Dr Hennesys Polocies

Practice use of CQC Schedule of Applicable Publications Protocol – Outcome 10D

Can we print out the following docs?
• All currently valid Health Technical Memoranda (HTMs) published by the Department of Health;
• All currently valid Health Building Notes (HBNs) published by the Department of Health;
• Legionnaires Disease: The control of legionella bacteria in water systems, approved code of practice and guidance (Health and Safety Executive, 2000);
• Controlling legionella in nursing and residential care homes (Health and Safety Executive, 1997);
• Guidance on Manual Handling operations Regulations (Health and Safety Executive, 2004);
• Alerts, rapid response reports, guidance and directives about all aspects of healthcare and social care premises published by:
 National Patient Safety Agency;
 DH;
 Secretary of State;
 Health and Safety Executive;
 Department of Environmental Health;
 Home Office;
 National Institute for Health and Clinical Excellence;
 National Patient Safety Agency;
 NHS Estates;
 Social Care Institute for Excellence;
 Care Services Improvement Partnership;
 Professional Royal Colleges and other recognised professional bodies;
• A professional approach to managing security in the NHS (NHS Security Management Service, 2003);
• Safety, privacy and dignity in mental health units. Guidance in mixed sex accommodation for mental health services (NHS Executive, 2000);
• Implementation Criteria for Recommended Specification: Adult Medium Secure Units (Quality Network for Forensic Mental Health Services, 2007);
• Environmental principles for medium secure accommodation (Health Offender Partnerships, 2008);
• The NHS constitution (DH, 2012).

Practice use of CQC Schedule of Applicable Publications – Outcome 11E

Can the following be printed out:

• MHRA DB 2006 (4) Single-use Medical Devices: Implications and Consequences of Reuse (MHRA, 2006);
• MHRA DB 2006(5) Managing Medical Devices: Guidance for health care and social care organisations (MHRA, 2006);
• Safety alerts, rapid response alerts, guidance and directives relating to equipment published by expert and professional bodies including:
 National Institute of Clinical Excellence;
 National Patient Safety Agency;
 Medicines and Healthcare products Regulatory Agency;
 Royal Pharmaceutical Society of Great Britain;
 DH;
 Product manufacturers;
• DH IRMER Guidance and Good Practice Notes;
• Mental Health Act 1983 and Mental Health Act Code of Practice (DH, 2008 relating to seclusion facilities).

Practice Use of CQC Schedule of Applicable Publications Protocol – Outcome 12C

Again can these be printed out?

• NHS employment check standards published by NHS Employers;
• Code of practice for the international recruitment of health care professionals (DH, 2004);
• The Health care Professionals Alert Notices Directions 2006 (DH, 2006);
• Relevant guidance and codes of conduct and practice about professional registration and qualifications published by professional registration councils and professional bodies including:
 General Medical Council;
 Nursing and Midwifery Council;
 Health Professional Council;
 General Dental council;
 General Social Care Council;
 Royal Pharmaceutical Society of Great Britain;
• Medical and other clinical royal colleges, faculties and professional associations;
• CRB Code of Practice;
• Safeguarding Vulnerable Groups Act 2006;
• Protection of vulnerable adults scheme (POVA);
• ISA Referral Guidance (Independent Safeguarding Authority, 2009);
• DH IRMER Guidance and Good Practice Notes.

Practice use of CQC Schedule of Applicable Publications Protocol – Outcome 17D

…….the Practice will ensure that all relevant staff are aware of the following guidance as listed below:

• NHS Constitution (DH, 2009)
• The Principles of Good Complaint Handling (Parliamentary and Health Service Ombudsman, 2008)
• Listening, improving, responding: a guide to better customer care (DH, 2009)
• NHS Litigation Authority guidance about complaints
• Being open – communicating patient safety incidents with patients and their carers (NPSA, 2009)

Are they all available and known to staff?

Practice use of CQC Schedule of Applicable Publications Protocol – Outcome 1D
This will ensure that the Practice complies with both National and Local guidance that the Government and the Department of Health request practices adhere to.

All these documents will be made known that they are available to staff, either in paper format or on the Practice intranet:
• The NHS Constitution (DH, 2012);
• Confidentiality: NHS code of practice (DH, 2003);
• Relevant national strategies, national service frameworks, and nationally agreed policy guidance and recommendations about involving people published by the Department of Health and other Government departments, including:
• Human Rights in Health Care – A Framework for Local Action (DH);
• Valuing People: a new strategy for learning disability for the 21st century (HM Government, 2001);
• Valuing People Now: a new three-year strategy for people with learning disabilities – Making it happen for everyone (HM Government, 2009);
• Real involvement: working with people to improve services (DH, 2008)
• Independence, Choice and Risk: A Framework for Supported Decision Making (DH, 2007);
• Refocusing the care programme approach: Policy and positive practice guidance (DH, 2008).
• Guide to the public sector equalities duties (Equality and Human Rights Commission, 2009)l
• Being open – communicating patient safety incidents with patients and their carers (NPSA, 2006)l
• Care Planning Practice Guide (NTA, 2006).

Are they available?

Practice use of CQC Schedule of Applicable Publications Protocol – Outcome 21A

…….the Practice will ensure that all relevant staff are aware of the following guidance as listed below:

• The NHS Constitution (DH, 2009)
• Confidentiality: NHS code of practice (DH, 2003)
• Caldicott Guardian Manual 2006 (DH, 2006)
• Records management: NHS code of practice (DH, 2006),
• Information security management: NHS code of practice (DH, 2007)
• NHS Information Governance: Guidance on Legal and Professional Obligations (DH, 2007)
• Relevant professional guidance and codes of conduct and practice relating to record keeping published by professional bodies and registration councils including the General Medical Council, Nursing & Midwifery Council, General Social Care Council, BMA, RCN, Health Professional Council, Royal College of Physicians and the Academy of Medical Royal Colleges
• DH - Procedures for the Approval of Independent Sector Places for the Termination of Pregnancy
• Codes of practice published by the Information Commissioner

Are they?

Practice use of CQC Schedule of Applicable Publications Protocol – Outcome 2D
…….the Practice will ensure that all relevant staff are aware of the following guidance as listed below:

This will ensure that the Practice complies with both National and Local guidance that the Government and the Department of Health request practices adhere to.

All these documents will be made known that they are available to staff, either in paper format or on the Practice intranet:
• The NHS Constitution (DH, 2012)
• Reference guide to consent for examination or treatment (DH, 2001)
• Good practice in consent: achieving the NHS plan commitment to patient centred consent practice (Health Service Circular HSC 2001/023)
• Seeking Consent: working with children (DH, 2001)
• Research governance framework for health and social care: Second edition (DH, 2005)
• Procedures for the Approval of Independent Sector Places for the Termination of Pregnancy (DH)
• Relevant guidance and codes of conduct relating to consent published by professional registration councils such as the General Medical Council, Nursing & Midwifery Council, General Social Care Council and the Health Professions Council
• Mental Health Act Code of Practice (2007)
• Mental Capacity Act Code of Practice (2008)
•

Are they?

Practice use of CQC Schedule of Applicable Publications Protocol – Outcome 9C
... the Practice will ensure that all relevant staff are aware of the following guidance as listed below:

This will ensure that the Practice complies with both National and Local guidance that the Government and the Department of Health request Practices adhere to.

All these documents will be made known that they are available to staff, either in paper format or on the Practice intranet:
• Relevant evidence-based guidance and alerts about medicines management and good practice published by appropriate expert and professional bodies, including:
 National Patient Safety Agency;
 National Institute for Health and Clinical Excellence;
 Medicines and Healthcare products Regulatory Agency;
 Department of Health;
 Royal Pharmaceutical Society of Great Britain (RPSGB);
 Social Care Institute for Excellence;
 Medical and other clinical royal colleges, faculties and professional associations.
• The safe and secure handling of medicines: a team approach (RPSGB, 2005);
• Safer management of controlled drugs: Guidance on strengthened governance arrangements (DH, 2007);
• Safer management of controlled drugs: Guidance on standard operating procedures for controlled drugs (DH, 2007);
• The handling of medicines in social care (RPSGB, 2007);
• Research governance framework for health and social care: Second edition (DH, 2005).

Are they?

Prescription Security Protocol
• All blank prescriptions are removed from the prescription printers, located in the office, by Reception staff at the end of each working day and placed in the Practice safe. They are replaced in the printer by the same person at the start of the next working day;
• The pads for hand-written prescriptions are also locked away in the Practice safe, located in back office;
• Each GP has their own prescription pad for hand-written prescriptions and each prescription is numbered. Alex Hennessy issues the pads to the doctors each morning and the doctor records, on a designated card, how many prescription sheets are on the pad when they receive it. Each doctor must then record how many they have issued during the day, then verify the number left on the pad at the end of the day when they hand it back to the issuer. (This procedure is also the same for locum doctors and is supervised by Alex Hennessy
;
Can the above be actioned?

Professional Qualifications & Registration Policy for New & Existing Staff

The Practice will make it clear to all relevant prospective employees that:
‘appointment to any position is conditional on a satisfactory registration, licence and qualification checks, and that any information disclosed on the application form will be checked’.

Any offer of employment made by the Practice to a prospective employee, whether conditional or absolute, will incorporate a clear statement to the effect that:
‘any offer of appointment may be withdrawn if they knowingly withhold information, or provide false or misleading information, and that employment may be terminated should any subsequent information come to light once they have been appointed’.

In addition, contracts of relevant employees will contain the clause that:
‘should an employee cease to become qualified or become “de-registered” at any time during their employment, that the employment will be deemed to have terminated’.
The Practice will make the following checks on relevant candidates prior to appointment:
• That the applicant is registered to carry out the proposed role
• Whether the registration is subject to any current restrictions that might affect the duties proposed
• If the applicant has investigations against them about their fitness to practise that the regulatory body has a duty to disclose.
• By going onto the GMC’s online register (the List of Medical Practitioners) at
http://www.gmc-uk.org/ and entering the individual’s GMC reference number. This will state either that they are registered ‘with a licence to practise’ or that they are ‘registered without a licence to practice’;
The Nursing and Midwifery Council (NMC)

The Practice will contact the NMC to provide the following registration status information on registered nurses:
• Removed
• Restored
• Conditions of practice
• Cautioned
• Suspended
• Lapsed
• Effective.
The Practice will contact the NMC to confirm registration status in one of the following ways:
• Online at http://www.nmc-uk.org/

Have we got proof from GMC re Rachel and NMC re Sian and Jayne?

Protocol for Booking an Interpreter

• When you are with the patient, please telephone the number on the card ***Insert Number*** and the operator will ask you for the following information:
• Access Code ***Insert Number***;
• Name of your Organisation: Silverdale Medical Centre
• User Name ***Insert User Name***
• The language you require.


We need the information for 'Language line'. I think the CCG can supply details.

Protocol to Identify Patients with Learning Disabilities

A learning disability is NOT
• Dyslexia (learning difficulty in educational legislation);
• People who have a learning difficulty (educational term);
• Presence of physical disabilities only;
• Stroke victims;
• Presence of mental health problem only;
• ADHD;
• Cerebral palsy;

Patients with the following diagnosis will be considered as suitable to be invited to join the register;
• Asperger’s Syndrome
• Autism
• Downs Syndrome
• Educational difficulties
• Turners Syndrome
• Congenital abnormalities

To clarify who should be coded

Record Keeping Policy and Protocol

To facilitate this requirement, the Practice will conduct an annual record audit, which will take place around December each calendar year.

As the worst offender I think this should be done - see policy

Referral Desk Aid & Audit Data Collection Template

To provide evidence and demonstrate that the Practice is compliant with CQC Outcome 6B, it is recommended that the Practice undertakes an audit of referral documentation on a regular basis (e.g. Monthly, Quarterly, Six-Monthly).
SILVERDALE MED CTR_HENNESSY TD
Referrals Audit Data Collection Template

Patient
Reference
Number Date of Consultation Date Referral document issued No. Working Days to issue Doc Clinician Involved Patient Information that should be included in the Referral Document NOTES / COMMENTS
Name Gender Date of birth Address Unique ID number Emergency contact details Any persons acting on behalf of patient, plus contact details Care records up to
point of transfer Assessed needs Known preferences and relevant diverse needs Relevant previous
medical history Any managed infections Any current medicines taken Any allergies Key contact at sending provider Reason for transfer Any advance decision Any assessed suicide / homicide or risk of self-harm or others
1
2
3
4
5
I think we should do this as per protocol.


Repeat Prescription and Medication Review Protocol
We need to use risk assessment tool in this protocol

Safeguarding Children – Practice Self-Evaluation Workbook
Can Alex and Lesley please complete!

Service Continuity Plan & Risk Assessment
Alex we need to embed our plan in this document

Service Review Policy & Example Audit Template
Alex we need to start doing this

Staff Screening and Immunisation Policy
We need to complete one form for each staff member

Staff Skills, Competencies & Training Record Summary
Alex we need to complete Excel sheet

Staff Training Record
We need to complete for each member of staff

Supervision Support Meetings
Sian Nicky - How do we do this?

Use of Medical Equipment Protocols – Staff and Patients
I need to do this report

That's all!!!!