CQC policies

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Re: CQC policies

Post by Lesley Williams on Tue Nov 03, 2015 1:20 am

[][/color]Daily monitoring checklists

Refrigerator Temperature Checklist -

do we record the temp am and PM and sign for this
being reocrded daily

Who takes over if Sian is off?
Aelx


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Re: CQC policies

Post by Lesley Williams on Tue Nov 03, 2015 1:23 am

Data Security and Policy Protection

• The Practice will display a poster in the waiting room, explaining the practice policy to patients.

• The Practice will make available a brochure on Access to Medical Records and Data Protection for the information of patients.

DO we have this poster displayed? yes in reception
Do we have a brochure?


At the bottom of this policy is a place for Tom and Alex to sign.  Does this need to be printed off and displayed? alex will check it is signed

The poster which shoudl be displayed is at the bottom of the policy

we are using this poster


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Re: CQC policies

Post by Lesley Williams on Tue Nov 03, 2015 1:28 am

DBS check policy and consent form

(DBS) checks on all relevant staff members, whether they be permanent, temporary or casual workers

Have all staff for DBS check?  Are we checking the medical students prior to starting work?
all staff checked. Liverpool uni chekc the studnets and send us this information in the folder

In addition to adhering with the above Code and Act, the Practice will specifically ensure that:
• Disclosure information is never kept together with other information on an applicant’s personnel file (it is always kept separately and securely in lockable, non-portable storage containers with access strictly controlled and limited to those who are authorised to see it as part of their duties in accordance with Section 124 of the Police Act 1997);

We need to take the DBS checks off the wall and put them in a locked file away from the personnel file according to this

will be taken down and locked away


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Re: CQC policies

Post by Lesley Williams on Tue Nov 03, 2015 1:33 am

Decontamination training policy and register

Training

• Members of staff involved in decontamination procedures must be competent, properly trained and supervised;
• Staff will receive training on decontamination which is appropriate to their area of work. The Practice Manager will identify training need and arrange both local induction and ongoing training in conjunction with the Practice’s medical devices trainer who is Sian
• The Practice Manager will identify core competencies and the individual staff member’s achievement of the core competencies via appraisal;
• Advice on appropriate methods of decontamination and on the possible adverse effects on medical devices of any proposed decontamination procedures can be obtained from Sian

What training has been undertaken?
If Sian is not in who else is trained?
Does SIan feel confident advising on point 3
Is there a copy of the training register on file - see template register on policy

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Re: CQC policies

Post by Lesley Williams on Tue Nov 03, 2015 1:38 am

Disciplinary Policy

Stage 3 - Sanctions

Following the Disciplinary meeting you will be informed of the outcome in writing. You will be informed of the sanction, how long this will remain on your personnel file and informed of your right to appeal against this decision.

Verbal Warning

Are we starting to document verbal warnings so we can then escalate to written warnings if need be?

Appendix D - Employee Disciplinary Record

all being kept on record

DO we keep this as a document in each employees file?


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Re: CQC policies

Post by Lesley Williams on Tue Nov 03, 2015 1:44 am

Dispensary risk management policy

Policy

Mrs Sian Irving is responsible for the operation of the Practice dispensary and will ensure that:
• An SOP is in place to cover each key area of operation and source of potential risk;
• SOPs are closely and routinely followed by staff using a system of regular check, observation and audit;
• Departures, failures or breakdowns in SOP Practice are reported using the Significant Event Procedure and that resulting action is implemented;
• Any training needs identified from significant event reporting or audits are addressed;
• The competencies of dispensary staff are assessed on a regular basis and the opportunities for development and maintenance of skills are available.

Is Sian aware of this?
Is this policy reflecting the drugs we have in the drugs cupboard as we dont have a dispensary
How can we assess the competencies of dispensary staff???

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Re: CQC policies

Post by Alison Williams on Wed Nov 04, 2015 5:01 pm

Job Description and Person Specification Templates

Policy gives description of each persons role within the practice, includes GP partner, Practice manage, nurses, admin staff etc. Alex can you print them off and give a copy to the relevant member of staff, ensure they have read and signed it and put it in their folder. This would also include Liz and Paula.


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Re: CQC policies

Post by Alison Williams on Wed Nov 04, 2015 5:03 pm

Job Reference Request Template

Do we have job references? Do we need them? This gives a letter for us to send to the relevant person to ask for a reference.

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Re: CQC policies

Post by Alison Williams on Wed Nov 04, 2015 5:11 pm

Key Holder Policy & Templates

Permanent Key Holder Agreement Form
Each identified person must each complete a Permanent Key Holder Agreement Form (see page 3) which registers them as a key holder and also highlights their responsibilities within this function.

Do the people who have responsibility for keys signed the agreement form? We need to keep a copy in their folder

The Practice Manager is responsible for keeping a master record Key Holder Register (see pages 5 and 6) of all keys held and by whom. Both permanent and temporary key holders are noted on this register.

Alex do you have the above?

This record certifies that I, ***Insert Name & Position of Person*** have been nominated by the Practice to be a permanent key holder.

We need to identify our permanent key holders
I have printed off a copy and will give to Alex to complete


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Re: CQC policies

Post by Alison Williams on Wed Nov 04, 2015 5:24 pm

Laundering of Linen, other Fabric Materials and Uniforms Policy

Refers to staff uniforms and them being cleaned. This mainly applies to the nurses and HCA. What is our practice policy with regard to washing uniforms?

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Re: CQC policies

Post by Alison Williams on Wed Nov 04, 2015 5:34 pm

Legionella - Management, Testing & Investigation Policy

The Approved Code of Practice entitled “Legionnaires’ Disease – The control of Legionella bacteria in water systems” provides practical advice with respect to the requirements as regards risks from legionellosis under the Health and Safety etc. Act 1974 and the Control of Substances Hazardous to Health Regulations 2002 and identifies the following essential duties:-
• A person should be appointed to be managerially responsible and to provide supervision for the implementation of the precautions;
• A thorough assessment should be carried out to identify and assess the risk of legionellosis from work activities, water sources and any necessary precautions;
• An action plan should be produced for the remedial work necessary to minimise the risks identified;
• Implementation and management of the precautions to control risk;
• Maintenance of adequate records.

Who looks after the air conditioner units, if they aren't being used we should make sure their initially safe before CQC come and then if they aren't going to be used to remove them.

Also whose responsibility is it to provide heating to this building? Is that Tom and Roger or is that deemed a tenants role?

The Practice’s Responsible Person and their Responsibilities

Alex Hennessy is the Practice’s Responsible Person.

Dr T Hennessy is the Practice’s Responsible Person’s Deputy.

The Responsible Person will be required to liaise closely with other professionals in various disciplines. This individual’s role involves:
• Advising on the potential areas of risk and identifying where systems do not comply with the guidance and preparing a scheme for preventing or controlling the risk, this includes checking:
a) Whether conditions are present which will encourage bacteria to multiply, e.g. is the water temperature between 20–45° C;
b) There is a means of creating and disseminating breathable droplets, e.g. the aerosol created by a shower or cooling tower; and
c) If there are susceptible people who may be exposed to the contaminated aerosols.
A Legionella Hazards Checklist is to be found in Appendix A
• Liaising with the Water Treatment Contractor to ensure that equipment that is permanently connected to the water supply is properly installed;
• Advising on the necessary continuing procedures and actions for the prevention or control of legionellae;
• Monitoring the implementation and efficacy of these procedures and actions;
• Approving and identifying any changes to those procedures and / or actions;
• Maintaining and co-ordinating adequate records;
• Co-ordinating with specialist competent help;
• Carrying out the necessary actions should an outbreak of Legionnaires’ disease be suspected.

Alex, as lead, have you ensured that the above has been completed?

Staff Responsibilities

There is a duty on all Staff to report biological hazards and therefore risks of Legionella.

Staff are required to immediately advise the Responsible Person if they notice the following:
• Loss of temperature in the hot water system;
• Any loss of pressure in either the hot water or cold water systems;
• Any suspected cases of Legionnaires disease;
• A basin, bath or shower that is infrequently used.

Alex, can you make all staff above of their responsibilites

Monitoring and Record Keeping
• The flow temperature from Domestic Hot Water (hot water provision to taps rather than to a central heating circuit) calorifiers or other DHW heaters should be not less than 60oC;
• The minimum temperature anywhere in the circulation pipe work should not be less than 50oC;
• Cold water outlet temperature shall be measured after allowing the water to run at full flow for 1 minute. The temperature should be less than 20oC. If the temperature is found to be above 20oC an investigation will be undertaken to find the cause, including enquiry of the water supplier;
• Hot water outlet temperatures shall be measured after allowing the water to run at full flow for 1 minute. The temperature should be at least 50oC. However where mixing or blending devices are used which prevent the outlet reaching this temperature, the pipe surface immediately before the device should reach 50oC within 1 minute;
• All areas will be monitored and water temperature at representative hot and cold outlets shall be measured and recorded at least twice per year;
• The results will recorded on a log sheet by the Responsible Person and all failures and large variations will be investigated – See Appendix A.

Alex, can you provide documented evidence for the above?



Appendix A – Legionella Hazards Investigation Report

This Report has been designed as an aid to assess the Legionella hazards within the Practice premises.

It can be used in conjunction with the general risk assessment sheet to help identify possible hazards.

Alex, can you please complete this report

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Re: CQC policies

Post by Alison Williams on Thu Nov 05, 2015 1:52 pm

Local Laboratory Accreditation Statement – Outcome 8 – Criterion 8

Needs simply to be signed and printed off, has this been done?

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Re: CQC policies

Post by Alison Williams on Thu Nov 05, 2015 1:58 pm

Maintenance, Servicing & Calibration of Equipment Protocol & Template

***Insert Service Company’s Name, Primary Contact, Address and Telephone Number*** is responsible for calibration and PAT testing of equipment. The Practice works in partnership with this company to ensure that all Practice medical equipment is fit-for-purpose and fully-functional.

Can we put the companies name in

Alex Hennessy has overall responsibility for the inspection, calibration and replacement of all medical equipment, however, the Practice understands that each user of Practice equipment also has a part to play.

When an item is purchased, Alex Hennessy should be made aware so that they can record the new entry and store it in the upstairs Office.

Alex, have you got a record of equipment as required above?

P.A.T Testing

Electrical equipment will receive an annual check during its portable appliance test which is conducted by ***Insert Service Company’s Name***.

Alex, Can you show evidence of the above?

Calibration

Equipment calibration will be carried out by ***Insert Service Company’s Name***, and each item of equipment requiring calibration (e.g. mechanical scales) will be recorded electronically by them and passed to Alex Hennessy who keeps a designated record folder which can be found in upstairs Office.

Alex have you got this also in the folder?


Nebuliser Annual Recall

Nebulisers must be checked and serviced once annually. Where this equipment is on loan to a patient for use in their own home, a Nebuliser Recall Form must be completed (see Appendix A) and sent to the patient’s home address so they know they must return the item.

Is our nebuliser checked? Im assuming we don't have nay pt's which we have loaned nebs machine to?


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Re: CQC policies

Post by Alison Williams on Thu Nov 05, 2015 2:01 pm

Making & Using Visual and Audio Recordings of Patients – Guidance and Protocol

Now that we don't have GP trainees I cant see why this would be applicable to us. However, it does include photographs! When Sue Reid took a picture of that persons leg with the haematoma this protocol should have been followed. So just to be aware to read this policy if you are taking photographs

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Re: CQC policies

Post by Alison Williams on Thu Nov 05, 2015 2:06 pm

Recording Telephone Calls

Telephone calls from patients to the Practice may be recorded for legitimate reasons, (e.g. for medico-legal purposes, staff training, and audit), provided the Practice takes all reasonable steps to inform callers that their call may be recorded.

Given the sensitive nature of many calls to a Practice, particular attention must be paid to ensuring that callers are aware that their call may be recorded and no intentionally secret recordings of calls from particular patients must be made.


Just rang the surgery number, it is not part of the recorded message that their call me be recorded!! Alex please amend ASAP.


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Re: CQC policies

Post by Alison Williams on Thu Nov 05, 2015 2:09 pm

Mandatory National Data Collection System Statement

In the SILVERDALE MED CTR_HENNESSY TD, all requests for mandatory national data collections are passed to Alex Hennessy who is the Practice Person responsible for actioning and managing this activity.

Whenever mandatory national data collections are requested Alex Hennessy will ensure that:
• All staff involved in this activity are made aware of the requirement in advance and receive a detailed briefing of the specific data collection requirements;
• The data is collected at the time / within the time-frame specified;
• The data is assembled and presented in the required format;
• The data checked and verified for accuracy;
• The data is submitted in a timely manner to the requesting organisation.

Alex, please make admin staff aware of the above policy

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Re: CQC policies

Post by Alison Williams on Thu Nov 05, 2015 2:15 pm

Medical Procedure Competency Audits

Needs to be completed as Tom does joint injections, skin lesion removals. Can we ask Tom to complete this audit prior to CQC coming, this would be a good audit cycle as it can be done retrospectively.

Inadequate Smear Tests Audit

Practitioners who carry out smear tests are required to keep a record of each one performed, along with the test results. The Practice audits the number of inadequate smear tests recorded as a percentage of all smear tests carried out by each practitioner.

[color=#6600ff]Can we also complete this audit Alex. This information can we collated from searches



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Re: CQC policies

Post by Alison Williams on Thu Nov 05, 2015 2:31 pm

Mental Capacity Assessment Guidance & Checklist

Worth a quick read. There is also a form you can print off and put in patients notes when deciding about capacity.

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Re: CQC policies

Post by Alison Williams on Thu Nov 05, 2015 2:36 pm

Military Veterans – Protocol for Priority Treatment & Access to Health Services

History Relating to Military Service - Xa8Da
History Relating to Army Service - 13q0
History Relating to Navy Service - 13q1
History Relating to Air Force Service - 13q2

With patients consent we can use the above codes

Where the patient does consent for their veteran status to be included, the Practice GPs will ensure that when making referrals relating to a military veteran for diagnosis or treatment, that status is recorded as part of the referral.

In the event that a Practice GP considers that priority treatment might be appropriate because the condition to which the referral relates is likely to be related to the patient's military service, this fact will be included in the referral.

JUST TO BE AWARE

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Re: CQC policies

Post by Rachael Winters on Fri Nov 06, 2015 5:55 pm

Disposal of Confidential Waste Protocol


The purpose of this protocol is to create a process for the safe disposal of confidential waste so that the chances of this information being used by unauthorised persons for illegitimate purposes is minimised as far as possible.


• Waste to be shredded on site where possible
• Staff members to place all other confidential documents to be disposed of in the locked confidential waste box. Alex Hennessy must ensure this facility is always available and regularly monitor that there is enough capacity left on an ongoing basis.
• Alex Hennessy to empty the waste box when full, tie all sacks securely, and place them in a locked room to which only they have access.

• Alex Hennessy must ensure that no confidential waste is left unattended before it can be collected by the nominated disposal company.


Alex do we have a locked confidential waste box. Know we have a shredder. Is all confidential papers shredded at the end of the day?




Dissemination of Drug Alerts, Patient Safety Notices, Guidance and Formularies Protocol
Protocol

Information received by e-mail will usually have been sent directly to the correct recipient. Where it has been sent to a generic Practice e-mail address, or where information has been received by fax or by post; this should be received by nominated person(s).

The person(s) responsible for receipt of the above types of information is Alex Hennessy.

Information received will indicate a timescale within which it should be actioned. The information must be disseminated and acted-upon within this timescale.

Depending on the type of information received, dissemination will take place as follows:

• Clinical alerts and guidance will be passed to the Practice Manager who will share these with clinicians at the Practice and any other healthcare professional (where relevant);
• MHRA alerts will be passed directly to the Practice Manager for investigation and subsequent further action;
• Drug Alerts must be passed to the Practice Manager so that s/he can ascertain which (if any) patients have been prescribed the affected item(s). Where the drug has been prescribed to patients, their usual doctor will contact them.

Copies of all alerts and notices received will be kept in a nominated folder and separated by type of alert. Alex Hennessy is responsible for the management of this folder.

Alerts and notices must be numbered sequentially by date of receipt.

The folder should be reviewed once every Quarter by Alex Hennessy. Any missing alerts should be investigated by the responsible person and where relevant, printed off and actioned.

All information documents should be annotated with details of any action taken, e.g. distribution list, which patients were informed, etc.

If a fax-back or e-mail response is required by the sender, a copy of the response should also be kept in the folder.

Alex have you been getting the above alerts. If so are they e mailed to you or sent in post. How are you showing the clinicians. I haven’t had any since starting.
Have we got folder for these alerts and are we checking that each clinician has had them and actioned them where appropriate?


Drug Storage Protocol

Storage of Refrigerated Medicines

Medicines that require storage below room temperature should be stored in a lockable medicines refrigerator. By definition refrigeration is a temperature of between 2 and 8°C.

The temperature of all fridges storing medicines is to be recorded daily using the thermometers provided. Both the minimum and maximum temperatures are to be recorded.

In the event that a medicine has not been stored at the correct temperature, or is suspected of not having done so, the matter should be investigated and advice sought from Dr T Hennessy

Food and drink and samples should not be stored in medicines refrigerators. Medicines must not be stored in a food or samples fridge.

Have asked Sian to look at the policy and let me know if we are checking temp daily and are they in locked fridge.

Duty of Candour
Extract from CQC Regulation 20 : Duty of Candour

“The aim of this regulation is to ensure that health service bodies are open and transparent with the “relevant person” (as defined in the regulation) when certain incidents occur in relation to the care and treatment provided to people who use services in the carrying on of a regulated activity.”

To meet the requirements of CQC Regulation 20, a Practice must be:

• Open and transparent way with relevant persons in relation to care and treatment provided to people who use services in carrying on a regulated activity.
• Tell the relevant person (in person) as soon as reasonably practicable after becoming aware that a safety incident has occurred, and provide support to them in relation to the incident, including when giving the notification.
• Provide an account of the incident which, to the best of the Practice’s knowledge, is true of all the facts the Practice knows about the incident as at the date of the notification.
• Advise the relevant person what further enquiries the Practice believes are appropriate.
• Offer an apology.
• Follow up by providing the same information in writing, and any update on the investigations.
• Keep a written record of all communication with the relevant person.


I think we do most of above. Alex do we keep all communications from person i.e in complaints/significant events




Policy for checking Emergency Drugs in the Surgery and Doctor’s Bags


The Practice needs to have a system in place to enable the checking the Expiry Dates of all Emergency Drugs within the Surgery, as well as those drugs in the Doctor’s Drug Bags.  

Frequency and Responsibility

The Practice will undertake these checks   every 6 months.

This is the joint responsibility of the Practice Manager and Sian Irving

Don’t think any of us carry drugs in our bags? With the emergency drug box do we check this and where is register for this?


Emergency Incident Procedure

Incident in a Consulting Room
Panic alarm to be activated on computer. Alarm rings in reception.

The reception team should:
• Identify location of alarm site;
• Telephone Doctors immediately;
• Close all the doors to Reception but do not lock;
• One Receptionist should remain by the reception counter

Can reception see where alarm is coming from?

we have this alarm and staff are told room number and name of person

This policy is straight forward and we just need to go to this if there are any incidents withi the surgery such as abuse verbal or physical



Emergency Telephone Call Handling Protocol


This policy categorises the calls into priority 1 (call ambulance), priority 2 (GP will call within 20 mins) and priority 3 (GP will call within 60 mins)

Alex can we print out algorithm and put up near reception or put in folder girls can access

Alex will print out and laminate the algorithm for all clinical rooms and one on reception. Duty doctor must follow protocol. Alex will do this today

Employee Handbook


We do have an employee handbook and seems to cover everything

Alex can we make sure everyone knows where this is kept and when we have new employees make sure they read through this within 2 months of employment. I have read it!!!


Employing Agency Workers


We just need to be aware of this policy its about the rights of agency workers. We don’t use agency workers do we?

End of Life Policy, Audit, Patient Charter and Advance Care Plan



SILVERDALE MED CTR_HENNESSY TD has a lead person responsible for End of Life Care and this is Dr T Hennessy

The End of Life Care Lead has undertaken an approved training course within the preceding 12 months that includes end of life tools, prognostic indicators for end of life, advanced care planning including advanced decision and “Do Not Attempt Resuscitation” (DNAR), review Liverpool Care Pathway (LCP) and drug packs.

Has Dr H had above training in last  12months
How often are we going to talk about our palliative patients
In this policy there is a good checklist re DNAR, POA, advanced care planning we should all read and be aware of this


we are having monthly palliative care meetings
As i am pallative care lead I will book onto a pallaitive care course



Equal Opportunities Policy for Practice Visitors and Patients


Am happy we do all of this again its making sure any problems with discrimination Alex is informed first.


Equality Act: Operational Procedures & Policy

A
The Practice will carry out the following audit of its facilities annually, or when significant changes are made to the Practice premises.

Having completed the audit and implemented all required compliance actions, the Policy on Page 6 will be adapted and implemented.

Alex can you look at the checklist its just tickboxes and make sure we fit all the criteria re disabled access etc.

It mentions about having an alert on patients with disability which then generates a member of staff meet and greet them. Should we do this?
I am not sure necessary


[color=#006600lAlex has printed off checklist will check today if any queries let me knoe have deleted meet and greet [/color]


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Re: CQC policies

Post by Rachael Winters on Fri Nov 06, 2015 6:38 pm

Equipment Loan Protocol, Loan Agreement & Register

Alex do we loan any equipment to patients? if not can we delete this policy

no we dont loan any equipment out


Equipment Purchase Compliance Statement


This responsibility includes ensuring that:
• Appropriate equipment and medical devices are purchased from recognised suppliers;
• The items themselves are manufactured by established, renowned and nationally approved companies and comply with all UK laws;
• The Practice obtains the best price / value for money in relation to the items purchased, by actively exploring alternative suppliers / buying groups / equipment ordering terms and conditions (including minimum orders and carriage charges) and will switch orders to where more advantageous terms can be found;
• The Practice purchases items which comply, where possible, with Quality Standard BS EN ISO 13485:2003, (the standard covering the design, development, production, installation and servicing of medical devices);
• Sufficient stocks are maintained, corresponding to historical usage patterns and levels.

Alex I think you do all above when buying devices. Just have quick read and check.


New Medical Equipment & Devices that require Assembly / Testing / Calibration prior to use.
Upon receipt of a new item of equipment, an acceptance check is performed which covers the following four aspects:
• The item is the correct one ordered;
• It comes complete with all necessary instructions on assembly, calibration, and use;
• Visible damage-in-transit check;
• An equipment function check.

Alex do we get someone in to check equipment for example pulse oximeters need testing annually (mine is well overdue) and Sian how about nurses equipmemt like spirometry, ECG, ear syringig machine are these checked annually? What other equipment needs calibrating ?

Alex has folder for calibration and testing we are update done April 2015

Estate Management Policies & Protocols

Scheduled Maintenance

Equipment / System Frequency

Fire Alarms Yearly
Fire Extinguishers Yearly
Practice Burglar Alarm System Yearly
Emergency Lighting Monthly
Portable Appliance Checking Yearly
Water System for Legionella Yearly

Alex do we do the above checks and where are they logged. Are they up to date?

We have done all the above checks and all in a folder


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CQC POLICIES REVIEW

Post by Rachael Winters on Wed Nov 11, 2015 12:16 pm

Help in compiling an Evidence Summary to demonstrate how you meet the requirements of an Outcome

When you are ready to compile your ‘Evidence Summary’ to demonstrate how your Practice meets a Sub-Outcome for people who use the service, you should already have created and implemented the policies, procedures and protocols for that Sub-Outcome.

When compiling your ‘Evidence Summary’, you should be thinking about the types of evidence you are gathering, and whether it is the most appropriate evidence you have available to demonstrate that the Outcome is being met for people who use your services.
Can Policies, Procedures, Protocols and Systems themselves be used as Evidence of Outcomes?

Although the CQC expect that when you evaluate your own compliance, you will focus on evidence that relates to Outcomes for people, they recognise that your Practice may not yet be collecting direct Outcome evidence for all services or all Outcomes and therefore anticipate that greater emphasis will initially be placed on evidence from policies, procedures, protocols and systems.

However, it must be remembered that these will not prove compliance with the Outcomes themselves. You will need to demonstrate that you have considered them in relation to the impact they will have on people who use your services.
If you Initially use Evidence from Policies, Procedures, Protocols and Systems; what will you need to Demonstrate?

If you intend to initially use policies, procedures, protocols and systems for your evidence of compliance, you will need to demonstrate the following:
• How they impact on the Outcomes and experiences of people using the service, and how you monitor this
• How they help to meet service user’s needs
• How they help to identify and manage risks to the health, welfare and safety of people
• How they are implemented and how their effectiveness is monitored
• How they are explained and made available to all relevant staff members
• How you consult with people who use your services and how they are involved in their own development

• How you gather feedback about the impact of your policies, procedures, protocols and systems from people who use your services

Alex are we doing this. Have we compiled an evidence summary? We could go through this together.

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CQC POLICIES REVIEW

Post by Rachael Winters on Wed Nov 11, 2015 12:22 pm

Existing and Transferred-in Patients – Allergy Protocol
Entering Drug Allergies – EMIS WEB Clinical System

1. Bring up the patient’s medical record [MR] from the main screen (for transferred-in patients: make sure the record has already been added to the clinical system);
2. Type [A] to add information;
3. Add the precise date of the allergic response (if known), otherwise enter today’s date;
4. Type [D] (for Allergy);
5. Select Drug Allergy [A] or Non-Drug Allergy [B];
6. Then select [ I ] (for Ingredient or Brand) and enter the name of the substance (you may be offered a pick-list of items);
7. Select the one that fits best. If a drug has one entry under a Trade Name (T) and also an entry under Generic (usually [G] followed by [T]) - select the Generic entry (If you are in any doubt then ask a doctor to advise);
8. Having entered the drug, the system will return you to the [Add any Data] screen. Enter any free-text (e.g. nature of allergy and qualifying text), or press [Return] if there is no text to enter;
9. The system will then ask [Is this a problem?] Enter [N].

Repeat the above process to add any additional allergies to the patient’s record.

Can everyone check they are adding in allergies as per protocol I think we are. The protocol also says when referring should come out on print out which I know it does.

Rachael Winters

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CQC POLICIES REVIEW

Post by Rachael Winters on Wed Nov 11, 2015 7:00 pm

Financial Control, Budgets and Forecasting
Budgets & Forecasting

The Practice’s financial year commences 1st April (Alex isn’t this July ??)

Prior to the commencement of each financial year, the Practice Manager is responsible for producing a financial forecast / budget for the forthcoming 12 month period. This is based on historical data and known future requirements.

This financial forecast / budget is presented at a meeting of the Partners by the Practice Manager prior to the start of the new financial year. At this meeting it is discussed, amendments agreed and approved.

The forecast comprises the following financial data:

Forecast Monthly Income:
NHS / PCT / CCG Income
Practice Income
Dispensing Income

Forecast Monthly Expenditure:
Staff Costs
Premises Costs
Administration Costs
Drug Costs
Capital Expenditure
Finance Expenditure

Forecast Monthly Partners’ Drawings

Forecast Monthly Income and Expenditure Summary Statement

Forecast Monthly Cash-Flow statement
At the end of each month during the financial year, Alex Hennessy is responsible for producing an Actual Summary for the previous month and cumulative, which comprises the following financial data:

Actual Monthly Income:
NHS / PCT / CCG Income
Practice Income
Dispensing Income

Actual Monthly Expenditure:
Staff Costs
Premises Costs
Administration Costs
Drug Costs
Capital Expenditure
Finance Expenditure

Actual Monthly Partners’ Drawings

Alex know that you couldn’t have done this this year as only just taken over but shall we start having a monthly financial meeting to go through the previous month. I think this would be very useful for us to all keep close track on it and we can also help with areas we feel we can improve/save money.

Additional Financial Control Roles of the Practice Manager

• Understand, manage and adapt the Practice’s accounting procedures and key internal financial controls, to ensure the Practice’s financial integrity is always maintained.
• Ensure that the Practice’s financial resources satisfy its current and future requirements.
• Ensure that the Partners are aware of the financial implications of the Practice’s short-term and longer term strategic plans.
• Ensure that the Partners are fully aware of their financial responsibilities and duties.
• Liaison with the Practice’s accountants including:
 Providing all necessary information and supporting documentation required in the preparation of the Practice’s Year-End Accounts;
 Ensuring that the Year-End Accounts have been correctly prepared;
 Understanding the content of the Year-End Accounts;
 Ensuring that the Partners are fully aware of any and all recommendations of the Accountants and are implemented appropriately.

Just copied above out for Alex to read through and check he is aware of everything.

The Financial Roles of the Practice Partners

• Designating one Partner who, in conjunction with the Practice Manager, is responsible for arranging regular reviews of all financial matters.
• Approving the Practice’s budget for the forthcoming financial year.
• Monitoring the Practice’s financial position based on the Actual & Actual v Forecast financial summaries presented by the Practice Manager at the monthly Partners’ Meetings and identifying and agreeing appropriate action.
• Approving purchases of equipment in excess of £20
• Agreeing calculations of drawings and profits.
• Evaluating reports produced by the Practice Manager on areas of concern and agreeing appropriate action.
• Nominating authorised signatories to the Practice’s Bank Accounts.
• Receiving and approving the draft Year-End Accounts.
• Receiving the Accountant’s report and recommendations and agreeing appropriate action.
• Appointing the Accountants for the subsequent financial year.

I am not aware as not a partner but do you have quarterly meetings about finances. Shall we start this (obviously for partners). We should have the accounts now for this year so can we go through these. Shall we also start to look for alternative accountants. I think a quarterly update from them would be useful. This accountant is  far too late in doing the accounts. I have got 2 contacts that I am happy to ask to come in.

Rachael Winters

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CQC POLICIES REVIEW

Post by Rachael Winters on Wed Nov 11, 2015 7:03 pm

Fire Safety Policy

We have appointed Alex Hennessy as the senior person, responsible for all aspects of fire safety including:
• Undertaking fire risk assessments;
• Overseeing fire contracts;
• Organising fire safety training;
• Organising fire drills;
• Coordinating an evacuation in the event of a fire;
• Record keeping.

Additionally, we have appointed Charlotte Gerard (or in their absence Alex Hennessy) who is are the Practice’s nominated Fire Marshalls and are trained to be able to fight fires with our equipment.
Alex I tried to amend policy as your name needs to be inserted. Wouldn’t save can you update it please.

(The person(s) responsible for this policy are ***Insert Name(s) and Position(s) of Person(s)***.)

Have all the staff now done the bluestream fire safety mosules. This was greyed out on my bluestreams. Have we had a practice evacuation recently think we should.  Know we have been doing weekly alarms. LW and I noticed they were not very loud when we were in our rooms can they be louder? Does everyone know where fire extinguishers are. Are they checked annually
jUST NOTIECD THE FIRE SAFETY POSTERS ON DOOR WITH NAMES OF EVERONE IN BUILDING ON EACH DAY V GOOD

Rachael Winters

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Re: CQC policies

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