CQC inspections

By autumn 2016 all general practices in England should have had a CQC inspection. What has the Care Quality Commission come across in its inspections so far?

Managers will need no reminding that the Care Quality Commission (CQC) is currently carrying out the first independent inspections of general practices in England. All 8,405 practices should have been assessed and rated by the autumn of 2016.
Focusing on quality and safety, the CQC says that the areas that are central to its inspections are those that matter most to patients and relatives. Inspection teams therefore seek to determine the extent to which a practice is:

• Safe.
• Effective.
• Caring.
• Responsive.
• Well-led.

Each is assessed through key lines of enquiry (KLOEs). Alongside each KLOE is a set of questions or ‘prompts’ that highlight the type of evidence required to produce a detailed response to each question (see Box 1).¹

The inspection process also assesses the quality of care provided to the population groups listed below:

• Older people.
• People with long-term conditions.
• Families, children and young people.
• Working age people (including those recently retired and students).
• People whose circumstances may make them vulnerable.
• People experiencing poor mental health (including people with dementia).

Inspectors look for ways in which practices have been particularly responsive to these groups. For example:

• Offering appointments outside normal working hours, including Saturday mornings.
• Working collaboratively with other providers to improve access to specialist services such as psychological therapies.²

After an inspection
Following an inspection a draft report is produced and the practice will be rated outstanding, good, requires improvement, or inadequate. At this stage the draft report will be scrutinised by a quality assurance panel to ensure fairness and consistency. The practice then has an opportunity to check the draft report for factual accuracy. The final report and the practice rating are published on the CQC website and the practice must display its ratings.
Findings from the inspections undertaken to 31 May 2015 are reviewed in the CQC’s report The state of healthcare and adult social care in England 2014/15.2 While 85% of practices inspected were rated good or outstanding, some providers fell short of the required standards. Eleven per cent were rated as requiring improvement, and 4% were inadequate. Where patients were deemed to be at risk, the CQC acted swiftly to close practices.
It is no coincidence that the practices rated good or outstanding also tended to score highly in relation to leadership. A practice that is well-led is therefore likely to be one that is safe, effective, caring and responsive. Strong leadership from practice managers as well as clinical staff is vital if practices are to provide the best possible patient-centred care, support and develop staff, and engage with local stakeholders and the wider community.
Outstanding practices prioritise quality and safety. In its report, the CQC summarised some of its findings from practices that were rated outstanding.² These included:

• Effective leadership, creating a strong patient-centred culture.
• An emphasis on patient safety among all practice staff.
• Effective team working across professions and other organisations.
• Services that empower patients to self-manage their long-term conditions.
• Support for carers.
• Involvement in community health initiatives.

The report’s examples
The report highlighted the work of two of the practices rated outstanding.
At Orchard Court Surgery in Darlington, staff all shared the same vision of quality and safety; for example, excellent systems were in place for reporting incidents, monitoring and learning from them, and constantly improving the service to patients. In addition there was a commitment to training and support for staff, as well as collaboration with other providers outside the practice.
 St Thomas Medical Group, Exeter, has taken a number of innovative approaches. These include the provision of a headache clinic on Saturday mornings, and enhancing the skills of practice nurses to enable them to provide complex dressings for patients with leg ulcers so that the patients do not have to travel across the city to access this service at the local hospital.
Practices rated as inadequate had a number of failings in common. These included:

• Ineffective leadership. For example, poor working relationships between the doctors and practice managers.
• A poor or absent culture of safety and learning. For example, failure to investigate and learn from significant incidents.
• Unsafe medicines management. For example, out-of-date vaccines and medicine fridges not kept at the correct temperature.
• Low numbers of practice nurse sessions.
• Relevant employment procedures not carried out, including failure to check qualifications, references, and registration with the appropriate professional bodies, as well as failing to obtain disclosure and barring checks for new and existing staff.
• Staff training found to be incomplete, or inadequate to equip people for their roles.

KLOEs
Many of the KLOEs and prompts underpinning the inspection areas relate to evidence of functioning systems and processes, together with related policies. These systems should not only be in place, they should be tested or checked on a regular basis. Staff should have a good understanding of the reasons behind the relevant policies, and why adherence to them is necessary to provide high-quality care and protect patients from harm. For example, one of the prompts relating to “reliable systems, processes and practices required to keep people safe” specifically asks: “Are there arrangements in place to safeguard adults and children from abuse that reflect relevant legislation and local requirements? Do staff understand their responsibilities and adhere to safeguarding policies and procedures?”¹
Clinical staff may be up-to-date with their safeguarding training and be conversant with policies relating to issues such as domestic violence. But reception and other non-clinical staff also need to be aware of their responsibilities and know what to do if a child or vulnerable adult discloses experience of abuse either in person or over the telephone.

Teamwork

Sharing relevant information with staff according to their roles and responsibilities will help ensure that they are able to contribute fully to the inspection process, and will know what will be expected of them both in advance of the inspection and on the day. This includes awareness of the documents, such as the Provider Information Return, requested by the CQC ahead of the inspection, and the potential areas for questioning: for example, policies, procedures, training schedules, audits, and the outcomes of investigations into serious incidents and complaints.
It is important that the practice can demonstrate a culture of continuous learning and improvement and that staff do not feel threatened or defensive if deficiencies or problems are raised by the inspectors. What matters is that difficult issues are handled effectively as and when they arise.
Thought should also be given to ways of capturing patients’ views and to the involvement of the patient participation group. This is an opportunity as well to review how the practice communicates with patients and ensures that information is accessible and provided in appropriate formats. An easily navigated, well maintained website can project the practice’s vision and values as well as giving up-to-date information about services and local health initiatives.
Going forward, we can expect to see changes in the way the CQC regulates and inspects general practice. It is likely that those practices rated good or outstanding will be inspected less often than those where there are concerns about the quality of care. The exact nature of the CQC’s inspection activity will be set out in its new strategy document that is due to be published in May 2016. Whatever the precise details, managers will continue to have a leading role in ensuring that their practices deliver “safe, effective, compassionate high quality care”⁴.

Anne Ward Platt, BA(Hons) PGCE, director, WP Medical & Professional Services Ltd.

References
1. Care Quality Commission. How the CQC regulates: NHS GP practices and out-of-hours services. Appendices to the provider handbook. Newcastle upon Tyne: Care Quality Commission, 2015.
2. Care Quality Commission. The state of health care and adult social care in England 2014/15. London: Her Majesty’s Stationery Office, 2015.
3. Care Quality Commission. How the CQC regulates: NHS GP practices and out-of-hours services. Provider Handbook. First published October 2014, Updated March 2015. Newcastle upon Tyne: Care Quality Commission, 2015.
4. Care Quality Commission. CQC’s strategy 2016 to 2021. Shaping the future: consultation document. January 2016. cqc.org.uk/2016strategy consultation. (Accessed 22 February 2016).