Download CQC Report 2014 - Meridian Surgery

Inspection Report
We are the regulator: Our job is to check whether hospitals, care homes and care
services are meeting essential standards.
Dr Starling and Partners
Anchor Healthcare Centre, Meridian Way,
Peacehaven, BN10 8NF
Tel: 01273588200
Date of Inspection:
Date of Publication: February
2014
21 January 2014
We inspected the following standards as part of a routine inspection. This is what we
found:
Respecting and involving people who use
services
Met this standard
Care and welfare of people who use services
Met this standard
Cleanliness and infection control
Met this standard
Requirements relating to workers
Met this standard
Assessing and monitoring the quality of service
provision
Met this standard
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Details about this location
Registered Provider
Dr Starling and Partners
Registered Manager
Dr. Andrew James Starling
Overview of the
service
Dr Starling and Partners is based within the Meridian
Surgery. It is a General Practitioner (GP) practice serving
the Peacehaven area.
The practice supports approximately 9,500 patients. The
practice offers general treatment and consultation services
along with some enhanced services. The practice has four
GP's who are registered as a partnership.
Type of services
Doctors consultation service
Doctors treatment service
Regulated activities
Diagnostic and screening procedures
Family planning
Maternity and midwifery services
Surgical procedures
Treatment of disease, disorder or injury
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Contents
When you read this report, you may find it useful to read the sections towards the back
called 'About CQC inspections' and 'How we define our judgements'.
Page
Summary of this inspection:
Why we carried out this inspection
4
How we carried out this inspection
4
What people told us and what we found
4
More information about the provider
5
Our judgements for each standard inspected:
Respecting and involving people who use services
6
Care and welfare of people who use services
8
Cleanliness and infection control
10
Requirements relating to workers
12
Assessing and monitoring the quality of service provision
14
About CQC Inspections
16
How we define our judgements
17
Glossary of terms we use in this report
19
Contact us
21
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Summary of this inspection
Why we carried out this inspection
This was a routine inspection to check that essential standards of quality and safety
referred to on the front page were being met. We sometimes describe this as a scheduled
inspection.
This was an announced inspection.
How we carried out this inspection
We looked at the personal care or treatment records of people who use the service,
carried out a visit on 21 January 2014, observed how people were being cared for and
talked with people who use the service. We talked with staff.
What people told us and what we found
We spoke with seven patients at the surgery. We spoke with the practice manager, two
receptionists, an administrator and two General Practitioners (GP's) and a nurse. We
observed the medical centre in operation and looked at policies and records to help us
understand how the practice was run.
We found that patients were involved in their care and the running of the surgery. A patient
said, "I come here because of the way they treat you. I feel listened to". The practice runs
a patient participation group (PPG). A patient and member of the PPG told us "I feel that
hopefully things are really moving on now with the PPG. We have further meetings
booked".
We saw that patients' records supported safe and effective clinical care. There were
systems for managing patients' medicines safely and for ensuring investigation results
were followed up. Patients expressed confidence in their care with one commenting "I've
just moved to the area. I called today and got an appointment. The doctors are really easy
to talk to".
We found that patients were seen and treated in a clean and hygienic environment. We
also found that appropriate checks were carried before people started work to ensure they
were of good character.
There were arrangements in place to assess and monitor the quality of service provided.
We found changes were made in light of complaints and critical incidents.
You can see our judgements on the front page of this report.
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More information about the provider
Please see our website www.cqc.org.uk for more information, including our most recent
judgements against the essential standards. You can contact us using the telephone
number on the back of the report if you have additional questions.
There is a glossary at the back of this report which has definitions for words and phrases
we use in the report.
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Our judgements for each standard inspected
Respecting and involving people who use services
Met this standard
People should be treated with respect, involved in discussions about their care
and treatment and able to influence how the service is run
Our judgement
The provider was meeting this standard.
Patient's privacy, dignity and independence were respected. Patient's views and
experiences were taken into account in the way the service was provided and delivered in
relation to their care.
Reasons for our judgement
Patients understood the care and treatment choices available to them. We looked at four
sets of electronic patient records. We noted that the records demonstrated that patients
were given health advice, and that options about treatment were discussed with them. We
saw an example where a patient had been given information about reducing cholesterol.
We saw there was a discussion which resulted in the patient deciding to start an exercise
regime, rather than take medication. A doctor we spoke with told us "I'm a big fan of
options. It values the patient and gives them status. We want them to be part of the
decision making process. Patients we spoke with felt that they were given sufficient time to
make any decisions. A patient told us "I've always found they give you the attention you
need". Another said "There was an occasion when I needed a bit of extra time and it was
given to me".
We observed that the reception and waiting areas of the practice contained information on
a wide range of health services run by the NHS, the council and voluntary groups. There
were also a wide range of leaflets available and posters advising patients on how they
could maintain and improve their health. When required patients were given specific
information, for example, we saw that alternative treatment information was given about
referrals to a local gym. A patient told us "They always ask me if I want any further
information and what kind of thing I am looking for". This meant that patients were given
information to help them understand their health and any treatment options.
The medical centre operated a patient participation group (PPG). The practice manager
told us that the group had only just resumed. We spoke with a member of the PPG who
told us "We've only just started the PPG again, as it fell by the wayside before. We had a
meeting last night and we've got another two booked going forward". A member of the
PPG represented the medical centre at the local clinical commissioning group (CCG) PPG
and feedback to other members. Another patient commented "We have just started the
PPG again, the previous one didn't get off the ground. We're working on the terms of
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reference and have two meetings booked". This meant there was a forum for patients to
be involved in the running of the medical centre and the development of its services.
We observed GP's, nurses and reception staff talking to people respectfully and kindly. A
patient reported "I think confidentiality is ok. I've not got concerns" We saw that patient's
privacy was maintained with consultations taking place in private. We saw that staff
knocked on doors before entering. A patient told us "They always knock first. They called a
nurse in once, and they still knocked, even though they were expected". We observed the
reception area and saw that there was a possibility that conversations could be overheard.
However, we noted that a private room could be accessed for conversations should the
patient wish this. One patient told us they had observed someone being taken to a private
room when this was requested. Patients' notes were securely stored in electronic formats.
The patients we spoke with had no concerns regarding the maintenance of their dignity.
One patient said "Dignity is not a worry here for me" This meant that patients' privacy,
dignity and independence were respected.
The medical centre took measures to meet the diverse needs of the patients' that used the
practice. We observed that the building was wheelchair accessible. The reception area
had an induction loop system to help patients who used hearing aids to communicate
more effectively. A patient told us "Help for disabilities are getting better. It's the best
practice in the area for support as a blind person". Reception staff told us that they knew
how to access translation services, and had done so on occasion. We saw poster a
displayed advising patients that a chaperone could be provided. We were told that nurses
acted as chaperones, and if one was not available some reception staff had received
training and could act in this role. Reception staff we spoke with told us that they had had
training and on occasion provided a chaperone service. This showed patients' diversity,
values and human rights were respected.
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Care and welfare of people who use services
Met this standard
People should get safe and appropriate care that meets their needs and supports
their rights
Our judgement
The provider was meeting this standard.
Care and treatment was planned and delivered in a way that was intended to ensure
patient's safety and welfare.
Reasons for our judgement
Patients' needs were assessed and care and treatment was planned and delivered in line
with their individual needs. We looked at four sets of electronic patient records. We saw
that these contained information on patients' current, active conditions, and also past,
inactive ones. We saw that important information such as medicines use and allergies
were also recorded. We noted that consultations with GP's and nurses were documented
with results of any examination, and any treatment or health advice recorded. The system
also displayed alerts to prompt the GP to carry out activities that were due, for example,
blood pressure checks, medication reviews or immunisations and other checks to monitor
chronic diseases, such as regular diabetic reviews.
The practice maintained information of patients receiving end of life care, had particularly
complex needs or for whom there was concern. We saw evidence of multi-disciplinary
meetings being held with practice staff, other health staff such as mental health workers or
district nurses, staff from the local authority adult social care department and voluntary
organisations. This showed that there were appropriate arrangements to plan and review
the care of the sickest and most vulnerable of the patients registered at the practice, with
representatives from a variety of health and social care agencies.
A GP demonstrated the system that ensured any investigation results were reviewed and
any necessary actions taken. The computerised records systems alerted GP's when any
test results were awaiting review. There was a system where GP's checked their own
results and those of any absent colleagues which ensured results were reviewed daily. If
there was any abnormality the GP took appropriate action such as calling the patient, or
asking reception staff to arrange a routine or urgent appointment. A GP told us "A lot of
care goes into getting it right with patients". The GP and an administrator also
demonstrated a similar system that ensured any correspondence from hospital consultants
or other health professionals was scanned into the records system and reviewed promptly.
This showed that the results of any investigations or consultations with other health
professional were reviewed in a timely way and appropriate actions taken.
The computerised patient records included a system that alerted GP's if they were
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prescribing medicines outside of normal usage. The system included safeguards that
ensured medications were reviewed by a GP regularly and for ensuring that patients did
not order too many medicines. We observed this system in operation and noted it was
working well. We saw one example where the system raised an alert which ensured that a
patient's prescription was reviewed. This meant there were appropriate arrangements to
ensure patients' medicines were safely managed.
We saw training records which demonstrated staff received training in resuscitation. We
found there was appropriate equipment to deal with emergency situations. We found there
were adequate supplies of oxygen, equipment to support breathing, and a defibrillator in a
clearly signed room. We saw records to show that this equipment was checked monthly to
ensure it remained ready for immediate use. A nurse told us that there had been instances
where patients had required resuscitation at the surgery and that the equipment available
had proved adequate. There was a supply of emergency drugs and in each clinical room
there was a small supply of medicines to enable prompt treatment of anaphylaxis, an
extreme, life-threatening allergic reaction. We saw that there was a robust system where
medicines were checked to ensure they had not expired. All medicines were tracked on a
computer system which alerted the person responsible when a medicine was due to expire
so replacements could be obtained. We saw this system in operation. This meant there
were arrangements to deal with foreseeable medical emergencies.
The medical centre has a system where patients could book appointments in advance with
a number of appointments also available on the day. After patients left their details, they
received a telephone call back from their GP. The practice manager told us "Patients get
to speak to their regular GP. If it's an emergency we will always see them. There will
always be an appointment for you if you need one". Patients we spoke with told us they
could obtain an appointment when required. One patient told us "There's no trouble getting
an appointment. It's great. I can get an appointment with the doctor I like provided it's a
few days ahead". Another patient said "The call back works well now I'm used to it. They
called me back within 20 minutes". A further patient said "If you need an appointment, you
get it". Although one patient told us "I don't think it's that easy getting an appointment here.
You can get seen the same day, but it's not always with my doctor". Out of normal
working hours urgent treatment was provided by the NHS 111 service. The practice
patients information and web-site contained information on how to access this service and
a recorded message also relayed this information if patients called the surgery. We also
saw information about the 111 service displayed in the reception area. This demonstrated
that patients could access routine, urgent and out of hour's appointments when needed.
Patients we spoke with were satisfied with the service they received and expressed
confidence in the clinicians. One patient told us "I'm happy with the practice. I feel safe
here and feel that the care is safe a well". Another said "In comparison with other
surgeries, I think they are very good". A further patient commented "I'm happy with the
service and I have recommended this surgery to my friends".
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Cleanliness and infection control
Met this standard
People should be cared for in a clean environment and protected from the risk of
infection
Our judgement
The provider was meeting this standard.
Patients were protected from the risk of infection because appropriate guidance had been
followed. Patients were cared for in a clean, hygienic environment.
Reasons for our judgement
In 2010 the government issued advice to all providers of health and social care entitled
'The Code of Practice on the Prevention and Control of Infections and Related Guidance'
(CoP). Patients were fully protected from the risk of infection because this guidance had
mostly been followed.
The practice had an identified infection prevention and control (IPC) lead. We saw
certificates which indicated they had undergone training to prepare them for this role. The
IPC lead told us that they had received refresher training too. The name of the lead was
clearly displayed for staff and all staff we spoke with knew the name of the lead and
showed understanding of their role. A GP reported "We know who to go to if we have any
queries and they keep us updated with any changes". When we spoke with the IPC lead
we found they were knowledgeable and confident in their role. This showed there was
effective leadership in relation to IPC.
We looked at the current IPC policy. We noted it was due for review in December 2012.
We found that although it did not cover all the areas required by the CoP, it contained the
most important information and procedures that would ensure safe practice at the surgery.
We also noted there was evidence that the policy had been reviewed in light of changes to
guidance. The practice manager and IPC lead told us that the surgery's IPC policy was
being updated. We saw that that the IPC lead was aware of the policy framework set out in
the CoP and had obtained expert guidance from commissioning bodies to inform the
review process. This meant that there was an adequate policy framework that was being
reviewed with reference to documented best practice.
We were told that an annual IPC audit was performed. We examined the last IPC audit
which had been carried out using a recognised tool provided by local commissioners of
services. We saw that an action plan had been generated to address the minor issues
identified. This action plan had been reviewed to ensure the actions were implemented.
We saw evidence that feedback was given in staff meetings. We observed that the IPC
lead was monitoring IPC practice on an ongoing basis, for example we saw them address
an issue with waste management with another provider in the same building. This meant
that IPC practice was formally and informally monitored and appropriate actions taken to
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address any shortcomings.
We saw records that showed all staff attended annual infection control update training
covering hand-washing, personal protective equipment (PPE) and waste management.
The IPC lead told us all new staff had hand-washing training. A receptionist told us "We
do hand-washing and we do infection prevention when we start". We saw than nonregistered nursing staff had training in aseptic procedures such as wound dressing and
injections. Aseptic procedures are those that carry a high risk of infection as the body's
defences are breached. We saw copies of certificates and a completed competency
assessment in staff files which confirmed this. This showed that there was a training
programme specifically in relation to IPC.
We saw that there were adequate hand-washing facilities and supplies of hand-sanitizer
throughout the premises. Patients we spoke with told us that they observed staff washing
their hands appropriately. We saw records that showed that all staff immunised against
Hepatitis B. We saw there was a system in operation for processing specimens such as
urine, which meant that reception staff did not come into contact with bodily fluids and we
observed this in operation. We saw that there was a body fluid spillage kit that ensured
any body fluids could be cleared without undue risk to staff. This meant that staff and
patients were protected from the risk of cross infection through the use of recognised good
practices such as hand-washing and the use of PPE.
We saw that wherever possible disposable items and surgical instruments were used.
However, when non-disposable surgical instruments were needed, there were
arrangements to source these from a local hospital sterilising department. We saw that
instrument packs were correctly stored and disposed of once used. We saw that
disposable curtains were used and that there was a system for ensuring that these were
changed when necessary. This meant that instruments and equipment were maintained to
minimise the risk of cross infection. However, the provider might like to note there was
some doubt if small items used in GP's surgeries' such as blood pressure cuffs and
stethoscopes were consistently cleaned between each patient.
The practice employed external cleaning contractors. When we toured the building we
noted the premises were in a clean and hygienic state. A patient told us, "It's squeaky
clean". We saw there were cleaning schedules to guide cleaning staff and that they signed
each task as it was completed. We also there was a system where a senior member of
surgery staff checked cleaning standards and addressed any shortfalls with the contractor.
We noted that cleaning materials, especially mops, were appropriately colour coded
according to their use, and were stored clean and dry. This meant there were
arrangements to ensure cleaning standards were satisfactory.
We found there were arrangements to safely manage hazardous waste. We saw that
clinical waste was segregated from domestic waste. We saw that there were appropriate
receptacles for the disposal of sharps (which includes items such as used needles and
blades) and cytotoxic waste (such as drugs that are highly toxic). We noted that in clinical
areas there were displays to provide guidance to staff on the correct segregation of all
waste and on the management of sharps. The provider had arrangements with a licensed
contractor for the removal of hazardous waste and we were shown collection receipts
issued by the contactor. We observed that hazardous waste was securely stored when
awaiting collection.
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Requirements relating to workers
Met this standard
People should be cared for by staff who are properly qualified and able to do their
job
Our judgement
The provider was meeting this standard.
Patients were cared for, or supported by, suitably qualified, skilled and experienced staff.
Reasons for our judgement
Patients were cared for, or supported by, suitably qualified, skilled and experienced staff.
Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations
2010 sets out the information that is required to be kept for workers engaged in a
regulated activity. We looked at five staff records and spoke with the practice manager.
We found that appropriate checks were undertaken before staff began work.
The practice manager showed us a matrix that they had maintained which checked that all
required information had been received and was on file. They also showed us a
spreadsheet which showed that nurses and GP's registrations had been checked to
ensure they remained current. This sheet also ensured that other items, such as
indemnity insurance or resuscitation training, were up-to-date. We also saw evidence of
this in the staff files we examined. This showed there were management arrangements for
ensuring that the necessary information was collected and was current.
When the provider employed locum GP's we saw a checklist was completed by the
practice manager that ensured they had an induction to the surgery, and were
appropriately qualified, registered and insured. There were also checks that the GP were
on the NHS England's performers list, which indicated that appropriate background checks
had been carried out. We also saw there were shared arrangements with the local NHS
training deanery to ensure trainee GP's had appropriate background checks. We saw
records that indicated other temporary staff were checked, to ensure that they did not pose
a risk to vulnerable people. This meant that non-permanent staff were subject to
appropriate checks of qualifications and character.
We looked at five staff files. We saw certificates and competency assessment records that
demonstrated staff had appropriate training for their role and had the opportunity to
develop and maintain their skills and experience. Some staff were supported to undertake
further qualifications such as national vocational awards. We spoke with a group of
patients who all felt confident in the skills of the staff and one said "They're all properly
qualified and trained, even the GP trainees are very good". This demonstrated the
provider's commitment to ensure patients were cared for by staff with the necessary skills,
experience and knowledge.
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Each file we looked at contained recent photographic evidence and evidence that verified
identity. However, on one staff file the photo appeared to have been misplaced as it was
recorded as provided, but could not be located. There were checks carried out to ensure
the staff member was eligible to work in the UK. This meant that the provider was assured
of the true identity of staff.
Disclosure and Barring Service (DBS) checks are an employer's check to ensure the
worker is not barred from working with vulnerable people or had a criminal conviction that
would make them unsuitable for their job. We saw that staff had undergone DBS checks.
The practice manager explained that the surgery was in the process of registering staff on
the DBS website, which would allow checks to be updated annually. We saw an
administrative worker did not have a DBS check, but that there was a risk assessment on
file which established their role did not require them to have one. We also saw that two
satisfactory references were obtained before staff started work. This showed that
appropriate background checks were made for staff who had access to vulnerable people
or children during the course of their work.
We found that a full work history was on each person's file, usually in the form of a
curriculum vitae (CV). In one case we noted that an employment gap had been explained
in a covering letter of application. However, the provider might like to note that the reason
for leaving employment where the job involved children or vulnerable adults was not
consistently recorded. However, when used, the provider's application form prompted this
information.
The provider might like to note, that in four of the files we looked at there was no
assessment of a person's mental and physical fitness to carry out work that involved a
regulated activity prior to the commencement of employment. The practice manager told
us this was discussed at interview, but this could not be supported in the records. In one
case where the applicant had used the provider's application form there was a signed
health declaration. In this case a health issue had been identified and we saw records that
showed the person's fitness was assessed by an independent occupational health provider
and that recommendations made and implemented. However, we saw that once
employment commenced staff's fitness was reviewed as part of the induction process. We
saw records of these reviews. We also saw people's work fitness was discussed during
personal health and safety assessments that were conducted annually. We saw records of
these assessments completed. We also saw that when an issue was identified through
assessment or absence monitoring, referral to an occupation health provider was made.
This showed that although applicant's fitness to undertake regulated activities was not
formally assessed prior to them starting their jobs, it was once they commenced
employment.
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Assessing and monitoring the quality of service
provision
Met this standard
The service should have quality checking systems to manage risks and assure
the health, welfare and safety of people who receive care
Our judgement
The provider was meeting this standard.
The provider had an effective system to regularly assess and monitor the quality of service
that patients receive. The provider had an effective system in place to identify, assess and
manage risks to the health, safety and welfare of patients who use the service and others.
Reasons for our judgement
Patients, their representatives and staff were asked for their views about their care and
treatment and they were acted on. The medical centre carried out an annual patient survey
focusing on a specific topic. In July 2013 the survey had asked patients' opinions on
telephone triage systems. The survey showed that patients felt the current model of
service had not worked entirely well, so changes to the system were made. The medical
centre also had a patient participation group. This showed patients opinions were taken
into account when developing services.
The Care Commissioning Groups and other commissioners of services set quality
standards using the Quality Outcomes Framework (QOF) for the practice. We saw that
QOF performance data was monitored by a partner GP who took responsibility for
overseeing a selection of the targets and for reporting back to the rest of the team. The GP
explained "We have lots of audit tools that we use and we analyse information line with the
CCG. There is no point doing things if you are not going to change habits". We saw
minutes of regular practice clinical meetings where discussion of current QOF
performance was a standing agenda item. This showed that the practice was monitoring
quality standards using an agreed and recognised set of standards.
We found there was evidence that learning from incidents and complaints took place and
appropriate changes were implemented. We looked at significant event reports. These
recorded what had happened, why it had, the learning points and changes to practice
made as a result. Staff we spoke with told us that significant incidents were discussed at
clinical meetings, and we saw one example in the minutes of a meeting to support this.
We were shown details of complaints received by the practice. From this information, we
could see that complaint had been responded to appropriately. We saw that where
appropriate, changes to practice were made as a result of the investigation of patients'
complaints. A GP told us "I have the view that people should be encouraged to complain.
For us it's an opportunity to learn and change the way we do things". This meant the
provider took account of complaints and comments to improve the service.
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We saw an example of an environmental health and safety risk assessment that had been
carried out in relation to the medical centre. We saw that the premises had undergone a
fire risk assessment and we saw that fire extinguishers equipment and appropriate
signage was in place. This showed that environmental risks were assessed and
appropriate actions taken to minimise risks.
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About CQC inspections
We are the regulator of health and social care in England.
All providers of regulated health and social care services have a legal responsibility to
make sure they are meeting essential standards of quality and safety. These are the
standards everyone should be able to expect when they receive care.
The essential standards are described in the Health and Social Care Act 2008 (Regulated
Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations
2009. We regulate against these standards, which we sometimes describe as "government
standards".
We carry out unannounced inspections of all care homes, acute hospitals and domiciliary
care services in England at least once a year to judge whether or not the essential
standards are being met. We carry out inspections of other services less often. All of our
inspections are unannounced unless there is a good reason to let the provider know we
are coming.
There are 16 essential standards that relate most directly to the quality and safety of care
and these are grouped into five key areas. When we inspect we could check all or part of
any of the 16 standards at any time depending on the individual circumstances of the
service. Because of this we often check different standards at different times.
When we inspect, we always visit and we do things like observe how people are cared for,
and we talk to people who use the service, to their carers and to staff. We also review
information we have gathered about the provider, check the service's records and check
whether the right systems and processes are in place.
We focus on whether or not the provider is meeting the standards and we are guided by
whether people are experiencing the outcomes they should be able to expect when the
standards are being met. By outcomes we mean the impact care has on the health, safety
and welfare of people who use the service, and the experience they have whilst receiving
it.
Our inspectors judge if any action is required by the provider of the service to improve the
standard of care being provided. Where providers are non-compliant with the regulations,
we take enforcement action against them. If we require a service to take action, or if we
take enforcement action, we re-inspect it before its next routine inspection was due. This
could mean we re-inspect a service several times in one year. We also might decide to reinspect a service if new concerns emerge about it before the next routine inspection.
In between inspections we continually monitor information we have about providers. The
information comes from the public, the provider, other organisations, and from care
workers.
You can tell us about your experience of this provider on our website.
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How we define our judgements
The following pages show our findings and regulatory judgement for each essential
standard or part of the standard that we inspected. Our judgements are based on the
ongoing review and analysis of the information gathered by CQC about this provider and
the evidence collected during this inspection.
We reach one of the following judgements for each essential standard inspected.
Met this standard
This means that the standard was being met in that the
provider was compliant with the regulation. If we find that
standards were met, we take no regulatory action but we
may make comments that may be useful to the provider and
to the public about minor improvements that could be made.
Action needed
This means that the standard was not being met in that the
provider was non-compliant with the regulation.
We may have set a compliance action requiring the provider
to produce a report setting out how and by when changes
will be made to make sure they comply with the standard.
We monitor the implementation of action plans in these
reports and, if necessary, take further action.
We may have identified a breach of a regulation which is
more serious, and we will make sure action is taken. We will
report on this when it is complete.
Enforcement
action taken
If the breach of the regulation was more serious, or there
have been several or continual breaches, we have a range of
actions we take using the criminal and/or civil procedures in
the Health and Social Care Act 2008 and relevant
regulations. These enforcement powers include issuing a
warning notice; restricting or suspending the services a
provider can offer, or the number of people it can care for;
issuing fines and formal cautions; in extreme cases,
cancelling a provider or managers registration or prosecuting
a manager or provider. These enforcement powers are set
out in law and mean that we can take swift, targeted action
where services are failing people.
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How we define our judgements (continued)
Where we find non-compliance with a regulation (or part of a regulation), we state which
part of the regulation has been breached. Only where there is non compliance with one or
more of Regulations 9-24 of the Regulated Activity Regulations, will our report include a
judgement about the level of impact on people who use the service (and others, if
appropriate to the regulation). This could be a minor, moderate or major impact.
Minor impact - people who use the service experienced poor care that had an impact on
their health, safety or welfare or there was a risk of this happening. The impact was not
significant and the matter could be managed or resolved quickly.
Moderate impact - people who use the service experienced poor care that had a
significant effect on their health, safety or welfare or there was a risk of this happening.
The matter may need to be resolved quickly.
Major impact - people who use the service experienced poor care that had a serious
current or long term impact on their health, safety and welfare, or there was a risk of this
happening. The matter needs to be resolved quickly
We decide the most appropriate action to take to ensure that the necessary changes are
made. We always follow up to check whether action has been taken to meet the
standards.
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Glossary of terms we use in this report
Essential standard
The essential standards of quality and safety are described in our Guidance about
compliance: Essential standards of quality and safety. They consist of a significant number
of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the
Care Quality Commission (Registration) Regulations 2009. These regulations describe the
essential standards of quality and safety that people who use health and adult social care
services have a right to expect. A full list of the standards can be found within the
Guidance about compliance. The 16 essential standards are:
Respecting and involving people who use services - Outcome 1 (Regulation 17)
Consent to care and treatment - Outcome 2 (Regulation 18)
Care and welfare of people who use services - Outcome 4 (Regulation 9)
Meeting Nutritional Needs - Outcome 5 (Regulation 14)
Cooperating with other providers - Outcome 6 (Regulation 24)
Safeguarding people who use services from abuse - Outcome 7 (Regulation 11)
Cleanliness and infection control - Outcome 8 (Regulation 12)
Management of medicines - Outcome 9 (Regulation 13)
Safety and suitability of premises - Outcome 10 (Regulation 15)
Safety, availability and suitability of equipment - Outcome 11 (Regulation 16)
Requirements relating to workers - Outcome 12 (Regulation 21)
Staffing - Outcome 13 (Regulation 22)
Supporting Staff - Outcome 14 (Regulation 23)
Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10)
Complaints - Outcome 17 (Regulation 19)
Records - Outcome 21 (Regulation 20)
Regulated activity
These are prescribed activities related to care and treatment that require registration with
CQC. These are set out in legislation, and reflect the services provided.
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Glossary of terms we use in this report (continued)
(Registered) Provider
There are several legal terms relating to the providers of services. These include
registered person, service provider and registered manager. The term 'provider' means
anyone with a legal responsibility for ensuring that the requirements of the law are carried
out. On our website we often refer to providers as a 'service'.
Regulations
We regulate against the Health and Social Care Act 2008 (Regulated Activities)
Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009.
Responsive inspection
This is carried out at any time in relation to identified concerns.
Routine inspection
This is planned and could occur at any time. We sometimes describe this as a scheduled
inspection.
Themed inspection
This is targeted to look at specific standards, sectors or types of care.
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Contact us
Phone:
03000 616161
Email:
[email protected]
Write to us
at:
Care Quality Commission
Citygate
Gallowgate
Newcastle upon Tyne
NE1 4PA
Website:
www.cqc.org.uk
Copyright Copyright © (2011) Care Quality Commission (CQC). This publication may
be reproduced in whole or in part, free of charge, in any format or medium provided
that it is not used for commercial gain. This consent is subject to the material being
reproduced accurately and on proviso that it is not used in a derogatory manner or
misleading context. The material should be acknowledged as CQC copyright, with the
title and date of publication of the document specified.
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