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Public Health Wales Clinical Governance Practice Self Assessment Tool 2010/11

Primary Care Quality and Information Service (PCQIS)

All Wales Clinical Governance Practice Self Assessment Tool

2010/11Proposed 11 Questions to be completed by 31st March 2011

Author: PCQIS TeamDate: 1 November 2010 Version: 1Publication/ Distribution:

Public Health Wales (Internet) NHS Wales (Intranet) Public Health Wales (Intranet)

Review Date: 1 April 2012 Purpose and Summary of Document:This document shows the 11 questions that the Primary Care Quality and Information Service (PCQIS) are suggesting practices to complete by 11th March 2011; completion of practices answers should be carried out in the on-line All Wales Clinical Governance Self Assessment Tool (CGPSAT) for General Medical Practices.Practices should read ‘the All Wales Clinical Governance Practice Self Assessment Tool - Tutorial’ and have been provided with a username and password to complete the on-line version, accessed via the Public Health Wales intranet site. This document is intended to enable interested parties to view the content of the tool without having to log in. Please note that this document shows the content only and the layout is different from the on-line version. Practices should complete the on-line version

© 2010 Public Health Wales. Material contained in this document may be reproduced without prior permission provided it is done so accurately and is not used in a misleading context. Acknowledgement of Public Health Wales is to be stated

Date: 1 November 2010 Version: 1


Clinical Governance Practice Self Assessment Tool 2010/12Proposed 11 questions to be completed by practices by 31st March 2011

PCQIS is mindful that as practices have to start afresh due to the change in format, there will not be time this year to complete the whole or even half the full set of questions within the CGPSAT. Therefore we are suggesting that practices complete their practice details and 11 questions by the end of March 2011. It is up to you as a practice if you want to complete more questions; you will need to check with your local contact in your LHB as they may wish you to complete a question/section set before the end of March.

Please also add in you ‘PDP’and ‘constraints’ this will assist practices in preparing a practice ‘action plan’ – see the CGPSAT tutorial for further information http://howis.wales.nhs.uk/sitesplus/888/CGPSAT

Section Question/Matrix

1. Introduction, Acknowledgements and Practice details Please scroll down and complete your Practice details

2. Care Planning and Provision 2.1 Availability of consultations3. Equality, Diversity and Human Rights 3.1 Equity of Access4. Patient Information and Consent 4.1 Consent for clinical examination and treatment5. Dignity and Respect 5.1 Chaperone10. Safeguarding children and vulnerable adults 10.1 Safeguarding Children13. Infection Prevention, Control and Decontamination 13.1 Waste Management

13.2 Infection Control14. Safe and Clinically Effective Care 14.1 Patient Safety alerts and reporting17. Communicating Effectively 17.1 Communication systems22. Managing Risk and Health and Safety 22.1 Risk Assessment 23. Dealing with Concerns and Managing Incidents 23.1 Raising concerns28. Feedback your comments Please provide suggestions on how the tool should be

improved (compliments also welcome)


Date: 1 November 2010 Version: 1 Page: 2 of 44

http://howis.wales.nhs.uk/sitesplus/888/CGPSAT


References, Guidance and Web-linksThe link below will take you to the Public Health Wales, Primary Care Quality and Information Service internet site where you will find a downloadable Excel workbook with links to all the references and guidance used in the All Wales Clinical Governance Practice Self Assessment Tool for 2010/11, Risk Assessment Tool, Infection Control Toolkit and other Quality Improvement Toolkits for General Medical Practices. http://howis.wales.nhs.uk/sitesplus/888/page/44038

Note:Sessional GPs include doctors working on the retainer scheme, salaried GPs and locum GPs. Some are peripatetic and work in a number of practices whilst others work only in a small number of practices on a regular basis. ref: 'Clinical Governance for Sessional GPs.' Department of Postgraduate Education for General Practice. Wales College of Medicine. Nov 20075

Please note that throughout the CGPSAT, 'staff' refers to all people working in the practice, both employed, including sessional GPs, and partners

1. Practice DetailsThere are particular features of our practice or patient population that we wish to comment on. (eg Age distribution/ethnic issues/drug abuse/housing, branch surgery provision etc) Our Practice offers work experience/education/training to other individuals - Y/N -We have a designated prescribing lead GP who undertakes regular work on prescribing issues - Y/N -Our Clinical Governance Lead is – name -We have - number - independent prescribers at our practice The definition of independent prescribing is “prescribing by a practitioner (eg doctor, nurse or pharmacist) responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about the clinical management required, including prescribing” Ref: Royal Pharmaceutical Society of Great Britain.We have - number - supplementary prescribers at our practiceThe definition of supplementary prescribing is "a voluntary partnership between an independent prescriber (doctor or dentist) and a supplementary prescriber to implement an agreed patient-specific clinical management plan with the patient's agreement". Ref: Royal Pharmaceutical Society of Great Britain. Supplementary prescribers may be Nurses or Pharmacists. A supplementary prescriber may prescribe all medicines including controlled drugs, medicines for unlicensed indications and unlicensed medicines, by agreement with the independent prescriber. We employ sessional GPs - Y/N -

2. Care Planning and Provision



http://howis.wales.nhs.uk/sitesplus/888/page/44038


This section contains 6 matrices. Other matrixes containing elements relevant to the Standards for Health Services in Wales, Care Planning and Provision are to be found under: Citizen Engagement and Feedback, Communicating Effectively, Workforce Planning, Health Promotion, Protection and Improvement and Medicines Management

2.1 Availability of ConsultationsThis matrix makes reference to elements of the GMS Dispensary Services Quality Scheme (DSQS)6 Level Description Supporting Information Additional Information ‘Help’Level 0 We have not

achieved level 1Level 1 We offer

consultations with an appropriate health professional to meet the reasonable needs of patients (this includes telephone consultations)

Copy of appointments policy Copy of appointments schedule/timetable showing

pre-book able appointments available Information in Practice leaflet Notices in waiting room Practice website Staff can explain how patients are asked who is their

usual doctor and how an appointment with that doctor is arranged whenever possible.

Training/ induction records for reception staff

Consider whether: Patients are provided with information

about opening hours and availability of appointments:

A system to ensure that a named healthcare professional can be contacted promptly in the case of an emergency.

QOF Management 5:The practice offers a range of appointment times to patients which as a minimum should include morning and afternoon appointments 5 mornings and 4 afternoons per week except where agreed with the LHB

Dispensing Practices: DSQS Minimum level of staff hours 2.2.2: The contractor must assure a level of staffing that reflects the practice’s dispensary configuration and hours of opening as agreed with the LHB

Dispensing Practices: DSQS Information 1.2.2: The contractor must inform the LHB (who will advise NHS Direct as for pharmacies)The contractor must ensure that opening times




are displayed prominently on the premises from which they carry out dispensing and that they are legible from outside the premises when they are shut.

Level 2 We offer a range of consultations of at least 10 minutes long. For practices with only an open surgery system the practice should ensure that the average face to face consultation with the patient is at least 8 minutes long.

Appointment/access audit reports Blank appointments template

Consider: Audit of appointment lengths Whether appointments are offered with a

doctor or nurse outside 9am to 5pm

QOF PE1: The length of routine booked appointments with the doctors in the practice is not less than 10 minutes. If the practice routinely sees extras during booked surgeries then the average booked consultation length should allow for the average number of extras seen in a surgery session. If the extras are seen at the end then it is not necessary to make this adjustment. For practices with only an open surgery system the practice should ensure that the average face to face time spent by the GP with the patient is at least 8 minutes. Practices that routinely operate a mixed economy of booked and open surgeries should report on both criteria.

Level 3 We have a system for spotting when we are running late and inform patients

Staff can explain how waiting times and reasons for delay are communicated to patients

Workload schedule/rota

Consider: Whether waiting times and reasons for

delay are communicated to patients A system for day to day operational

management of appointments: A timetable A workload schedule/rota

Level 4 We monitor access to consultations so

Agenda and minutes of meetings when appointment systems were discussed

Copy of Patient questionnaire / complaints / compliments

Consider whether: All clinicians have access to the patient’s

case records, summaries and prescribing




that we are responsive to patients’ needs and as part of this we encourage continuity of care

Agenda and minutes of meetings when complaints were discussed

Copy of DNA policy All clinicians can demonstrate how they access patient’s

case records, summaries and prescribing data. This includes sessional GPs

Copy of Sessional GP policy LocumPak or equivalent Copy/demonstration of the procedure for handling of

messages to OOH services eg palliative care Copy/demonstration of the procedure for home visits message book e-mail messaging Audit of record-keeping Timetable/schedule of chronic disease clinics

data Sessional GPs are informed (LocumPak) Patients are asked who is their usual doctor

and offered an appointment with that doctor whenever possible

you include comments made about dispensing services if provided

QOF PE 7: the percentage of patients who, in the appropriate national survey, indicate that they were able to obtain a consultation with a GP or appropriate health care professional within 24 hours

QOF PE 8: The percentage of patients who in the appropriate national survey indicate that they were able to book an appointment with a GP more than 2 days ahead

Level 5 We ensure that changes are made as a result of our reviews and that our system is updated

Evidence of changes/staff explanation of changes made to the appointment system as a result of complaints / audit /survey

Training records Evidence of communication of DNAs to patients eg:

copies of letters sent to patients, monthly DNA rate posters etc

Consider examples of best practice eg: the Practice opening and Appointments sections of ‘Developing General Practice, Listening to Patients’ BMA 20097

3. Equality, Diversity and Human Rights

This section contains 1 matrix. Other matrixes containing elements relevant to the healthcare standard Equality and Diversity and Human Rights are to be found under Dignity and Respect, Safeguarding Children and Vulnerable Adults, Environment, Patient Information and Consent and Workforce Recruitment and Employment practices.




3.1 Equity of AccessThis matrix makes reference to the social model of disability11 and EquIP Cymru Disability Access Self Assessment Audit Toolkit12

Level Description Supporting Information Additional InformationLevel 0 We have not

achieved Level 1

Level 1 Most patients can readily access our premises and services

Disability Discrimination Act compliance checklist / template

GMS contract Annex B: Where patients are requesting to join the practice list, the practice does not discriminate on the grounds of race, gender, social class, religion, sexual orientation, appearance, disability or medical condition

This includes equity of access to dispensing services if provided

Consider: Practice self assessment of premises

with regard to disability accessLevel 2 All patients can

readily access our premises and services

Appointment/access audit reports Copy of appointments schedule/timetable Workload schedule/rota large print practice leaflets, RNID recommended communication tools Welsh speakers available interpreter services translated literature Staff training schedules

Consider: The needs of patients with differing

abilities and whether appropriate adjustments have been made

Arrangements to help patients with sensory impairments:

Arrangements to help patients with long term mental health impairments

Arrangements to help patients with long term physical impairments

Assistance with communication for patients whose first language is not English,

The 'Social Model of Disability' 11 uses the




following definitions: Impairment: an injury, illness or congenital condition that causes or is likely to cause a long term effect on physical appearance and/or limitation of function within the individual that differs from the commonplace. Disability: The loss or limitation of opportunities to take part in society on an equal level with others due to institutional, environmental and attitudinal barriers.

Level 3 We are aware of when and which patients have difficulty with accessWe encourage patient feedback on access

Copy of EquIP Cymru Disability Access Self Assessment Audit Toolkit 12 or a similar tool

Copy of registration policy Copy of carers policy Copy of policy for highlighting in the patient record

eg: ‘Major Alert’ on the practice system Summarisation policy Patient questionnaires Patient Participation Group agenda, minutes /

feedback Complaints / compliments Report from CHC visit if undertaken locally

Consider: Completion of the EquIP Cymru Disability

Access Self Assessment Audit Toolkit12 or a similar tool

External assessment of DDA compliance by CHC if offered or undertaken locally

Level 4 We have an access policy

Copy of access policy Please see the PCQIS References and Resources webpage for the CGPSAT tutorial with details of what should be included in a good Practice policy

Level 5 As a result of review we have considered the needs of patients and updated our access policy accordingly

Agenda and minutes of practice meetings when policy and action plan discussed with staff

Updated access policy

Consider examples of best practice eg: the

Premises, Facilities and Waiting rooms section of ‘Developing General Practice, Listening to Patients’ BMA 20097

Whether the practice has an action plan arising from completion of the EquIP12 or




similar tool (An action plan template is provided in appendix 1 of the EquIP12 tool)

Whether the action plan has been implemented universally, reviewed annually, updated and embedded.

4. Patient Information and ConsentThis section contains 3 matrices. Other matrixes containing elements relevant to the Standards for Health Services in Wales Patient Information and Consent are to be found under Equality, diversity and human rights, Citizen engagement and feedback, Research development and innovation, Safeguarding children and vulnerable adults, Dignity and respect and Medicines management.

4.1. Consent for clinical examination and treatmentLevel Description Supporting Information Additional Information

Level 0 We have not achieved Level 1




Level 1 We have regard for the need to obtain valid consent for clinical procedures and treatments

Completed consent forms Staff training records Patients are provided with information to

help them make informed decisions Clinicians record patient decisions/consent

in the patient record (this may only be verbal consent)

Patient consent is required on every occasion the doctor wishes to initiate an examination or treatment or any other intervention, except in emergencies or where the law prescribes otherwise (such as where compulsory treatment is authorised by mental health legislation). Consent may be: Explicit or express - when a person actively

agrees, either orally or in writing. Consent can also be implied - signalled by

the behaviour of an informed patient. Implied consent is not a lesser form of consent but it only has validity if the patient genuinely knows and understands what is being proposed.

The provision of sufficient accurate information is an essential part of seeking consent. Acquiescence when a patient does not know what the intervention entails, or is unaware that he or she can refuse, is not ‘consent’. Consent is a process, not a one-off event, and it is important that there is continuing discussion to reflect the evolving nature of treatment. Ref: BMA Consent Toolkit 2009 Card 113 Guidance and seeking informed consent.

Consider A Sessional GP Booking form which specifies

the procedures Sessional GPs are expected to perform that are outside normal consultations.

systems for obtaining consent for immunisations and vaccinations and those who lack capacity and documentation of




competence for minors >16 Mental capacity act guidance using All Wales Consent Reference Guide &

model consent forms14 GMS contract Annex B: The practice has a

policy for consent to the treatment of children that conforms to the current Children’s Act or equivalent legislation

GMS contract annex B: For minor surgery, patients’ consent to any surgical procedures including wart cautery and joint injections, is recorded

GMS contract Annex B: For vaccination and immunisation, consent to immunisation, or contraindications if they exist are recorded in the records

Level 2 We ensure valid consent is obtained for clinical procedures and treatments as appropriate

Staff are aware of their responsibilities in obtaining relevant and valid consent

Consent checklist Record that issues considered and discussed Copy of policy for chaperone

See also matrix 5.1 ’Chaperone’

Level 3 We ensure valid consent obtained and recorded in the case record for all invasive procedures

A note or READ code in the patient notes that consent was obtained

You need to obtain verbal consent before undertaking any intimate examination. It is recommended that you obtain written consent for invasive procedures such as vaccinations and blood tests. There should be a record in the case notes that consent was obtained either in text or a READ code.Consider using the PCQIS Minor surgery audit tool

Level 4 We have a written Copy of consent policy Consider using Health Board resources eg:




up to date consent policy for clinical procedures and treatments in line with national guidance / good practice which all staff understand and follow

Agenda and minutes of meetings where consent policy discussed

Policy and consent forms

Level 5 We review use of consent procedures

Audits and reports Copies of Significant Event Analyses Patient complaints Patient surveys Audit case notes

Check if all clinicians are compliant with procedures. Is appropriate use made of consent forms? How often is consent recorded in the notes? Is your consent policy still in line with national guidance?

3. Dignity and RespectThis section contains 1 matrix. Other matrixes containing elements relevant to the Standards for Health Services in Wales Dignity and Respect are to be found under Equality, diversity and human rights, Environment, Dealing with concerns and managing incidents, Patient information and consent and Safeguarding children and vulnerable adults.

5.1 ChaperoneLevel Description Supporting Information Additional Information

Level 0 We have not achieved Level 1

Level 1 We provide the option for patients to request a chaperone.

Information for patients about availability poster/leaflets

Notice highlighting patient’s rights

Chaperones offer assurance to both patient and practitioner that intimate examinations are carried out with dignity and respect without inappropriate physical contact and can reduce potential misunderstanding. You need to consider who is appropriate to be a




chaperone

Level 2 We actively offer chaperones in all appropriate circumstances

clinicians training record clinical notes record whether chaperone offered

then accepted or declined

Consider whether: clinicians have received training in

relation to their role and responsibilities do you have sufficient number of

chaperones where do the chaperones position

themselves during the examination

Level 3 We review chaperone activity and documentation in the patient records

copy of audit of patient records audit of uptake

The onus is on the clinician to ensure they have a chaperone when appropriate

Consider: clinician training with regard to personal

risksLevel 4 We have a chaperone

policy copy of chaperone policy Consider whether:

the chaperone policy is informed by current national guidance

staff members are aware of the policy policy is understood and complied with

by all team members the policy is advertised to patients the policy is up to date

Level 5 We have trained chaperones

complaints/compliments chaperones training record

Consider whether: chaperones have received training in

relation to their role and responsibilities

Many practice staff do not know what is expected of them when they act as chaperone. Training is valuable and reduces risk. Some LHBs offer Chaperone training; please contact your LHB directly.




Please see the PCQIS References and Resources webpage for links to chaperone training resources for Healthcare Assistants and Practice Receptionists.

10. Safeguarding Children and Vulnerable AdultsThis section contains 2 matrices. Other matrixes containing elements relevant to the Standards for Health Services in Wales Safeguarding Children and Vulnerable Adults are to be found under: Equality, diversity and human rights, Communicating effectively, Dignity and respect and Patient information and consent.

10.1. Safeguarding Children This matrix makes reference to the All Wales Child Protection Procedures 200818 and the Public Health Wales 'Guide for Safeguarding Children and Young People in General Practice 2007'19

.Level Description Supporting Information Additional InformationLevel 0 We have not

achieved Level 1 Level 1 We are familiar with

local procedures relating to safeguarding children

Mandatory training records Staff can show that they know where to find

the procedure and have access to it Flow chart Updated phone numbers Copy of whistle blowing policy, Copy of risk management procedures Hard copy or website of All Wales Child

“If any person has knowledge, concerns or suspicions that a child is suffering, has suffered or is likely to be at risk of harm, it is their responsibility to ensure their concerns are referred to Social Services or the Police.” All Wales Child Protection Procedures 200818

Consider whether:




Protection Procedures18 saved as a ‘favourite’.

Description of access arrangements Name of nominated lead practitioner who is

responsible for child protection issues

All staff have access to the All Wales Child Protection Procedures18 and any updates. (eg for Sessional GPs this should be included in the Practice induction pack)

There is an identified person within the team to act as child protection lead. Best practice would be to identify a GP to undertake this role.

Staff can show that they know where to find the procedure and have access to it

QOF Management 1: Individual healthcare professionals have access to information on local procedures relating to child protection

Level 2 Our staff are all aware of their roles and responsibilities in relation to safeguarding children

Staff able to explain their roles and responsibilities

Copy of policy for consent to the treatment of children

Name of healthcare professional who can be contacted promptly in the case of an emergency. Eg: Public Health Wales designated nurse for child protection.

Copies of critical event analysis concerning a child’s welfare and evidence of any changes to practice

Personnel file of new staff member for CRB check

Staff training records All staff wear ID badges

GMS contract Annex B: Individual healthcare professionals should be able to demonstrate that they comply with the national child protection guidance and should provide at least one critical event analysis regarding concerns about a child’s welfare if appropriate

Criminal Records Bureau checks: All staff who work with children and families, and those who have access to children’s records should have appropriate CRB checks. Ref: Children’s NSF key action 2.6220. The NHS Employment Check Standards 2008 apply to permanent staff, staff on fixed-term contracts, temporary staff, volunteers, students, trainees, contractors and highly mobile staff employed through an agency.

Consider whether: Staff comply with Public Health Wales guide

to Safeguarding children




All staff are aware of the protocol and are able to make a child protection referral as detailed in the all Wales Child Protection Procedures18

You have a policy for consent to the treatment of children that conforms to the current Children’s Act or equivalent legislation

A named healthcare professional can be contacted promptly in the case of an emergency.

critical event analysis concerning a child’s welfare is undertaken (if appropriate) and changes are made to practice

Personnel file of new staff member for CRB check/training records

All staff wear ID badges (Recommendation from HIW review of child protection procedures in Wales) Oct 200921:

Level 3 We are readily able to identify children known to be at risk and we have a system in place to identify possible abuse and make appropriate and speedy referrals in accordance with the procedures.

Patient records ‘tagged’ to identify children on the child protection register (together with their parents / carers and siblings)

Patient records showing parents with special needs are ‘tagged’ by the practice and

patient records ‘tagged’ showing parents whose children have special needs

staff induction records contact details of named and designated child

protection professionals (health) and local social service departments (children departments)

practice contact lists are the latest version distributed by LHB.

NB: “There is nothing within the Caldicott Report, the Data Protection Act 1998 or the Human Rights Act 1998, which should prevent the justifiable and lawful exchange of information for the protection of children or prevention of a serious crime” Too Serious a Thing: The Carlile Review March 200222

Child protection induction training should include a basic awareness of child abuse and neglect an awareness of All Wales Child Protection

Procedures18

how to make a child protection referral and how and where to access support and advice

Consider




whether child protection issues are discussed with all staff at induction

staff have access to the contact details of named and designated child protection professionals (health) and local social service departments (children departments

whether there is a system in place to ensure children on the child protection register (together with their parents / carers and siblings) can be identified from their family records. READ codes can be used to identify children who are registered:

READ codes can be found in a Guide for Safeguarding Children and Young People - A Toolkit for General Practices19

Level 4 We review our systems and ensure they are consistent with national policy and best practice

Staff training records Staff certificates Copy / explanation of arrangements in place for

clinical supervision Reports

All staff should attend level 2 training every 3 years. The lead practitioner should attend level 3 training annually.

Consider: Arrangements for staff members who may

require guidance, support and / or supervision in respect of child protection issues: It is acknowledged that GPs and other staff are not subject to routine clinical supervision. However, GPs and staff members involved in child protection cases may require access to guidance and support / supervision for individual cases. The designated professionals can advise individual staff on access to support/ supervision as required in individual cases.

Level 5 We undertake regular case reviews of children at risk as a

Significant Event Analysis reports Copies of case reviews Copy / explanation of system to review, act on

Regular case review means reviewing each child known to the practice to be on the At Risk Register, at a minimum of




team and file all notifications from an accident and emergency department in relation to children and young people

Anonymised copies of reports produced for child protection case conferences

notices for crisis and advice organisations and advocacy services displayed prominently in areas accessible to children and young people

quarterly intervals for present status and new developments.

Guide for Safeguarding Children and Young People - A Toolkit for General Practices19 states that it is good practice for primary health care staff to discuss and share information prior to a case conference and that regular practice discussions with regard to vulnerable children will enable liaison between practice staff and community health staff.

Consider whether you have a system to review, act on as appropriate and file all notifications from an accident and emergency department in relation to children and young people

Consider whether: GPs routinely provide reports for child

protection case conferences when requested notices containing information for children

and young people to contact crisis and advice organisations and advocacy services are displayed prominently in areas accessible to children and young people. Appropriate leaflets and posters containing information for children and young people to contact crisis and advice organisations and advocacy services are available from ChildLine and NSPCC.

the Practice regularly participates in external events regarding quality improvement

the practice shares expertise in the practice by setting up with others.




Reports for child protection case conferences: The All Wales Child Protection Procedures 200818 state that GPs should always receive an invitation to attend child protection case conferences and if unable to attend they should provide a written report. The NPHS 'Guide for Safeguarding Children and Young People in General Practice 2007'19 chapter 9 has more information about reports for case conferences and a model GP Report proforma

13. Infection Prevention, Control and DecontaminationThis section contains 2 matrices. Other matrixes containing elements relevant to the Standards for Health Services in Wales Infection prevention, control and decontamination are to be found under Environment and Managing risk and health and safety.

13.1. Waste ManagementThis matrix makes reference to the key principles of Welsh Healthcare Associated Infection sub-group (WHAISG) Infection Prevention Model Policy 4. Occupational Exposure Management. 16

Level Description Supporting Information Additional InformationLevel 0 We have not achieved

Level 1Level 1 We put all clinical

waste directly into bags / containers

Copies/explanation of procedure / system in place

Inspection on visit

This includes waste produced in relation to dispensing services if provided

Level 2 We implement appropriate segregation and safe management of waste

Copy of Policy Staff able to show they are aware of and comply

with relevant aspects of policy / procedure Copies of contracts for waste removal Records of collections Invoices Environment agency registration number /

certificate if appropriate clinical and other hazardous waste management

policy in place which includes statutory

Waste may be ‘hazardous’ including clinical ie: waste

infectious to humans and non clinical waste ie; toxic

‘offensive’ or ‘hygiene waste’ which may be offensive in appearance and smell but is not known to be infectious.

Clinical waste should be segregated and put directly into the correct bags / containers.




requirements and requirements of the European Waste Code (EWC)

Surgery waste code (EWC)

Other hazardous waste must be disposed of appropriately depending on its nature. Provided offensive waste is appropriately wrapped, properly handled and free from excess liquid, the risk of ill health is considered to be low. However, there is a residual health risk, which should be assessed, and appropriate precautions should be implemented. Ref: Health and Safety Executive: Managing offensive/hygiene waste.

Examples of clinical waste: Human tissue Blood Infected bodily fluids and excretions Drugs or other pharmaceutical products Swabs and dressings Syringes, needles or other sharp

instrumentsExamples of other hazardous waste: Chemicals eg: mercury Asbestos Fridges Other electrical productsExamples of offensive/hygiene waste:- Human waste (faeces); Incontinence pads; Catheter and stoma bags; Nappies; Sanitary waste; Nasal secretions; Sputum; Condoms; Urine;




Vomit; Medical items of disposable equipment

such as :- bed sheets, tongue depressors, speculae, urine sticks Plaster casts; Plasters (minor first aid or self care)

generated by personal use; Wastes from non-healthcare activities such

as body piercing or application of tattoos.

WHAISG Infection Prevention Model Policy 416

Sharps containers should conform to UN3291 and BS7320 standards, be used according to manufacturers instructions, have labels completed accurately and be disposed of sealed as per local clinical waste policy

Hazardous Waste Registration:If the is practice a registered waste producer (ie producing over 200kg of hazardous waste per annum), the practice registration with the Environment Agency should be reviewed annually.

Level 3 We identify and remedy inappropriate or dangerous practice

Significant Event Analysis reports Copies of risk assessments Copies of action plans Staff training records

Please see matrix 23.3: Significant Events, for more information about how to carry out a significant event analysis

Level 4 We have a waste management policy

Copies of policies and procedures that have been updated within the past year

The policy for waste management should include ‘offensive’ or ‘hygiene’ waste, ‘clinical’ and other ‘hazardous’ waste. Staff able to show they are aware of and comply with relevant aspects of policy / procedure

Level 5 We have a policy Reports showing monitoring of remedial action Please see the PCQIS webpages for the CGPSAT




action plan in place and monitor and record failure to comply

Incident reports – shared with LHB tutorial with details of what should be included in a good Action Plan

13.2. Infection Control This matrix makes reference to elements of Seven Steps to Patient Safety in General Practice15 elements of the GMS Dispensary Services Quality Scheme (DSQS) 6 and key principles of Welsh Healthcare Associated Infection sub-group (WHAISG) Infection Prevention Model Policies 1. Environmental cleanliness, 2. Hand Hygiene, 3. Personal Protective Equipment16


Level 1Level 1 We take steps to

reduce the risk of healthcare associated infections (HCAI)

Arrangements for waste disposal Observation of general cleanliness Single use instruments or HSDU facilities. Hand washing facilities available – sinks and

taps, liquid soap, paper towels Sharps bins available Gloves (non-latex) and aprons available Face/eye protection available Patient information leaflets Alcohol hand gel available at all treatment

points Patient isolation areas provided (DSQS) Dispensing Practice SOP

GMS contract Annex B: the premises. Equipment and arrangements for infection control and decontamination meet the minimum national standards

Consider:WHAISG Infection Prevention Model Policy 116

cleanlinessWHAISG Infection Prevention Model Policy 216

Hand washing facilities Alcohol hand gel available at all treatment

points All staff have a responsibility to ensure

that they undertake adequate hand hygiene and encourage others delivering care to do so

WHAISG Infection Prevention Model Policy 316

Personal Protective equipment is available, ie: gloves and aprons, face/eye protection.

Waste disposal




Sharps bins Patient information leaflets Patient isolation areas

This includes the dispensing area if dispensing services if provided

Level 2 We have a comprehensive system to reduce the risks of HCAI

Procedure for decontamination including cleaning and sterilisation

Staff training records - e-learning, Public Health Wales Champion programme, NVQs

Audit Risk assessments undertaken Use of PCQIS Hand Hygiene and Infection Control

toolkits Safe disposal protocol

Consider: The clinical environment, (WHAISG Infection

Prevention Model Policy 116

Hand hygiene (WHAISG Infection Prevention Model Policy 216

Also consider provision of hand hygiene products and paper towels in the Doctors bag for those working in patients’ own homes. Appropriate use of protective clothing,

(WHAISG Infection Prevention Model Policy 16

A quick risk assessment may be required in order to decide if personal protective equipment is needed and which equipment is most appropriate for the situation.Policy 3 provides a one page summary guide for a range of situations.

Specimen collection, Decontamination procedures including

cleaning and sterilisation Procedure for spillages, Vaccine storage, Waste disposal, Handling of sharps, Toilets and baby changing facilities, Cleaning equipment, Vaccination of staff. Emergency Planning Whether all practice staff including cleaners

are fully trained eg: via e-learning, NVQs




Use of PCQIS Hand Hygiene and infection control toolkits

an identified and trained lead with regards to infection control.

Level 3 We monitor our infection control systems to identify and manage risks

Copies of risk assessments Action plans NHS Institute for Improvement help identify case

notes for infection risks Significant Event Analysis ands reporting

Seven Steps to Patient Safety in General Practice15 – Step 1: Build a Safety Culture. A good safety culture is one where staff have

a constant and vigilant awareness of the potential for things to go wrong, are able to identify and acknowledge mistakes, learn from them and take action to make them safer.

Consider: Specimen handling by A&C staff. PPE. Hep B

immunisation. Trigger tools. NHS Institute for Improvement

help identify case notes for infection risks Incident reportingCheck of sterilisation/decontamination cycle

Level 4 We have a written, up-to-date infection control policy in line with national guidance which all staff understand and follow

Copy of policy Staff training records Agenda and minutes of meetings where

infection control policy discussed Arrangements for nursing homes and home

visits

The policy should be easily accessible to staff and all staff should be aware of its contents. Methods of monitoring adherence to the policy should be included.

Seven Steps to Patient Safety in General Practice15 – Step 2: Lead and Support Your Practice Team.

Can the practice demonstrate clear and visible leadership for patient safety?

Consider Whether arrangements for instrument

decontamination including cleaning and sterilisation, comply with national guidelines




as applicable to primary care. Arrangements for visits to nursing homes

and home visits

Evidence-based policies and guidance to which you should refer: WHAISG Infection Prevention Model Policies16

o 1. Control of the environment /environmental cleanliness

o 2. Hand Hygieneo 3. Personal Protective equipmento 4. Occupational Exposure

PCQIS Hand Hygiene and Infection Control toolkits

Level 5 We undertake infection control audit at least every 3 years

Audit of decontamination including cleaning and sterilisation

Audit reports and action plans including evidence of change

Use of PCQIS Hand Hygiene and infection control toolkits

Community strategy HCAI Monitor antibiotic prescribing




14. Safe and Clinically Effective CareThis section contains 2 matrices. Other matrixes containing elements relevant to the Standards for Health Services in Wales Safe and Clinically Effective Care are to be found under participating in Quality improvement activities, Managing risk and health and safety and Dealing with concerns and managing incidents.

14.1. Patient Safety alerts and reportingThis matrix makes reference to National Patient Safety Agency, ‘Seven Steps to Patient Safety in General Practice’ June 200915

Level Description Supporting Information Additional informationLevel 0 We have not

achieved Level 1Level 1 All relevant safety

alerts received by our practice are circulated to appropriate members of staff

staff can demonstrate that they are aware of national guidance and policy for patient safety

Memos and/or e-mails Staff notice board Written procedures Copy of training records Evidence of e-mail circulation

‘Relevant’ means relevant to General Practice

Seven Steps to Patient Safety in General Practice15 – Step 1: Build a Safety Culture. A good safety

culture is one where staff have a constant and vigilant awareness of the potential for things to go wrong, are able to identify and acknowledge mistakes, learn from them and take action to make them safer.

Safety Alert dissemination: Practitioners owe a duty of care to their patients and ignorance of safety issues is not usually a defence. The responsibility for this usually lies with the Practice Manager and the system should include the following: (The list is not exhaustive) Welsh Assembly Government. National Patient Safety Agency, e.g. Safer

Practice Notices Rapid Response Bulletins Medical and Healthcare Products Regulatory

Agency. CSM. NICE.




LMC. BSC. Drugs and Therapeutics bulletins, Public Health alerts - CCDC, Drug companies. LHB child protection alerts. CMO.

Level 2 All relevant safety alerts are looked at by a nominated clinician (may vary depending on topic) who informs the team if significant changes to practice are required

Name of nominated clinician Agenda and minutes of staff meetings where

changes to practice were discussed

Seven Steps to Patient Safety in General Practice15 –

Step 2: Lead and Support Your Practice Team. Can the practice demonstrate clear and visible leadership for patient safety?

Level 3 We have a process in place for discussing safety alerts with appropriate staff

Copy of meeting plan /timetable Minutes and agenda of meetings were safety alerts

were discussed Staff attendance list Copies of incident reports Incidents reported to LHB to be recorded on Datix

or recorded by the practice where Datix has been made available directly.

Action plan Copy/explanation of system for recording and

acting on patient safety incidents and reporting to NPSA

Seven Steps to Patient Safety in General Practice15– Step 3: Integrate your risk management activity. What have you learnt from trends and

patterns in your significant events, case-note review, complaints or reported patient safety incidents and how have these been used to improve patient safety?

Level 4 We have standardised agreed protocols/guidelines for practice use

Copy of protocols /guidelines Minutes and agenda of practice meetings address

patient safety issues Copies of reports monitoring trends Copy/explanation of system for responding to

The protocols may be’ in house’, local or national and may be paper or electronic.




which include safety alerts

safety alerts Evidence of completion of checklists and action on

alertsLevel 5 We share learning

from patient safety incidents

Copies of reports of audit outcomes reviewed and evidence of change (re-audit)

Copies of reports sent to LHB or directly to NPSA Agenda and minutes of meeting outside the

practice

Consider whether the Practice regularly participates in

external events regarding quality improvement

The practice sends Reports to NPSA Practice Audits are presented at

protected time session at the practice or LHB CPD

Seven Steps to Patient Safety in General Practice15:Step 4: Promote Learning.

Learning from what happens in one practice can prevent harm to patients in other practices. Only if we share our experiences can others learn from us and can we learn from others.

Step 5: Involve and communicate with patients and the public. How does your practice respond when a

patient makes a suggestion for how you can improve your care?

Step 6 – Learn and share safety lessons. How confident are you that actions agreed

at a SEA meeting are carried through?Step 7:Implement solutions to prevent harm: Have you ever experienced a significant

event or near miss similar to one that had happened before and found that nothing had changed?

QOF Education 7: The practice has undertaken




a minimum of 12 significant event reviews in the past 3 years which could include: any death occurring in the practice, new cancer diagnoses, deaths where terminal care has taken place at home, any suicides, admissions under the MH Act, child protection cases, medication errors, a significant event occurring when a patient may have been subjected to harm, had the circumstance/ outcome been different (near miss)

QOF Education 10:The practice has undertaken a minimum of 3 significant events reviews within the last year

17. Communicating EffectivelyThis section contains 2 matrices. Other matrixes containing elements relevant to the Standards for Health Services in Wales Communicating Effectively are to be found under Care planning and provision, Information management and communications technology, Records




management, Patient information and consent, Equality, diversity and human rights, Safeguarding children and vulnerable adults, Workforce recruitment and employment practices and Governance and accountability framework

17.1. Communication systemsThis matrix makes reference to elements of Seven Steps to Patient Safety in General Practice15


Level 1Level 1 We have a system for

recording messages from patients and others for the doctor, nurse or other health professionals attached to the practice

Copy / explanation of the system for internal communication

message book sample of patients’ records

Consider: Whether every patient contact with a

clinician and prescription issued is recorded in the patient’s record

Face to face consultations, home visits, including those by Sessional GPs, telephone advice etc.

When entered in the patients’ record these are in chronological order.

Whether it is made clear to Sessional GPs what should be included.

The system also includes messages for sessional GPs

Level 2 We have a communications system which includes external communication eg, OOH, secondary / acute, palliative care etc

Copy / explanation of the system for external communication

fax templates contact details for OOH, secondary / acute,

palliative care personnel

Consider whether the practice communications system includes: systems for informing all relevant team

members involved when patients are admitted as an emergency by a member of the team.

systems for transferring and acting on information about patients seen by other doctors out of hours

written instructions for staff on how to handle emergency calls.

systems for dealing with any hospital report or investigation results, which identifies a responsible health professional




and ensures that any necessary action is taken. (The system for dealing with hospital reports or investigation results should also include requests made by sessional GPs)

a policy regarding the management of patients care following discharge from hospital which includes reviewing any amendments to medication.

procedures to track and manage patient test results medical reports, investigations and follow up results.

systems to alert the out-of-hours services or duty doctor to patients dying at home.

systems for ensuring that relevant team members are informed about patients who have died.

systems for ensuring all relevant information from incoming mail and out of hours consultations is recorded in the Patients Medical Summary either a written record or on the computer system so that all clinical staff are aware of new diagnosis or changes to a patient’s condition

procedures that ensure incoming information is seen by a GP before being filed in the patient record.

systems to ensure that messages and requests for visits are recorded and that the appropriate doctor or team member receives and acts upon them.

systems to ensure that a named healthcare professional can be contacted promptly in the case of an emergency.

Service specifications including end of life /




palliative care

QOF Records 3: The practice has a system for transferring and acting on information about patients seen by other doctors out of hours

QOF Records 13: there is a system to alert the out-of-hours services or duty doctor to patients dying at home.

Level 3 We record communication errors and significant events and use them to identify risk and refine the systems.

Copies of significant event analyses / Incidents reported to LHB

Records of actions taken following SEAs Records of / explanation of improvements in

the practice communication systems made as a result of SEAs

Seven Steps to Patient Safety in General Practice15 – Step 3: Integrate your risk management activity. What have you learnt from trends and

patterns in your significant events, case-note review, complaints or reported patient safety incidents and how have these been used to improve patient safety?

Step 6 – Learn and share safety lessons. How confident are you that actions agreed

at a SEA meeting are carried through?Step 7:Implement solutions to prevent harm: Have you ever experienced a significant

event or near miss similar to one that had happened before and found that nothing had changed?

Level 4 We have a written up to date communication policy which all staff follow

Copy of policy Names of those responsible for management,

administration, and accountability Copy of reporting structures within the team Copies of Audit reports Agenda and minutes of team meetings Staff training records

Consider examples of best practice eg: the Consultations and Staff Training sections of ‘Developing General Practice, Listening to Patients’ BMA 20097

Consider whether: Responsibilities for management and

administration, and accountability and reporting structures within the team are clearly defined and understood by team




members. Level 5 We regularly review the

effectiveness of our systems and ensure deficiencies are actioned

Copies of relevant SEA and review documentation Copy of updated policy Agenda and minutes of staff meetings where

deficiencies in the communications system were discussed

Copy of action plan Records of / explanation of improvements in the

practice communication systems made as a result of review

Consider whether: The Practice is explicit to

patients/public/OOHs (external organisations) on how messages are recorded.

There is a written policy for informing patients or where appropriate families and carers of the results of investigations

The policy is explained to patients the Practice regularly participates in

external events regarding quality improvement

22. Managing Risk and Health and SafetyThis section contains 5 matrices. Other matrixes containing elements relevant to the Standards for Health Services in Wales Managing Risk and Health and Safety are to be found under Infection prevention, control and decontamination, Environment, information management and communications technology, Civil contingency and emergency planning arrangements, Governance and accountability framework, Safe and clinically effective care and Dealing with concerns and managing incidents.

22.1. Risk Assessment This matrix makes reference to elements of the GMS Dispensary Services Quality Scheme (DSQS) 6, and the key principles of Welsh Healthcare Associated Infection sub-group (WHAISG) Infection Prevention Model Policies 3. Personal Protective Equipment and 4: Occupational Exposure Management16





achieved Level 1

Level 1

We have undertaken statutory risk assessments

Copies of risk assessment forms Risk assessment is defined by the NPSA as “The overall process of estimating the magnitude of risk to the population that might be affected and deciding whether or not the risk is tolerable” Also “to determine whether planned or existing controls are adequate. The intention is that risks should be controlled before harm can occur”.

Statutory risk assessments include: Health and Safety COSHH, Manual Handling Fire

Areas covered by the GMS contract ;GMS contract Annex B: the practice adheres to the requirements of the Medicines Act for the storage, prescribing, dispensing, recording and disposal of drugs including controlled drugs

GMS contract Annex B: Vaccines are stored in accordance with manufacturers’ instructions.

GMS contract Annex B: For vaccination and immunisation, fridges in which vaccines are stored have a maximum thermometer and daily readings take place on working days

GMS contract Annex B: Batch numbers are




recorded for all vaccines administered

Level 2 We have a system in place for identifying and assessing all risks

Copy /explanation of process Copy of completed PCQIS Risk Practice Self

Assessment Tool or other practice risk assessments

List of themes identified from risk assessments undertaken

Clinical risk areas include: Confidentiality Communication Complaints Incident reporting Practice guidelines Medical records Results Prescribing Consent

Also consider: Risk of injury or harm (to staff, patients or

wider community) Financial risk Organisational risk Reputation risk Risk of litigation Risk to quality of service provided Risks to the environment.

Vaccine storage and cold chain. Security of the vaccine fridge, use of a Max/Min thermometer. Whether the refrigerator is at the correct temperature of 2-8oC for storing vaccines and a record of temperature monitoring is maintained on a daily working day basis.

Legionella: Under general health and safety law you should consider the risks from legionella that may affect your staff or members of the public and take suitable




precautions. Details of what is required are given in 'Legionnaires' Disease - A Guide for Employers' HSE IAC27 Feb 200431

Refer to WHAISG Model policies 3 and 4 16 for information about risk assessment for use of personal protective equipment and likelihood of infection from occupational exposure incidents.

Please contact PCQIS for information about ‘Understanding Risk in Primary Care’ workshops in your area.

See the PCQIS References and Resources webpage for a link to the NPSA National reporting and Learning Service for guidance on risk assessment and other information about risk assessment.

Level 3 We have a documented risk assessment action plan to minimise risk

Agenda and minutes of staff meetings where risk reduction was discussed

Copy of action plan Staff training records Records of staff hours (DSQS) Dispensary Practice SOP

Risk assessments, evaluation and action plans should involve all staff to ensure that the practice’s procedures are based on shared perceptions of hazards and risk, are necessary and workable and will succeed in preventing accidents.Consider whether your action plan is owned by the team

Dispensing practices: DSQS Minimum level of staff hours 2.2: The contractor must ensure that a minimum level of staff hours is dedicated to dispensary services to ensure that patients needs for dispensing services and the time required to complete the




underpinning systems and processes can reasonably be expected to safeguard patient safety

Level 4 We review the outcomes of our risk assessment and produce a risk register

Copy of risk register Definition of a Risk register:A risk register can be described as a ‘log’ of risks of all kinds that threaten an organisation’s success in achieving declared aims and objectives. It is a dynamic living document which is populated through the organisation’s risk assessment and evaluation process. This enables risk to be quantified and ranked. It provides a structure for collating information about risks that helps in the analysis of risks and in decisions about whether or how those risks should be treated. Ref: Controls Assurance Support Unit (CASU), Keele University35

A Risk register should contain: Objectives Description of the risk Risk rating Name of lead person Sources of assurance reporting

mechanisms Existing controls Location Cost /benefit analysis Action plans Completion dates Review dateSee matrix 22.2 ‘Managing the Risk Register’ for more information about using your risk register and keeping it up to date.Please contact PCQIS for information about ‘Developing Risk Registers for General




Practice’ workshops in your area.

Dispensing Practices: DSQS SOPs, Clinical Audit and Risk Management 1.1.4: The contractor must have a written policy for managing risks in providing dispensing services and must ensure that this policy is understood and put into practice by all staff involved in dispensing.

Level 5 We review our risk assessment on an annual basis

Record of actions undertaken within the past year

Consider whether the actions documented in your risk

assessment have been carried out and are effective

there have been any significant changes in the practice. ie whether your risk assessment is still valid

Annual review is essential to ensure safe practice for patients, visitors and staff

23. Dealing with Concerns and Managing IncidentsThis section contains 3 matrices. Other matrixes containing elements relevant to the Standards for Health Services in Wales dealing with Concerns and Managing Incidents are to be found under Dignity and respect, Medicines management, Managing risk and health and safety, Safeguarding children and vulnerable adults, Participating in quality improvement activities, Safe and clinically effective care and Citizen engagement and feedback.

23.1. Raising concernsThis matrix makes reference to elements of Seven Steps to Patient Safety in General Practice15, ‘Putting Things Right – a better way of dealing with concerns about health services’ consultation and “Good Medical Practice for General Practitioners42


achieved Level 1Level 1 Staff who are really

worried about people or processes can

Verbal confirmation and description of incidents Staff records

“Good Medical Practice for General Practitioners”42 section 5 ‘Working with Colleagues’ states that GPs with management




mention this to a senior member of staff

responsibilities should make sure that systems are in place through which colleagues can raise concerns about risks to patients.

Level 2 Our staff are encouraged to raise concerns and are aware of procedures

Copy of the procedure for raising concerns Agenda and minutes of staff meetings Staff training records Copy of whistle-blowing policy

Seven Steps to Patient Safety in General Practice15 – Step 1: Build a Safety Culture. A good safety culture is one where staff have

a constant and vigilant awareness of the potential for things to go wrong, are able to identify and acknowledge mistakes, learn from them and take action to make them safer.

Consider whether staff are aware of the process for patients to raise concerns and the support to which affected staff are entitled. (see ‘Putting Things Right’ consultation) Consider:

Keeping a record of receiving the concern

Recording the concern Managing the concern Assessment of level of seriousness Staff awareness Where possible confidentiality is

maintained Ability of staff to raise concerns outside

the practice eg: with BMA, BSC etc Whether you have a whistle-blowing

policyLevel 3 We have a process

for managing concerns.

Copies of significant event audits Copes of SEA reports showing review and

reflection Action plan Copy of or explanation of the system for

Consider a system for protection of patients as well as support for a colleague if their health or performance puts patients at risk.

“Good Medical Practice for General




protection of patients and support for a colleague if their health or performance puts patients at risk.

Practitioners42 section 7 ‘Health’ states that doctors have a responsibility to do something if patients are being put at risk through poor performance or because a doctor or other healthcare professional is ill. A doctor responsible for leading a team should follow the guidance in General Medical Council: Management for Doctors.

Level 4 We have a written up to date policy for staff to raise concerns which is understood by staff and followed by the practice

Copy of policy Processes need to be understood by all staff and adhered to. Changes need to be made to the policy to ensure it is up to date

Level 5 We undertake an annual review of all concerns raised and the support given to staff raising concerns. We support staff who raise concerns and who have been affected by the concerns

Examples of Staff feedback Review and reflection Copy of action plan arising from review of

concerns

Putting Things Right’ consultation: (support to staff affected by concerns raised by patients)Staff should expect to be supported to be open with patients when

something has gone wrong, including being put in touch with a trained mentor

treated fairly during an investigation and to be given regular updates

provided with the appropriate level of support to help them deal with the situation

able to comment on investigation results able to involve their trade union or defence

organisation if they want to assured that actions will only be taken that

are in proportion to the issue being looked at.




28. Feed back your commentsThe Primary Care Quality and Information Service (PCQIS) would like to ensure that the Clinical Governance Practice Self Assessment Tool (CGPSAT) remains useful and relevant to Practices and therefore welcomes your feedback in order to improve the tool in future versions. The on-line version provides a form for practices to enter their comments

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