Health inequalities and health promotion |
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CC1 | New patients are offered a consultation to ascertain details of their past medical and family histories, social factors including occupation and lifestyle, medications and measurements of risk factors (for example, smoking, alcohol intake, blood pressure, height, weight and body mass index). Such consultations, suitably adapted, should be offered to newly registered children (to support delivery of the Child Health Promotion Programme). | Provider designed check. Evidence of implementation of checks. | 28 (93.3) | 2 (6.7) |
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CC2 | The provider has a system in place to collect information on the risk factors particular to their provider population. | Written policy regarding the recording of factors that put patients' health at risk, including stating where this information is recorded in case records. | 29 (96.7) | 1 (3.3) |
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Provider management |
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CC3 | The provider operates a system to ensure that a named healthcare professional can be contacted promptly in the case of emergency. | Written evidence that the provider operates a system to ensure that a named, appropriately qualified, healthcare professional can be contacted promptly in the case of emergency. This should include a rota identifying the healthcare professional who is available to deal with an emergency. The professional could be a doctor or nurse, or in certain circumstances the ambulance service. A flow chart or decision-making tool should make the system clear to all team members and should give information on what to do if any mobile communication is not responding. | 28 (93.3) | 2 (6.7) |
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CC4 | The provider has a written policy for informing patients or, where appropriate, families and carers, of the results of investigations, and the policy is explained to them. | Written policy including how the patient can obtain the results of investigations carried out by the provider; for example, patient information leaflet; website (hyperlink may be submitted as evidence); notice on wall. This information is up to date, revised when changes occur, and reviewed every 12 months. This policy may state that the provider contacts the patient or vice versa. The time and method of contact should be stated. If the patient is contacting the provider, then it should be clear who is likely to give out the result. It needs to be clear how patients are made aware of the contents of the policy when an investigation is carried out. These instructions about the policy may be verbal or written. | 23 (76.7) | 7 (23.3) |
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CC5 | The provider operates a policy regarding the management of patient care following discharge from hospital, which includes reviewing any amendments to medication. | Written policy covering all patients including children and young people: evidence of implementation and follow-up. | 25 (83.3) | 5 (16.7) |
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CC6 | Non-collection of prescriptions held by the provider are monitored and followed-up by the provider. | Written policy; checked by a clinician. Evidence of implementation and follow-up. | 25 (83.3) | 5 (16.7) |
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CC7 | An arrangement exists for private discussion between patients and non-clinical team members. | Written description of arrangement; inspection of premises. | 29 (96.7) | 1 (3.3) |
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CC8 | The confidentiality of patient data is respected by the whole team. | (1) Written provider policy on patient confidentiality; (2) written description of storage of patient medical records including evidence that medical records are not stored or left visible in areas where members of the public have unrestricted access; inspection of premises; (3) level of access to computerised access — password protection for different team members; (4) written policy for shredding any patient details/letters once they have been scanned/dealt with; (5) asking staff about how they maintain confidentiality. | 29 (96.7) | 1 (3.3) |
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Premises, equipment, records, and medicines management |
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CC9 | The provider keeps a record or log of their minor operations which will have the following information recorded: (1) date; (2) patient name; (3) procedure performed; (4) whether a specimen was sent for histology; (5) patient consent; (6) complications; (7) patient informed of result. | Minor surgery template or written policy; informed consent. Evidence of implementation and follow-up. | 24 (80) | 6 (20) |
CC10 | The provider will appraise the premises, listing the strengths and weaknesses of the current arrangements and changes they would like to make to improve the working environment including safety and patient care. | An annual written provider premises improvement plan listing the strengths and weaknesses of the current arrangements and changes they would like to make to improve the working environment and patient care, including access for specific groups (that is, disabled access), with set objectives and methods. Evidence of implementation and follow-up. | 18 (60) | 12 (40) |
CC11 | The provider will appraise all medical equipment to ensure that it is up to date, listing the strengths and weaknesses of the current arrangements and changes they would like to make. | There is an up-to-date inventory list detailing which items of basic medical equipment must always be based on site for that provider (as justified by the provider), and all equipment is up to date and present or revised/renewed when changes occur and reviewed every 12 months. Evidence of implementation and follow-up. | 25(83.3) | 5 (16.7) |
CC12 | The premises are clean, temperature regulated, well lit and well maintained. | Patient user group. Evidence of implementation and follow-up of any quality deficits. | 19 (63.3) | 11 (36.7) |
CC13 | All drugs in the emergency bag(s) and stock room are within expiry date. | Written policy on supplying and checking all emergency bags and stock room drugs including CDs. Evidence of implementation and follow-up. | 27 (90) | 3 (10) |
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Provider teams |
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CC14 | All first-contact team members have been trained to recognise and respond appropriately to urgent medical matters. | Written evidence that all first-contact team members have received training in last 12 months or at induction. Review of training materials. | 20 (66.7) | 10 (33.3) |
CC15 | A first-contact team member trained to recognise and respond appropriately for basic life support is always available. | Written monthly team member rota showing that there is always at least one person on the premises competent in basic life support, who has attended training/updating in basic life support skills in the preceding 18 months. | 28 (93.3) | 2 (6.70 |
CC16 | The provider will ensure that all team members employed by the provider are competent and have appropriate qualifications and training, and that all health professionals are currently registered with the relevant regulatory body on the appropriate part(s) of its register(s). | Evidence of qualifications and references. Instructions on how registration is checked. | 24 (80) | 6 (20) |
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CC17 | All members of the team are suitably trained and only carry out treatments that are within their competence. | Written description of the system(s) available to healthcare team members for demonstrating and maintaining professional competence, for example, appraisal, clinical supervision, preceptorship, reflection on provider. Team members asked about their experience. | 26 (86.7) | 4 (13.3) |
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CC18 | All team members have training at induction and are refreshed 3 yearly on the principles of the Data Protection Act. | Copy of written team member induction policy; written evidence of team member training dates either as part of appraisal or log of team member training dates. Team members asked about their experience. | 20 (66.7) | 10 (33.3) |
CC19 | All provider team members maintain patient confidentiality at all times and have signed a confidentiality agreement. | (1) Written provider policy on patient confidentiality; (2) confidentiality clause in all contracts of employment; (3) all team members have signed a confidentiality agreement/clause; (4) evidence that patient confidentiality forms part of the induction training; (5) question team members about confidentiality. | 30 (100) | – |
CC20 | There is a written policy for ensuring team members offering new patient checks are trained in recognising actionable findings and taking relevant action. | Evidence of written policy, set objectives, and implementation and follow-up. | 22 (73.3) | 8 (26.7) |
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Learning organisation |
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CC21 | The team identifies possible health and safety risks to team members, takes steps to minimise them, and has policies in place for responding when/if adverse events occur. | Written policy of latest team member risk assessment and actions taken in response. Evidence of implementation and follow-up. | 20 (66.7) | 10 (33.3) |
CC22 | The team identifies possible health and safety risks to patients and takes steps to minimise them, and has policies in place for responding when adverse events occur. | Written policy of latest patient risk assessment and actions taken in response. Evidence of implementation and follow-up. | 20 (66.7) | 10 (33.3) |
CC23 | The provider operates a policy to identify and learn from all patient safety incidents and significant events and to share learning points with all team members and also outside agencies who were stakeholders in the event. | Three examples of events (significant event, yellow card report, drug alert) for which there is evidence of shared learning (for example, pharmacist). Evidence of implementation such as a case discussion with learning points and follow-up. | 28 (93.3) | 2 (6.70 |
CC24 | The provider produces an annual development plan that contains clear objectives and timescales and takes account of their local delivery plan. | 2–3 written objectives for quality improvement set by the provider or which there is evidence (which includes evidence taken from aof range of patients using the provider) of a pre-existing quality deficit. | 19 (63.3) | 11 (36.7) |
CC25 | The provider has a written quality-improvement strategy for clinical governance which enables quality assurance of its services and promotes quality improvement and enhanced patient safety. | At least quarterly meetings about quality improvement; written agenda and minutes; set objectives; named people responsible for meeting objectives. Evidence that objectives are met. | 23 (76.7) | 7 (23.3) |
CC26 | The team works with other agencies, groups and the community to help improve local public health, prevent disease, and promote the health of their patients. | Description of two examples annually where the provider has worked with others to improve local public health, prevent disease, or promote the health of their patients. | 22 (73.2) | 8 (26.7) |
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Patient experience and involvement |
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CC27 | Patients are informed of the arrangements for care outside normal contractual opening hours. | (1) Written policy displayed in the provider premises and covered in detail in the patient information leaflet or website (hyperlink may be submitted as evidence); information provided in a format that is accessible to all patients; (2) up-to-date, revised when changes occur and reviewed every 12 months. Evidence of implementation and follow-up. | 28 (93.3) | 2 (6.70) |
CC28 | Interpersonal continuity of patient care is made a priority when booking appointments, or patients are asked who is their usual doctor and offered an appointment with that doctor whenever possible. | Written policy aligned to written evidence (that is, team member training log or annual appraisal) of team member training. Evidence of implementation. | 24 (80) | 6 (20) |
CC29 | Relevant information is provided to patients about provider opening hours and appointment availability standards. | (1) Patient information leaflet; website; notice on wall; (2) up-to-date. Evidence of implementation and follow-up. | 25 (83.3) | 5 (16.7) |
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CC30 | Relevant information is provided to patients about arrangements for contacting team members directly. | Patient information leaflet; website (hyperlink may be submitted as evidence); notice on wall; information includes opening hours; telephone access opening hours; rota; flow chart; decision-making tool. Evidence of implementation and follow-up. | 28 (93.3) | 2 (6.7) |