pms inspection team planning and briefing template dragon ...€¦ · web viewquestions and...

Commands: ‘Next Field’ will take you to the next box or greyed out area. ‘Previous Field takes you back to the previous box or field. ‘Tab’ followed by a number will get you to boxes/greyed out areas by jumping forward by the specified number. When deleting as appropriate, please say the word you wish to use and the alternatives will be deleted

[Insert name of provider]

[Insert Location ID]

Inspection of NHS GP practice & out-of-hours servicesInspection team planning and briefing pack

[Insert date]


Dear colleague,

May I firstly take this opportunity to thank you for your support with CQC’s inspection of [insert name of provider] (“the provider”).

All members of the inspection team for this provider will receive this briefing pack. Its purpose is to provide you with information to help you prepare for the briefing session and the inspection itself.

The inspection briefing session has been scheduled for [time] on [date] . The session will be held by conference call, dial-in details for which are listed on page 7.

Contents of the inspection briefing pack

We have enclosed the following documents in this pack – please review them ahead of the inspection briefing session:

Joining instructions and inspection team This provides logistical information and key dates for the upcoming inspection visit, and the names and contact details of the inspection team members.

Summary from pre-inspection meeting This is a summary of the pre-inspection meeting with the Clinical Commissioning Group (CCG) & NHS England Local Area Team (LAT).

Agenda for the provider visitPlease read carefully for information about the inspection visit. The agenda has been tailored to the provider’s KLOEs.

Procedures for provider location visitThis details the key procedures for the inspection, including introducing yourself as a member of CQC’s inspection team, procedures for logging and storing evidence, interactions with the media and escalation procedures.

Appendix AInspection team roles and responsibilities

Appendix BPersonal safety on inspections

We have attached the following documents to your email; again please review these ahead of the inspection briefing session:

1) Data pack CQC has prepared this to help inform the work of the inspection team. The pack brings together existing available information from a wide range of national data


sources, and also draws on the information submitted by the provider and other stakeholders. The data pack includes a summary of provider and other local contacts’ responses to an information request.

2) Key lines of enquiry (KLOEs) and prompts Standard KLOEs have been developed for use on the inspection, which are underpinned by standard prompts. The prompts are to be added to, and tailored to the provider, following a review of the data pack, discussions with local stakeholders and a review of feedback from patients specific to the provider.

3) Note-taking templateA standard note-taking template has been developed to record your findings during the inspection. Each member of the inspection team will need to complete one of these, sign and date each page and return to the lead inspector at the end of the inspection.

Please could I ask you to review all this information in detail and to bring a printed copy of this planning and briefing template, the note-taking template and a copy of the KLOE on the inspection visit? Where it is not possible for you to print these documents, please let the lead inspector know in advance.

I look forward to meeting and working with you all. If you have any questions please do not hesitate to get in touch.

Kind regards,

[Insert name of CQC Lead Inspector]


These instructions provide the logistical information for your inspection:

AccommodationIf requested a hotel has been booked by the National Customer Service Centre (NCSC) for the date/s you required.

Please contact the NCSC ([email protected]) for all queries relating to accommodation during the inspection.

Pre- inspection briefing meeting / TCA briefing meeting / TC will be held on [date] at [time] .

Inspection detailsLocation Name: [location name] Location Address: [location address]

Location contact details: [name and contact telephone number]

The announced inspection visit commences at [time] on [date] and is scheduled to be completed by [time] on [date] .

Please bring photographic ID with you for the inspection visit.

ExpensesCQC staffCQC will reimburse its staff for any expenses that they actually and necessarily incur during the inspection, within clear rules for claiming expenses.

CQC has a number of arrangements and rules for booking and paying for travel and accommodation to ensure that business travel and expenses are both effective and efficient. Please note: all travel and subsistence claims made under this policy should be submitted using CQC’s online intranet expenses system.

In addition, claim forms must be authorised by a signature from the claimant’s line manager before they have been submitted for processing. All claims must be supported by receipts; claims without supporting documentation will only be processed in exceptional circumstances.

Specialist AdvisorsIt is CQC policy to remunerate individuals for the days spent on a CQC inspection and will reimburse mileage costs which will allow members to attend inspections.

The Associate Inspector’s general expenses, travel and subsistence Policy and Procedures can be found at: http://www.cqc.org.uk/sites/default/files/20140630-associates-ts-policy-final.pdf

http://www.cqc.org.uk/sites/default/files/20140630-associates-ts-policy-final.pdf

http://www.cqc.org.uk/sites/default/files/20140630-associates-ts-policy-final.pdf


All individuals who have agreed to the terms of CQC in their contracts should only use CQC's central travel and hotel booking facilities; and should not arrange their own tickets and should not arrange for reimbursement through their employer unless their contract specifies. All claims for remuneration must be completed using a Specialist Advisors Payment Form which will need to be signed by a Head of Inspection/ Inspection Manager along with hard copies for receipted items if an individual is on a casual workers agreement through CQC. A soft copy of the payment and expenses form will be sent to CQC’s HR department by the Head of Inspection/ Inspection Manager to process for payment.

Please follow the rules within the CQC’s expenses policy. If you have any further questions, please contact: [email protected] / 0191 233 3631.

Experts by ExperienceExperts by Experience will be reimbursed by their Support Organisation.

For individuals who are on secondment agreements, it will be your own organisation that will reimburse your expenses and then invoice CQC.

Dress code for visitsThe dress code for the inspection is business dress for CQC staff and professional advisors and smart casual for experts by experience.

Inspection team Appendix A contains information about the roles and responsibilities of inspection team members.

Inspection Role Name Phone Number Email AddressLead inspector

CQC Inspector

Expert by Experience

GP

Practice Nurse

Practice Manager

Inspection Manager

Inspection Planner

mailto:[email protected]


Further InformationFurther information on CQC’s new inspection methodology for NHS GP practices and out-of-hours can be found on the CQC website at:

Signposting document:http://www.cqc.org.uk/sites/default/files/documents/20131211_-_gp_signposting_statement_-_final.pdf

Handbook:http://www.cqc.org.uk/sites/default/files/20140409_provider_handbook_consultation_gp_practices_final_for_web.pdf

Handbook appendices:http://www.cqc.org.uk/sites/default/files/20140409_provider_handbook_consultation_gp_practices_appendices__final_for_web.pdf

Please speak to your CQC Lead Inspector in the first instance if you have any queries.

http://www.cqc.org.uk/sites/default/files/20140409_provider_handbook_consultation_gp_practices_appendices__final_for_web.pdf



http://www.cqc.org.uk/sites/default/files/20140409_provider_handbook_consultation_gp_practices_final_for_web.pdf

http://www.cqc.org.uk/sites/default/files/20140409_provider_handbook_consultation_gp_practices_final_for_web.pdf

http://www.cqc.org.uk/sites/default/files/documents/20131211_-_gp_signposting_statement_-_final.pdf

http://www.cqc.org.uk/sites/default/files/documents/20131211_-_gp_signposting_statement_-_final.pdf


Guideline agenda for the inspection briefing sessionOverviewThe inspection briefing session is an important preparatory step to ensure all members of the inspection team have the necessary information and tools to complete the inspection in a consistent and robust manner.

Date: [date] at [time] pm

Location / TC details: [insert details]

Agenda items1. Welcome and Introductions.

2. Briefing on the background to the inspection process. Key messages about the methodology, guidance and logistics.

3. Information about the provider. Why they were selected, overview of the data pack and analysis completed during preparation stage.

4. Reminder of the principles of the inspection process We put people who use services at the centre of our work. We are independent, rigorous, fair and consistent. We have an open and accessible culture. We work in partnership across the health and social care system. We are committed to being a high performing organisation and apply the

same standards of continuous improvement to ourselves that we expect of others.

We promote equality, diversity and human rights.

5. Discussion of the key areas of focus identified Inspection domains, key lines of enquiry (KLOE) and detailed prompts.

6. Discussion regarding roles, responsibilities and inspection focus Inspection plan Access to medical records Evidence gathering / note-taking

7. Ratings

8. Questions and answers

7


9. AOB, round up and close

8


Summary from pre-inspection meeting with the Clinical Commissioning Group (CCG) & NHS England Local Area Team (LAT)

Please find below the summary from the meeting held between the CQC, CCG & LAT:

[insert summary]

Key issues / themes across the CCG

Any action being taken by CCG / LAT

Location specific issues

Note: If this information is not available at the time of sending out this pack, this information will be discussed at the inspection briefing session.

9


Guideline agenda for the inspectionTeam Members

[Name of lead inspector]

[Name of CQC inspector]

[Name of GP] [Name of Practice Nurse]

[Name of Practice Manager]

[Name of Ex by Ex / other team member]

Areas to focus on

Insert domains / KLOEs / pop groups to focus on. For detail see prompts.






[start time]

Arrive on site (Please ensure that all the inspection team arrive and enter the location at the same time, this may mean having to meet at an alternative location first).

30mins Meeting with practice staff – discuss what they think they do well / completed clinical audits and significant events.

Inspection visit:

Following inspection methodology, roles & responsibilities & areas to focus on.

Inspection visit:


Inspection visit:


Inspection visit:


Inspection visit:


Inspection visit:


[times tbc]

Corroboration Meeting/s - At some point during the inspection visit (to be determined by the lead inspector) a meeting to discuss emerging findings will be held. The aim is to identify what evidence has been collected and any key themes emerging. Discussing domains, findings, outstanding practice and any issues identified. It may be that more than one corroboration meeting will be required.

[end time]

Inspection team depart

The lead inspector and the GP will provide feedback to the provider and confirm the process and timescales for completion and reporting of

10


the inspection.

11


Procedures for the provider visitSpeaking with staff members and patients

Introduce yourself and your role on the inspection team.

Ask the interviewee’s name, role / why they are at the provider, and if it would be convenient to speak to them now or at another time.

Explain:

• you would like to ask some questions to inform the CQC inspection

• it is an inspection looking at the quality of care and treatment provided - more information can be found on the CQC website

• one of the key principles of the inspection is public, patient and staff participation – which is why you would like to speak to them

• personal identifiable information will not be included in any published reports

• However, if you hear something of particular concern you will need to escalate the matter further (you will inform the interviewee if that happens).

• the inspection report can be found on the CQC website, at the earliest, approximately six weeks after the visit. Note that practice staff may be invited to be interviewed but if they refuse please note why.

Confirm that the interviewee would still like to go ahead with the interview and ask if they have any questions before you begin.

If they would prefer not to, they can provide feedback through the CQC website.

Written notes of the discussion must be made to make sure that information is recorded accurately

The interviewer should confirm their notes with the member of staff at the end of every interview to ensure their notes accurately reflect the member of staffs’ comments.

The lead inspector must ensure that they have the option of re-interviewing certain staff, particularly senior staff, by coming back to them with the findings from the inspection.

Procedures for recording and sharing inspection findings on site

Overview

All members of the inspection team will discuss emerging findings in collaboration meetings at regular points during the inspection.

Members of the inspection team should: record summary points from interviews stating who they spoke with and at what time

onto the note taking template


record evidence and corroboration of that evidence onto the note taking template use notes taken in this way to aid collaboration discussions

Procedures to follow on completion of the evidence collection

It is very important to give original inspection notes to the lead inspector before leaving the inspection location. This is because these have been asked for in tribunals as the key source of evidence. When inspection team members need to use their notes to write up information after the inspection visit, wherever possible the lead inspector should request to use copying equipment if available at the inspection location. The lead inspector must keep the original notes at the end of the inspection, and the inspection team member should destroy their copy once they have finished writing up inspection information.

Interactions with the media

Important - Inspection Team members should note that they should not speak to the media directly unless this has been agreed with CQC’s media team. If approached you should refer to the lead inspector who will advise that the outcome of the CQC inspection visit and all information is published on the CQC website (see details below). Please refer any journalists to CQC’s media team on 020 7448 9401 during office hours or out of hours on 07917 232 143. Email: [email protected].

Contact details for staff and patients

If you are approached by patients or staff asking you to respond to an individual case please advise them to submit their feedback to the CQC website. The details for submitting any information or to raise any concerns individuals may have about the provider can be submitted in the following ways:

Call usYou can contact us at our National Customer Service Centre:Telephone: 03000 616161Fax: 03000 616171Opening hours are Monday to Friday, between 8.30am and 5:30pm, excluding bank holidays. Calls will be charged at the standard rate.

Write to usCQC National Customer Service CentreCitygateGallowgateNewcastle upon TyneNE1 4PA

All information submitted will be treated confidentially but may be shared with other organisations, for example regulatory bodies such as GMC.

Inspection teams have a responsibility to do two important things when people raise concerns about the NHS or want to make a complaint:

2



First, ensure that the complainant is fully briefed on the appropriate procedure for pursuing their individual complaint against a provider. This includes signposting either to the provider’s complaints procedure, the Clinical Commissioning Group, PALS or to the Parliamentary and Health Service Ombudsman, if they have already been through the first stage process.

Secondly, we should obtain as much information as we can from the complainant who is then used to inform our inspection evidence base and shape the regulatory response. This helps us to judge the overall quality of care being provided.

Please advise them to follow the NHS complaints procedure which you should make yourself familiar with. The NHS complaints procedure can be found on NHS Choices. If the individual has tried the NHS complaints procedure but is dissatisfied with the response to their complaint, they should contact the Parliamentary and Health Service Ombudsman. The Ombudsman carries out independent investigations into complaints about government departments, their agencies and the NHS.

Escalation of concerns

If you have immediate concerns about patient safety including patients currently receiving treatment at the provider please inform the lead inspector

Types of issues requiring escalation

There are different issues of concern you may encounter on the visits:

A patient in immediate danger, this should be reported without delay to the most appropriate senior person in attendance.

A patient reports a previous poor experience at the provider. This should be directed through the normal complaints procedure and details taken for corroboration with other evidence the inspection team identifies

Where there is an unsafe practice or procedure you must report to this to the lead inspector

Where there is a systemic problem this should be recorded and reported as part of the evidence gathering process

Professional judgement is needed to arrive at a decision whether or not escalation of the issue is required. If you are in any doubt, then consult with the lead inspector who will consult further if necessary.

3

http://www.ombudsman.org.uk/

http://www.nhs.uk/Pages/HomePage.aspx

http://www.nhs.uk/choiceintheNHS/Rightsandpledges/complaints/Pages/NHScomplaints.aspx


CONFIDENTIALITY – KEY MESSAGES

The information below must be provided to all people taking part in a Care Quality Commission inspection before they enter any registered location or are given access to any confidential documents. This information can be provided verbally, or by circulating a copy of this guidance.

You have a personal responsibility to protect confidentiality, and to take proper care of any confidential documents or information that comes into your possession before, during or after the inspection.

You may only use CQC’s powers to access medical or care records, or other confidential records, if you are carrying formal, written authorisation to do this. This authorisation may be printed on the back of a CQC ID badge, or in a letter or document signed by an appropriate CQC manager.

Medical and care records, or other confidential records, may be shared with members of the inspection team who are not authorised to use CQC’s powers themselves, on a strict ‘need-to-know’ basis – for example, where this is necessary to obtain advice from an expert advisor.

Confidential records must only be accessed where this is necessary for the purposes of the inspection, and access must be proportionate (do not access more records than you need, don’t access particularly sensitive records unless you have a particularly strong reason for doing so).

Confidential records must not be accessed for personal reasons or purposes of curiosity. You must not knowingly access personal records relating to your family, friends, colleagues or personal acquaintances, or celebrities or public figures, other than in exceptional circumstances and with express permission from the lead Inspector.

Wherever it is possible and practical to do so, tell people if you intend to access their own confidential records (e.g. sensitive records about them such as medical and care records, staff disciplinary records etc.)

In general, tell the people that you meet on inspection that CQC has powers to access records, including medical and care records, and that we do this in order to check that services are meeting required standards of care, and that there are strict rules of confidentiality to protect the records that we access.

Where you are aware that someone has objected to CQC accessing their own records – either by telling you directly, by telling another member of the inspection team, or telling a member of the provider’s staff – you must only access those records where there is a particularly strong reason to do so, and with the agreement of the lead Inspector. Where possible, the person to whom the records relate should be informed of this, and the reasons for accessing them against their wishes should be explained.

Only seize, or take copies of, or make a record of confidential personal information where it is strictly necessary to do so. Where possible, make anonymised records instead.

Confidential information obtained during inspection must only be disclosed outside of CQC in accordance with our policies and guidance on sharing information. You may be committing a criminal offence if you disclose confidential personal information inappropriately.

Securely return any confidential document to the care service staff when you are finished with it, (unless a decision has been made to seize the document). Any records being retained by CQC must be stored and handled securely.

If in doubt, refer to CQC policies and inspection guidance – in particular, our Code of Practice on Confidential Personal Information - or seek advice from the lead Inspector, your line manager, or from CQC’s Information Rights Manager ([email protected] – 0191 233 3599).

4



Appendix A: Roles and responsibilities of the inspection team

Inspector Lead the inspection planning stage, ensuring all intelligence available is used in the most effective way and leads development of the risk based prompts

Participate in listening events / focus groups and other meetings

Initial contact (telephone call) to the practice Draft the agenda for the inspection visit Brief the inspection team, working closely with

the clinical lead Completes and coordinates the inspection team

plan and briefing pack Use the judgement framework throughout the

inspection to consider shadow ratings Ensure sufficient evidence is gathered that meets

CQC regulatory requirements When requested, present the inspection team

findings at the regional or national quality panel Oversee the logging and analysing of evidence Make regulatory judgements based on all

evidence presented Lead enforcement and follow-up process Complete the reporting evidence documents with

findings under each domain Completes the draft report Sign off inspection team expenses

Clinical/specialist advisors Liaise with NCSC to arrange travel / accommodation

Provide clinical leadership during the inspection Lead peer to peer focus groups and interviews

with staff Carry out observations and provide advice to

other members of the team on service specifics Review draft report for factual accuracy Complete the reporting evidence documents with

findings under each domainExperts by experience Liaise with NCSC to arrange travel /

accommodation Carry out interviews with staff, patients and their

relatives and carry out service observations To conduct telephone interviews where

necessary Contribute to corroboration meetings Facilitate breakout sessions listening event Review draft report for factual accuracy Complete the reporting evidence documents with

findings under each domainInspection manager Co-Lead the work (with the PMS – Delivery lead)

5


of the local inspection team throughout the process and be accountable for delivering of the local programme

Approve all local reports and ensure they are in line with reporting requirements

Prepare all local reports for local and/or national panel

Manage the local PMS Team and delivery of local programme

To attend PMS delivery meetings as required Link with the PMS – Delivery Lead and national

advisors to disseminate learning and information to Inspectors

Coordinate input from CQC’s Involvement team on hard to reach groups and the public

Attend (where required) and provide feedback to the board in the absence of the PMS – Delivery Lead

Convene with the inspection team and approve all local briefing materials

Manage and lead on local regulatory issues in line with our current enforcement policy and methodology

Provide support, advice and guidance to Inspectors on CQC regulatory requirements

Provide information/updates to the PMS – Delivery Lead as required

Attend, weekly/fortnightly engagement the PMS – Delivery Lead throughout the programme

Ensure local delivery of key messages, training and quality assurance feedback is disseminated to Inspectors

To represent, attend and support at local quality panels as required

To deliver training to Inspectors Ensure robust and rigorous judgement for each

inspection Ensure the skills and experience of inspection

team members are used in the most appropriate way to deliver a robust and thorough inspection

Work to the national prompts, agenda and the lines of enquiry for inspections

Support and attend the local/national programme at public events

Engage and liaise with the local stakeholders and ensure collection and dissemination of information as part of the inspection process

Relationship with CCG/LAT Attend and support with inspection visits Ensure all inspection activity is line with the

national delivery plan and report any outliers to the PMS – Delivery Lead

Approve the inspection team planning and

6


briefing document, including the inspection agenda and key lines of enquiry / areas of focus

Inspection planner Arrange pre-inspection sharing meeting Plan quality assurance panels, book rooms and

send out calendar invites Liaise with the analytical support team Liaison with the inspection manager over focus

groups Inform lead inspectors of inspection team

contact details Liaise with NCSC to send out pre-inspection

letters and information requests Draft letters of authority (to be sent to inspection

manager for signing) Provide support to the lead inspector in planning

the inspection agenda Ensure non-CQC staff have completed

evaluation / timesheets Arrange post-inspection sharing meeting

Appendix B: Personal SafetyPersonal Safety on Inspections

7


The Health and Safety at Work Act 1974 outlines the responsibilities for both the employer and employee. CQC have a number of policies and systems in place to ensure the safety of their employees during inspections.

All staff should familiarise themselves with the Health and Safety policy and Lone Working policy before they attend an inspection. This document can be found on the CQC intranet or by asking your Lead Inspector for a copy.

Who is responsible?

When visiting various sites throughout the inspections there is a shared responsibility between the management of those establishments and CQC to ensure the health and safety of Commission staff as visitors

Personal safety checklist – Things to remember throughout the inspection

√ Be aware of your environment. Plan your activities and be prepared for when things change by making dynamic risk assessments

√ Always ensure that you sign in at reception and let someone know that you are on site

√ Familiarise yourself with the environment – are the doors locked? Who is present in the room? Is there a security alarm? Where are the fire exits etc.

√ Keep your belongings to a minimum and keep them close to you

√ Ensure you carry your CQC / ID badge at all times

√ Wherever practical avoid being in a situation where the person is between you and the exit

√ If you face verbal or other inappropriate behaviour, or you are not confident that you can continue your work safely, you should end the activity as soon as possible.

√ Report the incident and carry out a risk assessment on the activity, if may be that the inspection has to be carried out with further people present

8

pms inspection team planning and briefing template dragon ...€¦ · web viewquestions and...

Documents