Going for Gold

The countdown to CQC registration has begun. Julie Wilson shares some tips to help practices jump through those tricky final hoops

From July this year the race begins for practices to register with the Care Quality Commission

A poll commissioned by GP newspaper revealed that 42% of participating GPs believe they are not ready for registration.¹ From July this year the race begins for practices to register with the Care Quality Commission (CQC), the independent regulator of all health and adult social care in England.

This registration must be completed by 1 April 2013 when new legislation will come into force requiring providers whose sole or main purpose is NHS primary medical services to register with the CQC.

This includes those providers of General Medical Services (GMS), Personal Medical Services (PMS) and Alternative Provider Medical Services (APMS). Regulations require practices to register as either an individual, a partnership or an organisation.

As part of the process practices will also be required to adhere to a set of essential quality standards, which will be continuously monitored.

You have got to register – there is no alternative!

So what does this mean to you as a provider of primary medical services? You have got to register – there is no alternative! From July practices will receive an invitation from the CQC to begin the application process (registration). Practices will then be able to choose a date between September and December 2012 to submit their online application.

In the application practices will be asked to state whether or not they are compliant with the Essential Standards of Quality and Safety.² If a practice is not compliant with a standard then an action plan must be submitted, detailing what the practice will do to become compliant and the date that this will be completed.

Warming up

Before you start tackling the obstacles, there is some preparation work to be done

Before you start tackling the obstacles, there is some preparation work to be done. For example:

• Decide if you are going to register as a partnership (the CQC expect most GP practices will register as this), organisation or individual (eg, single-handed practice).
• Confirm your location – the place where the regulated activities take place. If you have a branch surgery, which is managed by the main practice, then you will not have to register it as a separate location. 
• Appoint two leads for the CQC registration process: 
  • One is the overall lead, ie, the ‘registered manager’, who will have legal responsibilities (eg, GP partner) 
  • The other, the 'nominated individual', will be the main contact for the CQC (eg, practice manager).
• Consider which regulated activities your practice is going to register for, eg: 
  • Treatment of disease, disorder and injury
  • Diagnostic and screening procedures 
  • Surgical procedures (above and beyond curettage, cautery and cryotherapy procedures. Practices who undertake the ‘minor surgery enhanced’ service may need to register this activity)
  • Maternity and midwifery services 
  • Family planning services – only for those practices who undertake insertion or removal of intrauterine contraception devices. 
• Identify which staff in the practice will need to have a CRB check. 
• Organise a CQC training session for all the staff.

On your marks – get set.... the application

The CQC will want evidence to demonstrate compliance; it is not enough to have policies and procedures in place

The CQC will want to know that a provider has reviewed their evidence to determine whether they are compliant. MPS is aware that many practices are anxious about how they will comply with the requirements.

The key thing to remember is that the CQC will want evidence to demonstrate compliance; it is not enough to have policies and procedures in place.

Undertaking a Clinical Risk Self Assessment (CRSA) will assist you by highlighting areas where you may not be fully compliant.

GO!!! – scaling the top risks

MPS has produced a guide to the CQC registration process, Signposting the CQC. Below are risk tips for practices based on an analysis of MPS CRSAs, which revealed the most common risks present in practices.

1. Communication

The CRSA research revealed that 99.4% of practices had risks relating to communication. The risks identified relating to communication are split into two categories; internal communication (CQC Outcome 6, Regulation 24) and communication with patients (CQC Outcome 1, Regulation 17).

A. Internal communication

To negate the danger of messages/patient information being inadvertently lost, the use of Post-It® notes and pieces of paper should be discouraged

1. Practice meetings: Ensure that the minutes of key practice meetings are signed by the chairman, dated and reviewed for both accuracy and “matters arising” at the next meeting. It is possible that the CQC will regard the quality of minutes as an indicator of managerial standards generally within a practice. 
2. Internal message system: It is essential to have an effective internal messaging protocol; eg, via an electronic message system. To negate the danger of messages/patient information being inadvertently lost, the use of Post-It® notes and pieces of paper should be discouraged.
3. Primary healthcare team: Ensure there are effective systems in place for communicating/liaising with district nurses, health visitors and other members of the multidisciplinary clinical team. Ensure that all contacts from the out-of-hours service are reviewed by a clinician and action taken as applicable.

B. Communication with patients

Only send text messages to those patients where consent has been recorded for you to undertake this form of communication

1. Patient information: Ensure that there is an up-to-date practice leaflet and website that includes details of the practice services, opening times, etc. Consider whether there is a need to publish the leaflet in other languages. consider whether the needs of visually and hearing impaired patients are being adequately met, eg, audio loops.
2. Text messaging: While the use of text messages can offer greater convenience and flexibility for patients and doctors, only send text messages to those patients where consent has been recorded for you to undertake this form of communication. MPS has produced a factsheet on Communicating with patients by text message.
3. Involving patients: Practices must be able to demonstrate that patients are encouraged to be involved in how the service is run. This can be through patient participation groups/forums, patient surveys and the practice newsletter/website. This is a core area identified by the CQC and one where they anticipate most practices will not achieve the standard.

2. Confidentiality

Ensuring that a service user’s privacy and dignity is upheld is an important element of CQC Outcome 1, Regulation 17

Of the practices, 98.7% had risks relating to communication. Ensuring that a service user’s privacy and dignity is upheld is an important element of CQC Outcome 1, Regulation 17; therefore practices may want to consider their approach to confidentiality.

1. Practice layout: Looking at the layout at reception, perhaps repositioning the computer screen or moving the telephones away from the front desk, would help to reduce the risk of breaching confidentiality. 
2. Staff confidentiality clause: Many of the staff live in the area where they work, so it is very important to reinforce the need to keep this information confidential. It is also not appropriate for staff to discuss the practice or staff members on social networking sites, eg, Facebook. A clause could be included in a staff member’s contract. It is important that all members of staff are trained in confidentiality issues and that the message is regularly reinforced.

3. Prescribing

You will need to demonstrate that all staff have been trained in the repeat prescribing process and that they adhere to the protocol

Of the practices, 87.8% had risks relating to prescribing. Common specific examples include wrong dose, inappropriate medication and failure to monitor for toxicity and side effects. To demonstrate compliance with CQC Outcome 9, Regulation 13 management of medicines, you will need to demonstrate that all staff have been trained in the repeat prescribing process and that they adhere to the protocol.

Best practice indicates that medication added to the prescription list should be done by the GP. If medication is added to the computer or changed by administration staff, it must be closely checked by the doctor afterwards; considerable care needs to be taken to ensure that all the details are correct and that it has been added to the correct patient record. The doctor has responsibility for the prescriptions he/she signs.

4. Record keeping

Of the practices, 87.2% had risks relating to record keeping. With CQC Outcome 21, Regulation 20, the CQC will be looking to see that the service users are protected against the risks of unsafe and inappropriate care and treatment arising from the lack of proper information about them. Contemporaneous records are essential for good quality care and are needed if a complaint or claim is made.

Common risks:

1. Letters scanned onto computer occasionally saved into wrong record
2. Telephone advice and home visits not always recorded
3. No summarising protocol. This is an important task and should ideally be undertaken by a person with a clinical background.

MPS Educational Services deliver medical records workshops for GPs, offered as a benefit of membership.

5. Staff training

It seems very likely that the CQC will consider a well-documented programme of mandatory training to be a basic requirement for practices. To demonstrate compliance with CQC Outcome 14, Regulation 23, practices will need to demonstrate that staff are competent to carry out their work and are properly trained, supervised and appraised.

Practices may wish to keep a simple spreadsheet record of staff training – where the cells in the spreadsheet contain the date on which each named employee last had training in a particular mandatory topic.

The finishing line

So don’t be downhearted; overcome the CQC hurdles with a winning mentality and aim for Gold. Prepare, warm up, go and win.

Julie is speaking about these issues in more depth at the MPS General Practice Conference 2012.

How are practices tackling CQC registration?

Here is a profile of St Georges Medical Centre

  
While many practices are gearing up for registration, some practices have been working hard to demonstrate compliance with the CQC’s requirements for many months. Here is a profile of St Georges medical centre, who have developed a fantastic computer recording system to assist with their registration. We hear from practice manager Doreen Phoenix and finance administrator Pam Leonard, the brainchild of this innovative system.

Doreen Phoenix, practice manager:

The key is having evidence embedded in any data you collect

“About a year ago we began preparing for CQC registration – we took Pam Leonard, our finance administrator, away from her normal job to organise it all. All 27 practices in our consortium pay for the use of First Practice management protocols and templates, so that we are all singing from the same hymn sheet. It was one of these templates that Pam used as a base to develop our CQC registration system. Pam is a real whizz – she has created an Excel spreadsheet containing all the CQC’s Essential Standards, every CQC Outcome and embedded our evidence behind each one.

“The key is having evidence embedded in any data you collect. When we began, we had already pooled a lot of the information together for information governance, so for the CQC registration it was simply pulling the evidence into another area.

My advice to practices is the sooner you get started the better – you have to comply with the 16 regulations

“My advice to practices is the sooner you get started the better – you have to comply with the 16 regulations. I was chatting to a practice manager from a practice in Liverpool, who told me that their CCG had instructed them not to do anything with the CQC registration for now. I would be worried if I hadn’t started yet.

“At a CQC roadshow the registration process was downplayed, not such a big thing. I would disagree; if practices don’t start pooling their protocols etc, it will bean even bigger task for them to finish by the deadline.

“We haven’t struggled with the overhaul protocols, as they are visible and accessible. It is the timescales that are worrying us and the other practices in our consortium. When you have registered you have 28 days to get the registration through and submit all your evidence – there is no leeway.

We haven’t struggled with the overhaul protocols, as they are visible and accessible. It is the timescales that are worrying us

“Looking ahead the hardest part for me will be making sure that all the staff are trained and constantly aware. If the CQC visit and speak to staff and you’ve got no evidence of their training that is a big thing. The biggest thing for staff is time and knowing about all these policies. The tricky thing with this will be allocating time to train. Increasingly we are using e-learning software to train our staff on health and safety, manual handling, fire safety, etc; doing it this way means staff can fit it around their day jobs.”

Pam Leonard, finance administrator:

“I was updating the protocols and procedures library, when Doreen suggested I look at the CQC information. I felt I could organise it in a more accessible format. Each CQC standard is defined on the front page of the spreadsheet; this is then followed by the CQC Outcomes – each one contains subsections that show how the evidence has been embedded, eg, who is doing it, who is responsible for it, what stage it is at and what training is required.

“As you click through each outcome, the protocols that the practice has in place are easily accessible. Under these headings, a traffic light system is in operation – you can see who is dealing with each one, whether it is a work in progress, has been completed, or further training needed. This allows you to see at a glance where you are with each one, who has been trained and who hasn’t. Once this has been completed there is a button where you can print a certificate off to demonstrate that certain outcomes have been achieved.

We are working our way through our protocols and adding to them as we go along. I will continue to do this alongside my day job up to and after registration

“So basically this is an easy-to-use spreadsheet containing 205 documents based around the CQC’s Essential Standards, where the evidence is embedded. Some of the protocols will be duplicated under different outcomes, but that shows how well the practice is prepared for registration.

“At the moment we are working our way through our protocols and adding to them as we go along. I will continue to do this alongside my day job up to and after registration.”

For more information about what St Georges Medical Centre have done, please contact Doreen on the practice telephone number: 0151 6302080 or visit www.stgeorgesmedicalcentre.com.

Examples of CQC outcomes and the practice protocols that underscore each one

Outcome 7, Safeguarding children
(eg. 28 protocols in this file)

For example, complaints procedures, chaperone policy, carers’ registration, child health surveillance guidelines, health protection flow chart.

Outcome 10, Safety and suitability of premises
(eg. 33 protocols in this file)

For example, bomb scare handling, building hazards and information, CCTV, CCT access, cleaning rota, clinical waste management, disability protocol, maintenance logs, fire risk assessment, health and safety policy, infection control, inspection checklist, violence and aggression.

Outcome 9, Safety of medicines
(eg. 26 documents in file)

For example, controlled drugs, anaphylaxis statement, repeat prescribing policy, medicines management, and medication review.

Outcome 2, Consent
(eg. 14 documents in file)

For example, advance directives, chaperone policy, carers’ policy, confidentiality and consent protocols, disclosure of patient information, Mental Capacity Act, military priority, vulnerable adults.

Useful links

Practice Xtra – the new practice reward package

Practice Xtra has been designed with the needs of practices in mind – the more doctors in your practice that are with MPS, the more benefits you can receive.

Depending on the level you are eligible for there are many extra benefits to help you meet the CQC requirements

There are two levels of Practice Xtra – Silver and Gold.

• Silver is intended for practices when approximately 50% of GP partners (minimum of two GPs) are MPS members
• Gold is intended for practices where approximately 80% of GPs (minimum of two GPs) are MPS members.

Depending on the level you are eligible for there are many extra benefits to help you meet the CQC requirements. These include a free CRSA, free risk management training and employment law and health and safety advice.

To find out how you can benefit from Practice Xtra visit the GP section of the MPS website.

References

1. Soteriou M, GPs face a year of turmoil in 2012, GP (15 May 2012)
2. CQC, Essential Standards of Quality and Safety (2010)