The Caring KLOE is the shortest of all key lines of enquiry, but arguably the one with most impact on the patients and their families/carers. It’s also the one where no practice will ever feel they fall short of 100% compliance.

Experience leads those involved in inspections to recognise that a culture of caring is something that is obvious within a very short time of arrival in a surgery. You only have to listen to reception staff on the telephone or dealing with patients at the desk to determine whether they have customer care skills or see themselves as gatekeepers whose sole task is to ensure “none shall pass”.  The reception staff are almost exclusively the first point of contact with the practice and if they are fully absorbed into the paradigm of the practice (the way things are done around here) then they will reflect it for all to see. Hopefully it will be good rather than bad!

The Caring KLOE looks to the practice to have care as the basis of everything it does, to treat people with “compassion, kindness, dignity and respect”. It is firmly targeted at practice staff at every level and in all roles.

Compassion, Dignity and Kindness

Every inspection will take time to look at what is a very easy indicator – chaperoning and intimate examinations. Staff properly trained and DBS checked to be a chaperone gives an easy win. However, checking that the chaperone puts their own entry on the clinical system to verify they were there and nothing untoward happened is something often overlooked. Use of a room where people may want to enter during an examination (the issue of where the Emergency drugs and oxygen/defibrillator are kept has already been discussed earlier), the absence of privacy curtains or where the chaperone stands are all obvious but sometimes missed. Take a look at the Chaperone Policy[PLUS] for supporting guidance which can be adopted for use in your practice.

How staff respond to people in distress is another area to be aware of. Distress may be caused through pain, or the significant emotional nature of information that is being passed over, or it could be emotional distress caused by social issues or mental health. Dealing with bereavement or bad news in a caring way does not always come easily to non-clinical staff and training is available to assist.

It would be hoped that clinical staff do have the skills to deal with patients in significant pain or with mental health problems, but it is not always the case.  Should there be a complaint in the system on this issue, it is quite likely to be picked up and questioned, especially about what has been done to resolve the issue for the future – so better for it not to have happened in the first place.

Privacy

On the basis that it is caring to respect the privacy of patients in areas such as clinical records, there is a clear need for a robust policy – widely disseminated to all the staff through training – to give them the necessary information about what can be disclosed, when and to whom. This is another favourite inspection topic. The Practice Privacy Policy [PLUS] illustrates your approach to privacy (this is also available for practices in Northern Ireland, Scotland and Wales).

The advent of GDPR has widened the scope for disclosure and you can be reasonably sure that it will be tested out with staff on an inspection. Interviews with receptionists and secretaries (if the practice still has them and is not using type as you talk technology) will ask about what can be disclosed and observations at the patient counter will note if staff give out more information than they should.  Practice Index has a range of GDPR related information, such as policies, blogs, videos and eLearning. Take a look here to see what is available.

A note of caution here. Practices may be tempted to use relatives as interpreters and in some cases as chaperones. However, this poses significant risks to both the clinician and the patient when alone in a consultation with just a relative there. Some may be inclined without any warning to allege impropriety. Plus, in some cultures where FGM is an issue or where male dominance is the norm, interpretation may be what the relative wants to say and not what was actually said, or the patient may feel intimidated and unable to raise important issues.

Respect and Consideration

Practice staff should recognise personal and cultural needs for patients as individuals with specific requirements and be able to respect their wishes or be alert to what might be appropriate but not actually said.

Equality and diversity training is a good way to evidence that the practice recognises and tries to address the problem. The availability of online training, especially where it is combined with an effective management database showing who has been trained, when and on what date training is next due, can make any inspection much easier. The KLOE does however take patient needs one step further by requiring practice knowledge about an individual’s needs to be shared on referral to any external organisation.

Safeguarding is a recurring theme in KLOEs and it appears again in this section where staff at all levels and in all roles need to understand the impact of care on the patients or carers and recognise discrimination or abuse. Offering support to people quickly and at the time it is needed has to be demonstrated and this is an opportunity for the clued-up PM to wheel out the thank you letters or cards or to have the NHS Choices positive feedback printed out (but you may find that the clued-up Inspector already has got this freely available information – and it may not always be good!).

Good practices will have available a range of data, leaflets and contact numbers for organisations who are able to offer support to their patients. Having staff who know where that information can be found and who can demonstrate they know how to use it well does evidence a caring practice.

Communication

The caring practice tailors its approach to the individual, even though they may have systems and information in place to cover some issues that span different groups. The essence here is how they communicate effectively.

Any sort of advice can be communicated rapid-fire to one individual who will understand and absorb it. The next patient through the door may, however, have some impairment or condition that makes it necessary to give advice and/or support in a much simpler way or by different means (printed-off leaflets or advice sheets are a classic example).

Caring also carries a strong element of communication when involving patients, carers and families in planning care. Reassuring a patient that their care is taken seriously and that they are not just part of a conveyor belt system is part of the KLOE as well. Sharing decisions and information, listening to them, respecting their views and not dismissing their worries out of hand are all good practice. An Internal Communication policy[PLUS] has been produced and can be adopted by practices.

Conclusion

This series of articles has endeavoured to put the CQC Key Lines of Enquiry into a Practice Manager context. Rather than dealing with each one in turn and in detail – there is ample documentation available online for that – the series highlights some aspects which the Inspection Team are likely to want to look at in more depth.

Practices are learning what needs to be done each time an Inspector calls, but some themes still seem to recur and, regrettably, some partnerships or boards of directors will still not really have got the message. Mergers, federations and acquisitions will continue to complicate matters, especially where the less able individual practices have to make major moves forward to catch up with the rest.

Large organisations also have their troubles where frontline delivery can seem detached from the boards` aims and their span of control is too wide. Hence the CQC intention to build an inspection system that looks at what the centre thinks it is achieving, but then examines those intentions at the service delivery level.

As the CQC builds its expertise, more in-depth inspection is likely, probably thematic and certainly crossing the artificial boundaries of care that DevoManc is intended to abolish. The saying that “working in a practice would be great if it was not for the patients” should be banned, because if it was not for the patients no-one would be working there at all. Care standards are just that – standards! It is external interference and a lack of resources (including finance) that make it difficult for practices and not the standards themselves or the inspection system.

Helpful document for your CQC inspection: CQC guidance

Missed part of the series? Catch up with the rest of “The inspection insider” series here.