The Safety KLOE has arguably undergone the most change in the new inspection regime – and more than likely reflects the results from the first round of inspections where safety issues were not found to be either well-applied or consistent.
Safety here applies to patients and service users and as would be expected, the issues of safeguarding for both children and adults is particularly emphasised, as are the emerging issues of inter-agency and primary-secondary care co-operation that ensures continuing safe treatment for patients.
Protection of service users from physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse is always going to be a principal line of enquiry taken on an Inspection. A practice need not only show it has the proper policies in place (policies that are specific for the practice and not just simply the generic Safeguarding Board policy) but also that it takes the topic seriously (training), plays its part (by providing necessary reports on time and attending meetings where needed) and can demonstrate all appropriate actions have been taken (producing examples of cases where safeguarding has been recognise as an issue – even though there may not have been any formal referral resulting).
Monitoring what happens in a practice has been emphasised as part of well-led, and here is a prime example where a practice can demonstrate one activity covering two KLOEs. Having a clear nominated lead(s) for safeguarding and those leads making sure actions are carried out and followed through, as well as showing staff are generally alert and identifying issues, is always good evidence. The changes in this section are quite extensive so being aware of them and reading the guidance is a strong recommendation. A Safeguarding Policy [PLUS] is available here.
Training is highlighted throughout many of the KLOEs and again safety is no exception. This includes quality training to reduce the risk of discrimination, on time and right level safeguarding training for everyone and, of course, infection control relating not only to hygiene but also to managing waste and clinical specimens. The stories of urine samples arriving over the counter in marmalade jars and stool samples in Quality Street tins are the stuff of legend, but showing staff are trained how to deal with those situations and how to use spill kits is again good evidence. Saying that staff should be able to use their common sense has never been an acceptable response.
Safety-related training also includes ensuring staff have the right skills to enable them to deliver safe treatment, recognise when conditions are deteriorating (progressive dementia or diabetes are the first conditions that come to mind) and awareness of the effects and issues with prescribed medication (so that proper advice can be given and monitoring to detect excessive or improper use) are some of the areas to cover. Training of chaperones will be in this section – it’s surprising how often a `trained` chaperone will say they only stand outside the curtain or just by the patients` head!
One important training point remains – infection prevention and control training, especially for whoever in the practice is charged with responsibility for IPC in the practice. The individual must be trained to a level of competence that enables them to complete the annual audit and ensure actions identified are taken. IPC training for all staff is also a must and having all training records available for an inspection will save considerable time and anxiety.
There is a range of information available regarding training:
Staff Development Policy [PLUS]
Along with lots more online training available on the HUB.
Medical supplies and equipment
PMs will, by now, all be aware that there has been a consistent theme of checking the security and issue of prescriptions during inspections. Locked printer trays, removal of cut-sheet prescriptions into locked drawers at night and records of issue are often checked (does everyone know that cut-sheet scripts have consecutive serial numbers? The last digit of the number needs to be disregarded and then the sequence becomes obvious!). Current guidance can be found in the Prescribing Policy[PLUS].
Medicine safety has similarly had a major overhaul and the emphasis is on monitoring and checking safety issues. Storage and disposal of material such as oxygen cylinders (in a room with the appropriate hazard warning on the door), liquid nitrogen (decanting or purchase of single-use canisters) and emergency medicines or defibrillators (secure but quickly available i.e. not in a treatment room where access might interrupt an intimate procedure) are all looked at by inspectors. The following guidance/policies will prove useful (all are PLUS documents): Emergency Drugs Monitoring Policy, Emergency Equipment Checklist, Liquid Nitrogen Policy, Medical Device Management Policy, Medicines & Medical Gases Storage Policy.
Does the practice check that patients pick up prescriptions? The introduction of EPT makes this rather problematical, but on inspections it is still a regular occurrence that printed scripts, up to six months old, are found in the `pick-up box`. While finding one for paracetamol might not be too much of an issue, one for an anti-psychotic or psychotropic medication or controlled drug will ring alarm bells.
On the topic of medication, the practice needs to also be clear that they have access to the latest guidance and follow it. Inappropriate prescribing or failing to record what condition a prescription is for and why will also be part of the inspection carried out by the GP Specialist Assessor. Medication reviews must always be done by the most appropriate person and recorded in the clinical notes.
Learning about safety issues
Significant events (as well as complaints, which are covered elsewhere in this series) should generate institutional learning, which needs to be embedded across the organisation. This also ties in with the Well-Led KLOEs. Staff at every level need to be risk and hazard-aware – should they come across any issue that could be defined as a Significant Event (does your policy define for them what an Event is?) they know what to do. Inspection teams will often take time to speak to staff to test their knowledge and to see if they have ever generated an Event, as well as check that they are involved in the discussion or at least advised of the learning points in each case.
Are practice Event meetings inclusive of all staff roles and the issues comprehensively investigated? And can the practice prove it? When changes are made does the relevant policy/protocol receive an update? And does anyone check some time down the line that those changes are being applied across the board? These are two areas where practices often struggle to demonstrate safety. Learning from the mistakes of others also falls into this category and comparing the safety track record of a practice against its` peers makes good use of shared learning opportunities.
General safety issues
Staffing issues have a safety constituent that can often be overlooked. Having the right number of staff, properly trained and with a contingency plan for absences, forms part of the KLOE. A practice that has a staffing plan, with the risks to patient safety having been assessed and staffing monitored against the plan, is well on the way to a good assessment.
The availability of good quality information to enable staff to properly deal with patients is also a safety issue. Again, one of the areas where practices sometimes need to improve is in the way they bring information into the surgery and ensure the `right` people see it. Covered under this heading is having a system to pick up CAS alerts/NICE guidance and similar information that ensures someone (and a deputy) is responsible for receiving the data, passing it to whoever needs it (which may be a clinician tasked in reviewing the contents and whether the practice needs to change its procedures) and also ensuring it is disseminated as appropriate. The use of back-office software that registers when someone has read what they been sent or consistent use and follow-up of emails with read-receipts attached are simple ways to monitor compliance. The Central Alerting System Policy [PLUS] can help here.
Information is also a two-way flow and the KLOE looks for practices having systems in place that ensure not only incoming patient data is processed effectively (test results; discharges; A&E reports etc being reviewed by a competent person and attached to the clinical records) but also how information is sent out by the practice. Included in this area will be referrals that contain all the information necessary for the receiving organisation to deal with the issue and are timely so that shared care is effective. Use the Correspondence Management and Management of Incoming Pathology Results policies [PLUS] to ensure compliance.
Finally, the practice is required to maintain proper clinical records which are legible, accessible and usable by others, an issue that sometimes gives the GP Assessor problems when viewing incomplete consultation records or understanding what the author is trying to convey.
Missed part of the series? Catch up with the rest of “The inspection insider” series here.
Helpful: Practice Index has worked with the Clinical Audit Support Centre to develop a barometer that allows practices to quickly assess their current level of competency in the area of significant event audit. It takes five minutes to complete and should provide a useful insight into how your practice supports patient safety and managing incidents, in comparison to best practice and CQC expectations. Click here to access.
Further useful document for your CQC inspection: CQC guidance
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