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CQC Information


CQC Report we were last inspected on Wednesday 7th August 2019 see the report here Full Report

Please find below our action plan for the issues identified in the report

  1. Fire Risk Assessment – External Fire Risk assessment completed on 17th October 2019, observations were that we had good practice and low risk. Findings will be implemented and reviewed as recommended by the inspection.

  2. Health and Safety Risk Assessment was completed in July 2019, less than a month before the visit.  Actions have been worked through as per the time frame detailed in the report. This will be an annual external assessment.

  3. Since receipt of this report we can confirm that we have learnt that a full calibration of all equipment was completed by an external organisation on the 22nd January 2019. This information was not known at the time of the inspection. We will repeat every year in January.

  4. Infection Prevention and Control – Nurse Team working with the CCG Infection Prevention and Control specialist to ensure audit is completed and process for regular review in place.

  5. Completed – since the visit two sets of prescription paper lockers have been installed. Each clinician has their own key, takes the paper for the day and at the end of each day returns their prescriptions back. They are locked away overnight.

  6. Quality Improvement plan for areas of poor performance –

Quality improvement plan NRMC

Monitoring of Quality

  • Performance report developed by end October 2019

  • Clinical effectiveness and quality group (CQEG) comprising lead partner, operations manager, lead nurse, and clinic coordinator - established end October 2019.

  • Performance report and CEQG report to monthly partners meeting – October 2019

Managing areas of poor performance

  • Specific QI programme for areas of poor performance starting with:

    • Diabetes

    • Asthma

    • COPD

    • Learning disability checks

    • Cervical smears

    • Childhood immunisations

  • Programme commencing October 2019 and comprises:

    • Protected time

    • Key stakeholders identified to lead work

      • Lead clinician

      • Dedicated admin time

      • Supported by operations manager

    • Initial meeting

      • Assessment of current performance

      • Identification of areas to target to improve performance (fish diagram, process map etc)

      • Identification of change(s) required

      • Identification of how to monitor (run chart etc)

    • Implement change

    • Monthly meetings with PDSA cycle

    • Reports to partners meeting and CQEG

A culture change

  • Funded partner time to lead on this – starting October 2109

  • Audit report to evolve to quality report based on CQC domains – April 2020

  • Quality report to be reviewed at practice half day closure - 2020

  • All GPs accountable for clinical quality for their registered list around:

    • Exception reporting, maximum tolerated etc.

    • Repeat non attenders

    • Management of complex patients with frailty or multi-morbidity for whom a person centred approach is more appropriate

    • Starting November 2019

  • QI training for staff as part of standard practice training programme – April 2020

  • Aim for RCGP QI ready      

Staff appraisals, supervision and competency checks – In autumn 2019 we are recruiting an Operations Manager to support the governance of the practice and ensure that all staff receive an annual appraisal.

All staff members have a DBS check, the one mentioned above was employed before CRB and DBS checks were introduced, this has now be received and recorded as clear. 

Staff have now produced evidence of their immunisation checks, information contained in a staff matrix. 

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