CQC Registration A Practical Guide John Canning Secretary Cleveland LMC July 2012
38
Embed
John Canning Secretary Cleveland LMC July 2012. What is CQC? Care Quality Commission Replaced 3 previous regulators Mental Health Act Commission Healthcare.
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Slide 1
John Canning Secretary Cleveland LMC July 2012
Slide 2
What is CQC? Care Quality Commission Replaced 3 previous
regulators Mental Health Act Commission Healthcare Commission
Commission for Social Care Inspection Duty to ensure services meet
government set standards Funded by registration fees &
government grant Presently undergoing internal review
Slide 3
CQC and GPs Government policy is that all services should be
regulated Phased approach Private providers (including GPs) and
social care, private GPs [registered with previous regulators] NHS
providers Dentists OOH providers Ambulance providers NHS GPs
Slide 4
Registration for GPs Two elements Setting up an account Making
the application Registration required from 1 April 2013 Protection
for existing providers who register in the official window even if
non-compliant
Slide 5
Accounts Do this now You will receive A letter with your login
details A code which will allow you to start the application
process You need to Set up an account Various people to enable data
entry and sign off Choose one of four deadlines (between September
and December 2012) to submit your application Set up accounts for
various people to help you fill in the form and sign it off If
youre expecting to register with CQC and havent received your
letter by the end of July, email [email protected] with
your full contact details and well send it to you.
[email protected]
Slide 6
The Application and Submission Window Electronic form Do not
wait till near the deadline to start Can be done in stages
Who registers Individual Sole practitioner Partnership The
partnership You should have an arrangement to share liabilities
Organisations Limited company LLP Social enterprise etc If
uncertain ask
Slide 10
Registered Managers Required other than for individual
registration Is in day-to-day control of one or more regulated
activities NOT the same as a practice manager Usually be one or
more partner(s)/director(s)
Slide 11
Nominated Individuals Not the same as registered managers
Required for organisations Responsible for supervising the way that
the regulated activity is managed Should be an employed director,
manager or secretary of the organisation
Slide 12
Regulated Activities All practices Treatment of disease,
disorder or injury Diagnostic and screening procedures Most
practices Surgical procedures Maternity and midwifery services Some
practices Family planning services Termination of pregnancies Few
if any GP practices Nursing care Services in slimming clinics
Transport services, triage and medical advice provided remotely
Assessment or medical treatment for people detained under the
Mental Health Act 1983 Management of supply of blood and blood
derived products Accommodation and nursing or personal care in the
further education sector Personal care Accommodation for people who
require nursing or personal care Accommodation for people who
require treatment for substance misuse
Slide 13
Service Types All practices Doctors consultation services
Doctors treatment services Diagnostic and/or screening services
Many practices Mobile doctors services Few practices Acute services
Unlikely to include Prison healthcare services Hospice services
Long-term conditions services Dental services Hospital for mental
health/learning disability Hospital for substance misuse Hyperbaric
chamber services Rehabilitation services Residential substance
misuse treatment/rehabilitation Community healthcare services
Community LD services Community MH services Community substance
misuse services Urgent care services Care home WITH nursing Care
home WITHOUT nursing Specialist college services Domiciliary care
services Extra care housing services Shared lives Supported living
services Ambulance services Blood and transplant services Remote
clinical advice services
Slide 14
Location A place in which, or from which, regulated activities
are provided or managed Each place if the regulated activities
provided are managed independently Generally means each separate GP
surgery, walk-in centre, etc is a location A single GP practice is
one location Branch surgeries Include if associated with the main
surgery the main surgerys location Only if patients from the same
registered list are seen or treated at all these places If the
branch surgery treats patients from a different registered patient
list to that of the main surgery, it will need to be included in
your registration as a location in its own right More than one
location requires one registration application with details about
all locations
Slide 15
Fees Application is free Annual fee for maintaining
registration GP Provider fee rates subject to consultation Suggest
you respond OOH fees 800 for single location 1,600 for 2 3
locations
Slide 16
Essential Standards CQCs conversion of the Regulations into
patient outcomes Standards and outcomes are best viewed as being
interchangeable terms CQC has created prompts that provide further
detail on the patient outcomes
Slide 17
Essential Standards I 1Respecting and involving people who use
services 2Consent to care and treatment 4Care and welfare of people
who use services 5Meeting nutritional needs 6Cooperating with other
providers 7Safeguarding people who use services from abuse
8Cleanliness and infection control 9Management of medicines
10Safety and suitability of premises 11Safety, availability and
suitability of equipment 12Requirements relating to workers
13Staffing 14Supporting workers 16Assessing and monitoring the
quality of service provision 17Complaints 21Records
Slide 18
Essential Standards II 3Fees 15Statement of purpose
18Notification of death of a person who uses services
19Notification of death or unauthorised absence of a person who is
detained or liable to be detained under the Mental Health Act
20Notification of other incidents 22Requirements for an individual
or partnership providers 23Requirement where provider is a body
other than a partnership 24Requirements relating to registered
managers 25Registered person training 26Financial position
27Notifications notice of absence
Slide 19
Standards and Registration Applicants make a specific
declaration of compliance or non- compliance against 16 of the
standards These are the standards that relate most directly to the
quality and safety of the care you provide The remaining 12
standards relate to the routine day-to-day management of a service
include certain notifications you must make to the CQC once
registered No declaration of compliance with these in an
application Still required to meet the outcomes
Slide 20
Non compliance At registration of an existing provider Can be
registered for 1 April 2013 Declaration forms the basis of your
legal registration with the CQC so it is important that your
declarations are true and honest It is highly unlikely that CQC
will refuse your application just because you declare
non-compliance with any of the essential standards Registration may
sometimes be subject to conditions If declaration of non-compliance
against any of the essential standards Must submit an action plan
of how to achieve compliance Action plan should be concise and
succinct
Slide 21
Compliance Not necessarily straight forward May be achieved in
more than one way Some very obvious Some by addressing the issue
differently Take advice and consider option Is not achieved by
having policies but by implementing them Keep records of why
compliance is achieved
Slide 22
Compliant? GPC guidance takes GPs through each standard where
compliance must be declared Full explanation of the 12 requirements
Some examples
Slide 23
Inspections Regime not yet determined Likely to be a minimum of
biennial Specific visits after concerns Some notice will be usually
given Focus on outcome not policy
Slide 24
Possibly difficult standards 5Meeting nutritional needs
6Cooperating with other providers 7Safeguarding 8Cleanliness and
infection control 10Safety and suitability of premises
12Requirements relating to workers
Slide 25
Meeting nutritional needs Only relevant where food and
hydration are provided As part of the services provided This is not
the case for most primary care providers No option to declare
irrelevant Declaring non-compliance requires CQC to act as non
compliance implies risk to patients As there is no risk you should
declare compliance
Slide 26
Cooperating with other providers Patients will receive safe and
coordinated care, treatment and support where more than one
provider is involved, or they are moved between services A practice
will expect to be compliant if cooperate with others involved in
the care, treatment, and support of a patient when the provider
responsibility is shared or transferred to one or more services,
individuals, teams, or agencies; share information in a
confidential manner with all relevant services, individuals, teams,
or agencies to enable the care, treatment, and support needs of
patients to be met; work with other services, individuals, teams,
or agencies to respond to emergency situations; support patients to
access other health and social care services they need
Slide 27
Claiming compliance? Discuss with patients the options and
arrangements for referral Include in correspondence all of the
information that would reasonably be required to treat the patient
safely and effectively [see guidance for a list] When patients
leave transfer the relevant information to the new provider(s) in a
timely manner so that the needs of patients can be met in an
appropriate timescale In the case of children and patients without
the capacity to give consent, ensure that their
parents/guardian/representatives are involved and informed about
referral decisions When referring patients, ensure that patients
know at least what type of information is being transferred
Respects the right of patients to request information about them to
be transferred to another provider unless there is a good reason
for not doing so
Slide 28
Documentation An emergency preparedness plan including
arrangements for sharing information and working with other
providers Have a confidentiality protocol/information governance
protocol that refers to information disclosures to ensure that data
is transferred/received safely and securely A protocol for acting
on correspondence and results, to ensure that your staff are able
to respond in a timely manner to incoming information
Slide 29
At a visit No good just having your policy document CQC is
about demonstrating outcomes What do the staff and doctors actually
do What will they say they do Much of visit is talking to service
users and staff
Slide 30
Safeguarding Patients are protected from abuse, or the risk of
abuse, and their human rights are respected and upheld Compliance
is anticipated if the practice takes action to identify and prevent
abuse from happening in a service responds appropriately when it
suspects abuse has occurred or is at risk of occurring ensures that
Government and local guidance is accessible to all staff and put
into practice understands how diversity, beliefs and values of
people who use services may influence the identification,
prevention and response to safeguarding concerns protect others
from the negative effect of any behaviour by people who use
services
Slide 31
Claiming compliance Ensure staff have had safeguarding training
appropriate to their role Take appropriate action to protect
patients if any member of staff exploits a vulnerable adult or
child Ensure patients can raise concerns and make complaints
related to abuse Have a mechanism for patients to make comments and
a publicised complaints procedure. Share relevant information with
other providers, in accordance with local safeguarding procedures
Comply with the Vetting and Barring Scheme
Slide 32
Documentation A safeguarding children (child protection) policy
A safeguarding adults policy A patient information leaflet about
abuse What patients should do if they have suspicions that another
person has been abused What they might expect to happen under
safeguarding procedures
Slide 33
At a visit No good just having your policy document CQC is
about demonstrating outcomes What do the staff and doctors do What
will they say they do
Slide 34
Safety and suitability of premises Patients are treated in safe
accessible surroundings that promote their wellbeing Premises
should be safe and secure from risks created by premises design and
layout Premises should be managed to reduce risks The key to this
outcome is to recognise risks and manage them Where possible, make
adjustments that are reasonably practical
Slide 35
Claiming compliance Patients, staff and others know they are
protected against the risks of unsafe or unsuitable premises by:
The design and layout of the premises being suitable for the
activity Appropriate measures being in place to ensure the security
of the premises The premises and any grounds being adequately
maintained Compliance with any legal requirements relating to the
premises Account is taken of any relevant design technical and
operational standards When an issue cannot be resolved seek to
manage the risks Displaying appropriate information (e.g.
alternative practices, how to access support) Providing appropriate
support to patients Adjusting how you use different parts of your
premises
Slide 36
At a visit No good just having your policy document CQC is
about demonstrating outcomes Why did you claim compliance What do
the staff and doctors do in practice What will they say they
do
Slide 37
Table work I Registered managers Who should have the role in
our practice Why What support is needed Who should manage the CQC
account The registered manager Practice manager How do they get
support
Slide 38
Table work II Each table has at least: One Essential Standard
requiring compliance to be claimed at application One other
Essential Standard Your tasks Make a record of why you are/are not
compliant Write an action plan to achieve compliance Consider how
you would ensure the reporting standards are met