliative pt at home we should document in their care records the outcome of the visit. This also refers to housebound pt's, so as GP's we need to consider who would benefit from having a medical record folder at their home address

Needlestick Injuries Policy

Cheshire and Wirral Partnership Occupational Health Department. St Catherin’s Hospital this is our occupational health department that we shoul dcontact if we have had a needlestick or other injury that puts us at risk of infection

INFORMATION ONLY

Appendix A
Management of Occupational Exposure to Blood-Borne Viruses Flowchart


Alex is going to print out this flow chart with the occupational team details and consultant microbiologist details, to be put in each dr's and nurses room. We need to ensure all the nurses have read this, Alex can you please ask them to

New Employee Recruitment, Selection, Interview & Appointment Policy & Protocol

• Upon receipt of completed applications, separate the completed Equal Opportunities Form from the Application Form and pass it to Alex Hennessy for analysis and retention for a minimum of 12 months.

Do we have this?

• Recruiting only the friends or relatives of your existing work force.

To attract a wide field of applicants, the Practice will select media that will be accessible and relevant to the target audience (for example, the Practice will avoid using a publication or employment agency that is focused on a niche market as this may limit the diversity of applicants and may constitute indirect discrimination).

We need to show that we are being fair with recruitment. Please ensure that the other 2 applicants for Dr L Williams are stored. What are we going to do about Rachael's recruitment. We have now confirmed that Alex has a temporary contract and that the job will be issued to all internal members of the team. However, this doesn't comply with this policy

Monitoring the Equal Opportunities Policy

Because the Equality & Human Rights Commission’s guidance on the Equality Act recommends monitoring recruitment and internal promotion, the Practice will use the Equal Opportunity Policy Form template as found in Appendix C – (the categories shown on the form are approved by the above body as appropriate for monitoring collections).

The Practice will issue this form with all application forms and upon its return, immediately separate it and pass it to Alex Hennessy, prior to any selection decision being made.

This will enable the Practice to compile a statistical report showing the Protected Characteristics of all applicants, those who are shortlisted and those who are eventually offered employment and demonstrate that the people offered employment are a true representation of those who apply.

This analysis will be kept on record for a period of at least 12 months.

We need to show that we are complying with this

New Partner Checklist

We need to complete the checklist, we need to sign contracts, inform pension agency of our likely pay and to sort out the building. Lesley I have left a copy in your tray for reference and what we need to complete

New Staff Performance Review Policy & Supporting Templates

It is the Practice Policy that the new member of staff and their Line Manager will have performance review meetings within one month of starting, after their initial three month period and after their initial six month period.

Annual appraisals will subsequently be conducted, as per the Practice’s Appraisal Policy.


Can we show this is taking place. I now Alice and Sheila did do reviews. There are actual forms to complete so we can use these in the future. Alex can you print these off so you use them in the future

I think it would be a good idea if we completed this for Alex, to show he is being supported in his temporary PM role.

NHS Constitution

The text of the Constitution on the following pages will be incorporated into the Practice Website www.silverdalemedicalcentre.nhs.uk and also placed on the Notice Board in the Patient Waiting Area of the Practice.

Do we have this in both areas?

• Ensures that it works across organisational boundaries and in partnership with other organisations in the interest of patients, local communities and the wider population.

We need to show we are engaging with other members of the MDT. Can we ask our community matron to come in and also the drug workers. We regularly see the health visitor. The palliative care nurses were coming in at one point can we restart this with them, so that once a month they come in. When are the live well team coming in? Can we ask our practice pharmacist to also come to one of our meetings so we can find out their latest projects.

• To have a process for staff to raise an internal grievance.

Can we ensure all staff know how and who to go to should they have any grievances

NHS Number – Practice Use Policy

Policy

Checking if an NHS Number has been allocated to a Patient

To ensure the correct NHS number is used and to avoid duplication, the Practice will perform the following when registering a new patient:
• Gather as much information as possible about the person during the registration process using the standard set of questions below (this will establish whether there has been previous contact within the NHS and should uncover whether an NHS number has already been created):
 Has the patient ever previously registered with a GP Practice in England, Wales or Isle of Man?
 Were they born within England, Wales or Isle of Man?
 Have they ever been a serving member of the armed forces?
 Have they ever been a dependent of a serving member of the armed forces?
 Have they ever attended any NHS hospitals, NHS clinics or other NHS establishments?
 Are they returning to England, Wales or Isle of Man after a period abroad?


Are these all questions we ask patients when they join th epractice

• Displaying posters and leaflets in Practice waiting areas promoting the use of NHS numbers (the following link contains various patient communication mediums that could be used: http://www.connectingforhealth.nhs.uk/systemsandservices/nhsnumber/staff/imptool/comms )

Can we ensure we have this in the waiting area

Notification of Death - Outcome 18 Composite Statement and Form

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

To clarify Dr H initial persons, I am second. This conflicts another policy in which it states that Alex is second to Tom, but if we are all aware that I will be second to Tom.

If you see this in your policies to make Alex aware and we can amend this

Notification of Other Incidents – Outcome 20 Composite Statements and Forms

Dr T D Hennessy at the Practice is responsible for notifying the CQC without delay of any application to deprive a person of their liberty.

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


Lesley were you are of this?

Can I check that, Lesley your pt 3466, would we need to inform CQC in this instance?