Mock CQC and the actions we’ve taken
NHC received CQC registration in October 2020 and, has been providing patient-facing services since then. We have yet to experience a formal CQC visit, but we conducted an internal mock CQC in August 2022 and another MOCK CQC assessment by an external expert in May 2023.
The CQC inspector interviewed Senior Leadership Team (SLT), board members and a few key office staff on the day. Following this was a hub visit on the 2nd of May and two more hub visits on the following Saturday during NHC’s service operation time.
The mock inspection highlighted some areas of improvement, particularly around infection prevention control (IPC), clinical and management. The CQC inspector made some recommendations and we have taken most actions to address these, with continuous monitoring set up for many items.
Key findings from the MOCK CQC are listed below.
NHC has a sound HR system that can disseminate this learning and share good practices as an update with member practices. All workforce training matrix was well managed, and HR was following up on gaps in a systematic manner.
NHC received recommendations for improvements in the following areas
1) NHC needs to ensure that IPC standards are maintained and compliant at all sites
2) Small appliance calibration and PAT testing must be within a valid date.
3) Clear understanding between NHC and the hub practices about IPC, cold chain maintenance, access to the emergency medicine trolley and overall health and safety assessment.
4) Suggestion to improve a few policies, i.e Business Continuity Plan, and have a new policy on patient DNA management and CCTV where appropriate.
5) To ensure GP practices are receiving and acknowledging those 2 week wait referrals that are getting passed back to the practice, having been unable to make contact with the patient to complete a referral for 2 week wait so that this is safety-netted.
Task and Finish Actions:
Following the CQC Inspector’s recommendation, we have taken around 30 actions for all the patient-facing services and the corporate team. We have completed the following actions with continuous monitoring set up.
- We have created monthly, quarterly, six-monthly, and yearly hub checklists to ensure IPC compliance, health, and safety at all the hub sites. Monthly Hub checklist to submit to Quality Committee: this list includes all IPC and building safety elements identified during the MOCK CQC visit.
- Monthly Hub visits by CQC registered manager to ensure CQC compliance.
- Reviewed Clinical governance framework and set up clinician admin and receptionist forum.
- Continuous quality improvement for complaints, Significant Event Analysis (SEA), learning events and incident reporting.
- Monitor HR, finance, and all service activity data through the monthly balance scorecard data. Continuous review of the balanced score card data improves data reporting to monthly QC, SLT and the NHC Board.
- Learning, sharing and evidencing for learning events, complaints and significant events
- Continuous updates and monitoring CQC evidence on the clarity team portal
