Be sure to showcase your contribution to patient care
The role of the Care Quality Commission is to regulate providers of health and social care
The role of the Care Quality Commission is to regulate providers of health and social care.
The Health and Social Care Act 2008 was amended in 2015 with the introduction of fundamental standards (see panel below). These reflect the recommendations made by Sir Robert Francis following his inquiry into care at Mid Staffordshire NHS Foundation Trust.
My role at the CQC is national adviser for practice nursing. The aim of this role is to ensure practice nursing is given the appropriate level of attention during the inspection process.
Nurses are central to the team delivering primary care. It is important that the professional risk associated with the autonomy of the practice nursing role is understood as well as the underpinning support required by the employer. The model that the CQC uses to ensure the provider is providing high quality care is to ask five questions of services: are they safe, effective, caring, responsive and well-led?
The five quality of care questions
Are services safe?
Covers the practice’s management of risk, including:
- Significant event management
- Medicine and equipment alerts
- Recruitment processes
- Infection prevention and control
- Medicines management
- Health and safety
Are services effective?
Covers clinical outcomes and services offered to patients. For example:
- Relevant evidence-based guidelines
- Measurable outcomes
- Staff training and updating
- Co-ordination of care
- Health promotion
Are services caring?
Covers evidence for dignity and compassion. This involves:
- Observation of verbal communication between staff and patients such as in the waiting room and on the telephone
- Patient survey results
- Support for patients, such as referral to other services
- Support for, and identification of, those with a caring responsibility
Are services responsive to people's needs?
- Examination of where and how the practice has organised services:
- Are the premises and facilities appropriate?
- Flexibility of, and access to, appointments
- How are services tailored to the needs of the local population?
- Listening and learning from complaints
Are services well-led?
- Covers whether the leadership and governance of the practice ensure high-quality, person-centred care:
- Staffing structure, roles and responsibilities
- Communication and duty of candour
- Feedback from staff and patients
- Continuous improvement
The CQC has published just over 3,000 inspection reports since it launched its approach to inspecting GP practices in October 2014; 83% of practices it has inspected are providing a good or outstanding standard of care (see panel below). Most practices provide good care, but a small number of concerning cases of poor care have emerged. We found a strong link between good leadership and good care, and likewise between poor leadership and poor care.
Outstanding practices have:
- A strong, shared vision by practice staff.
- Effective staff training and support.
- Effective working practices with multiprofessional colleagues, including other organisations.
- A positive, patient-centred culture.
- Additional clinical services and empower patients to self-manage long-term conditions.
- Support for patients and carers with emotional needs.
Inadequate care can be due to:
- Disregard for human relations processes.
- Poor systems for quality improvement and assurance of clinical care.
- Unsafe medicines management.
- Limited access to appointments.
- Lack of practice nurses or low numbers of nurse sessions.
Most nurses provide excellent care in a challenging and pressured environment. Many practices report problems trying to recruit practice nurses, and demand for services is growing in quantity and complexity of need.
The following are themes that have emerged where there is a lack of support for the nurses, leading to safety concerns:
- Lack of infection control procedures.
- Poor practice with condition and storage of emergency equipment and medicines.
- No effective system for managing the cold chain.
- Unable to demonstrate training and updating for extended roles such as long-term conditions and first contact care of patients with undifferentiated conditions.
- Administering medicines without an appropriate legal framework.
We also see many examples of nursing innovation and excellence in care delivery for the practice’s population, such as:
- Engaging with the community to improve uptake of services.
- Training and mentorship for new practice nurses and undergraduate nursing students.
- Identification of gaps in services and tailoring them such as in-house leg ulcer services, Saturday vaccination clinics, support for patients recovering from, or who have been cured of, cancer who would otherwise fall through the net.
- Extra support for those with a long-term condition and literacy problems.
- Case finding, such as for chronic obstructive pulmonary disease.
I urge practice nurses to take an active part in the CQC inspection and showcase the value of their contribution to patient care. If possible, they should attend initial meetings between practice staff and inspection teams to discuss their role. Time could be set aside to talk to inspectors and practice nurses should be prepared to demonstrate the impact of their work, such as in reduced admissions and new diagnoses of diabetes.
Results of the CQC programme and the Health and Social Care Act fundamental standards are shown below.
As of March 18 2016, the Care Quality Commission (CQC) had published 3,159 inspection reports since it launched its approach to inspecting general practices in October 2014. As the chart shows, 83.7% of general practices inspected by the CQC are providing a ‘good’ or ‘outstanding’ standard of care
Health and Social Care Act fundamental standards
Patients’ needs must be met, and patients must be treated with dignity and respect.
Patients must give consent to care or treatment.
Providers must assess the risks to patients’ health and safety, and staff must have the relevant qualifications, competence, skills and experience.
Patients must be safeguarded from abuse and must not experience neglect, degrading treatment, unnecessary or disproportionate restraint, or inappropriate limits to freedom.
Food and drink
Patients must have enough to eat and drink.
Premises and equipment
Care settings and equipment must be clean and suitable, kept secure, and used properly.
Patients must be able to complain about their care. Care providers must have systems to handle and respond to complaints. They must investigate thoroughly and take action if problems are identified.
Care providers must ensure they can meet these standards, and provide effective governance and systems to check on the quality and safety of care.
Care providers must have enough suitably qualified, competent and experienced staff to meet these standards.
Duty of candour
Care providers must be open and transparent.
Display of ratings
Care providers must display their Care Quality Commission ratings where they can be seen by patients.
Elaine Bisco is Care Quality Commission national practice nursing adviser
There are many helpful resources for practices. Visit the CQC site for links to mythbusters and the outstanding practice toolkit.