Docstoc

Apology Letter Templates 1eb8ec1c 8429 41f1 912b 090b180abaf2 xls

Document Sample
Apology Letter Templates 1eb8ec1c 8429 41f1 912b 090b180abaf2 xls Powered By Docstoc
					                                                1eb8ec1c-8429-41f1-912b-090b180abaf2.xls


                                                                                                              Last/next
                                                                                                              audit/review
      Standard/Criteria                      Reference document for information            Where to find it   date

1     ACCESSIBILITY
      Patients are able to obtain the services of the team at appropriate times and without undue delay

1.1   Demand and capacity
      The service has assessed the
      demand for their services and has
      planned capacity to respond to it.

1.2   Urgent appointments
      Patients who have, or consider they
      have, an urgent problem can be
      clinically assessed the same working
      day.

1.3   Emergencies
        A system is in place to allow
        emergency problems to be dealt
        with immediately and
a)      appropriately.
        The service staff understand the
        system for responding to
b)      emergencies.

         The service staff have received
         appropriate training in managing
         emergencies including basic life
c)       support skills.




                                                             1 Accessibility                                                 Page 1
                                               1eb8ec1c-8429-41f1-912b-090b180abaf2.xls

         The service has a system to
         ensure that a doctor can be
         contacted promptly in the case of
d)       emergency.

1.4   Routine appointments
         Patients with routine matters are
        normally seen within two working
        days by any doctor or nurse, and
        within seven working days by a
a)      chosen doctor or nurse.

         The average length of booked
         appointments with the doctors and
         nurses in the service is not less
         than 10 minutes. (At least 7.5
b)       minutes face to face contact).
         The service has a system for
         monitoring the availability of
         appointments and waiting times,
         which aims to identify and correct
c)       significant delays.

1.5   Telephone Access

         The service has sufficient
         telephone lines and staff to answer
a)       them to meet anticipated demand.
         Patients can contact a doctor or
         nurse by telephone at some time
b)       during the day.

1.6   Waiting in the waiting room


                                                            1 Accessibility               Page 2
                                                1eb8ec1c-8429-41f1-912b-090b180abaf2.xls



      Patients are not kept waiting
      unnecessarily in the surgery and are
      informed of the reasons for any delay.

1.7   Continuity of care
        The Service has a clear policy
        which encourages continuity of
a)      care.
        There are rotas for doctors, nurses
        and service staff that ensure that
        an adequate service can be
b)      provided at all times.

1.8   Home visiting
        Patients are visited at home if their
        condition so requires at the
a)      discretion of the clinician.


1.9   Out of hours care
        The service has a system to allow
        patients to contact the duty doctor
        out of hours, normally by making
        no more than two telephone calls
a)      to do so.

         If an answering system is used the
         message is clear and the contact
b)       number is given at least twice.




                                                             1 Accessibility               Page 3
                                                   1eb8ec1c-8429-41f1-912b-090b180abaf2.xls



         The service has an effective
         system for transferring and acting
         on information about patients seen
c)       by other doctors out of hours.
         The service only uses a GP co-
         operative or deputising service
         where it is assured that high
         standards of care are provided
         (e.g. demonstrated by monitoring
         of access times, types of doctor
d)       employed)
         There are working links with out of
         hours community nurses, mental
         health teams and social work
e)       departments.

1.1   1.10 Registration and removals
         The service does not discriminate
         on the grounds of race, gender,
         social class, age, religion, disability
         or medical condition when
         accepting patients requesting to
a)       join its list.
         If a patient is removed from a
         service‟s list it provides an
         explanation of the reasons in
b)       writing to the patient.




                                                                1 Accessibility               Page 4
                                                   1eb8ec1c-8429-41f1-912b-090b180abaf2.xls



                                                                                                                 Last/next
      Standard/Criteria                       Reference document for information              Where to find it   audit/review date

2     AVAILABILITY OF INFORMATION
      The team communicates openly with patients and encourages patients’ choice and autonomy

2.1   2.1 Service leaflet
         The service provides patients with
         a leaflet that describes the
         services provided by all members
         of the team and how patients can
a)       access them.
         There is a statement that
         describes patients‟ rights and
b)       responsibilities.

2.2   Notices and displays
      Notices and educational displays for
      patients in the surgery convey clear
      and informative and helpful
      messages and are up to date.

2.3   Other sources of information
        Information leaflets on a range of
        topics and health promotion
        literature are readily available to
a)      patients and are up to date.
        Patients are encouraged to
        access other sources of good
        quality information, for example
        the National Electronic Library for
b)      Health.

                                                           2 Availability of Information                                   Page 5
                                                1eb8ec1c-8429-41f1-912b-090b180abaf2.xls



2.4   Other agencies
      The service has available up to date
      information for patients about
      national and local self help groups
      and support services for each of the
      major care groups including children,
      mental illness, women‟s health,
      cancer, chronic illnesses, and
      disability.

2.5   Communication Difficulties

      If the team serves significant groups
      requiring assistance with
      communication, interpreter services
      and translated literature is available.




                                                        2 Availability of Information      Page 6
                                                1eb8ec1c-8429-41f1-912b-090b180abaf2.xls


                                                                                                              Last/next
                                                                                                              audit/review
      Standard/Criteria                               Reference document for information   Where to find it   date

3     MANAGEMENT OF ILLNESS
      The team manages patients with chronic diseases in line with modern medical opinion and guidelines

3.1   Protocols
      The team has adopted protocols for the
      management of chronic diseases which are
      used to guide the care that they provide,
      including I. Asthma II. Diabetes III.
      Hypertension IV. CHD V. Stroke VI. At
      least one other (e.g. COPD, Heart failure,
a)    Atrial fibrillation, Epilepsy)
      These protocols are evidence based,
      compatible with national and local guidelines
      and requirements, and are reviewed at
b)    regular intervals.

3.2   Registers
        The service maintains up to date and
        complete registers of patients with these
a)      chronic diseases.
        There are agreed definitions for entering
b)      data.
        There are effective mechanisms that
        ensure that the disease register is
c)      updated and complete.


3.3   Guidelines for service



                                                          3 Management of Illness                                  Page 7
                                                    1eb8ec1c-8429-41f1-912b-090b180abaf2.xls

         The service identifies patients with
         ischaemic heart disease and offers them
         appropriate advice and treatment
a)       according to the service protocol.

         The service identifies patients at high risk
         of developing heart disease and offers
b)       them appropriate advice and treatment.
         The service identifies patients at risk of
         stroke because of high blood pressure,
         atrial fibrillation or other risk factors, and
c)       manages them appropriately.
         The service identifies patients with
         transient ischaemic attack or stroke, and
         ensures that they are managed according
d)       to locally agreed protocols.

3.4   Diabetes
      The service ensures that patients with diabetes:
           Are reviewed at least annually and are
           managed according to the service
a)         protocol.
            Have good glycaemic control, as
b)         measured by their HbA1c
           Have their other risk factors assessed
c)         and controlled
           Have an annual check of their eyes by
d)         a suitably trained person.

3.5   Asthma
      Patients with asthma on treatment are
      reviewed annually and are offered
      appropriate supportive education according
      to the service protocol.
                                                             3 Management of Illness           Page 8
                                                   1eb8ec1c-8429-41f1-912b-090b180abaf2.xls



3.6    Patient education and involvement
       Patients with chronic diseases are offered
       appropriate education and advice to enable
       them to be involved in their care and to
       control their disease and reduce associated
       risk factors.


3.7    Support for patients and carers
       Patients and carers are given information
       about appropriate self-help and support
       groups.

3.8    Primary/ secondary care communication
       There is effective communication between
       the team and hospitals and other
       professionals caring for their patients.

3.9    Records

       Clinical data for patients with chronic disease
       is entered in any structured records,
       computer templates or patient held records
       that have been adopted for local use.

3.10   Audit
       The service regularly audits the care of
       patients with chronic diseases using the
       criteria in their protocols.




                                                            3 Management of Illness           Page 9
                                                     1eb8ec1c-8429-41f1-912b-090b180abaf2.xls


                                                                                                                 Last/next
                                                                                                                 audit/review
      Standard/Criteria                                 Reference document for information      Where to find it date

4     MEDICINES MANAGEMENT
      The team ensures high quality, effective prescribing and involves patients in the appropriate use of medicines.

4.1   Prescribing
      The professionals in the team prescribe
      effectively and economically, and in line with
      published evidence

4.2   Repeat prescribing
        Arrangements for repeat prescribing
        ensure that all patients receiving regular
        medications are reviewed at intervals,
a)      and at least annually.
        Older people taking four or more
b)      medicines are reviewed six monthly.

         These reviews include the patients
         understanding and use of their
         medication, significant side effects, any
         appropriate monitoring, and a review of
c)       the need for continued treatment.

         Care is taken to ensure that the patient‟s
         clinical record and any patient held record
         accurately lists the medication the patient
d)       is currently receiving.


4.3   Patient information

                                                             4 Medicines Management                                  Page 10
                                                  1eb8ec1c-8429-41f1-912b-090b180abaf2.xls

      Patients are given information about the
      options for treatment, and involved in
a)    decisions about their treatment.
      Patients are informed about the medications
      that are prescribed to them including how to
      take them, the benefits and significant side
b)    effects.

4.4   Monitoring

      The service reviews its prescribing regularly,
      including adherence to their formulary,
      generic prescribing rates, and costs.

4.5   Controlled Drugs

      The service adheres to the requirements of
      the Misuse of Drugs Regulations 1985 and
      2001, for the storage, prescribing, recording
      and disposal of controlled drugs.

4.6   Nurse prescribing

         Those nurses in the team who prescribe
         have received appropriate training and
a)       are easily identified within the team.

         Details of any nursing prescriptions are
b)       entered into the patient‟s clinical record.
         All vaccines or other medication
         administered by the nurses in the service
         without an individual prescription are
         covered by a properly completed patient
c)       group directive.
                                                          4 Medicines Management             Page 11
                                                   1eb8ec1c-8429-41f1-912b-090b180abaf2.xls


                                                                                                               Last/next
                                                                                                               audit/review
      Standard/Criteria                               Reference document for information      Where to find it date

5     INVESTIGATIONS
      Investigations are used, and the results responded to, appropriately by the team.

5.1    Appropriate use
      The team has a policy for the appropriate
      use of investigations, including those for
      patients with chronic diseases and on
      regular medication.

5.2   Results
        There is an explicit and reliable system to
        receive any hospital report or
        investigation result, to identify the
        responsible doctor, and to ensure that
a)      any necessary action is taken.
         There is an explicit policy for informing
        patients of the results of their
b)      investigations.




                                                                5 Investigations                                  Page 12
                                                  1eb8ec1c-8429-41f1-912b-090b180abaf2.xls


                                                                                                                Last/next
                                                                                                                audit/review
      Standard/Criteria                               Reference document for information     Where to find it   date

6     REFERRALS
      Patients are referred to team members and to other agencies when appropriate.

6.1   Available services
      Patients can obtain a full range of Primary
      Care services if required, either from within
      the team, or by referral.

6.2   Cancer services
        Patients who have, or are suspected of
        having cancer are referred promptly,
        according to national and local guidelines
a)      and procedures.
        Patients who are referred under the “two
        week rule“ are informed of the
b)      significance of this procedure.
        The team ensures that patients
        diagnosed with cancer have been
        informed about the diagnosis, treatment
        plans, and follow up, and offered
        information about local and national
c)      support groups and services.

6.3   Referral letters
      Referrals are recorded, and copies of
      referral letters are kept in the patient‟s
a)    record.
      Patients are offered a copy of their referral
b)    letter.

                                                                 6 Referrals                                      Page 13
                                                 1eb8ec1c-8429-41f1-912b-090b180abaf2.xls



6.4   Hospital and other letters
      There is a reliable system for receiving all
      letters, reports and messages, identifying the
      responsible doctor and ensuring that the
      necessary action is taken.

6.5   Monitoring
      The service monitors and reviews its referral
      patterns, including urgent referrals.




                                                                6 Referrals                 Page 14
                                                     1eb8ec1c-8429-41f1-912b-090b180abaf2.xls


                                                                                                                   Last/next
                                                                                                                   audit/review
      Standard/Criteria                                  Reference document for information     Where to find it   date

7     PREVENTIVE CARE AND HEALTH PROMOTION
      The team identifies the health needs of their population, delivers appropriate preventive health services, and works

7.1   New patient checks

         Newly registered patients are offered a
         consultation to ascertain details of their
         past medical and family histories, social
         factors including occupation, lifestyle, and
a)       measurements of risk factors.
         Those findings are recorded in the
         medical records, and patients with
         significant medical conditions are
b)       reviewed.

7.2   Recording of lifestyle and risk factors
      The service collects information on the
      factors that put their patients‟ health at risk,
      including significant family history, smoking
      habit, exercise, alcohol intake and blood
      pressure.

7.3    Lifestyle advice
      Patients are given appropriate advice about
      general health and risk factors including
      smoking cessation and lifestyle.


7.4   Influenza vaccination

                                                           7 Preventive Care & Health Pro                             Page 15
                                                  1eb8ec1c-8429-41f1-912b-090b180abaf2.xls

      Patients over 65 years and those in other at-
      risk groups are offered influenza vaccination
      annually.

7.5   Health needs

         The team is aware of the health needs of
         their population and the priorities in their
a)       Local Health and Modernisation Plan.
         The team has adopted strategies to meet
b)       them.




                                                        7 Preventive Care & Health Pro       Page 16
                                                   1eb8ec1c-8429-41f1-912b-090b180abaf2.xls


                                                                                                                 Last/next
                                                                                                                 audit/review
      Standard/Criteria                               Reference document for information      Where to find it   date

8     CARE FOR CHILDREN
      The team provides comprehensive care for children, including immunisations, surveillance, and accessible care when

8.1   Child protection
        All clinical team members are aware of
        the local procedures for Child Protection
a)      and adhere to them.
        A member of the team is designated as
b)      Child Protection lead.
        Training in Child Protection is regularly
c)      updated for the lead and for the team.

8.2   Team care
      The roles of the GPs, service nurses,
      community children‟s nurses, school nurses
      and health visitors in providing care of
      children in the service, and the methods of
      communication between them, are defined
      and agreed.

8.3   Children Act
      The team has a policy for consent to
      treatment by children that conforms to the
      Children Act.




                                                              8 Care for Children                                    Page 17
                                                1eb8ec1c-8429-41f1-912b-090b180abaf2.xls


                                                                                                              Last/next
                                                                                                              audit/review
      Standard/Criteria                              Reference document for information    Where to find it   date

9     WOMEN’S HEALTH AND FAMILY PLANNING
      Women patients have access to a comprehensive service which meets accepted professional standards and their needs.


9.1   Cervical cytology
        Women are called and recalled for
        cervical cytology in accordance with local
a)      policies.

         There is an agreed policy for identifying
b)       and following up non-attendees.
         There is a reliable system for responding
         to and ensuring follow up of abnormal
c)       smears.
         Women are clearly informed of the way
         that they will obtain the result of their
d)       smear.

         Women are offered a choice of a female
e)       doctor/nurse to take their smear.
         Doctors and nurses taking smears will
         have received appropriate training and
f)       updating.
         The inadequate smear rate is audited
g)       regularly and responded to.




                                                     9 Womens Hlth & Family Planning                             Page 18
                                                1eb8ec1c-8429-41f1-912b-090b180abaf2.xls

         The service achieves an uptake rate of
         80% or more for those women registered
         with the service for two or more years and
         who have not signed a statement
h)       declining cervical cytology.


9.2   Family planning and sexual health

         The team ensures that women have
        access to a comprehensive range of
        family planning services. If some services
        are not available in the service women
a)      are informed how they can obtain them.
        The team ensures that family planning
        services are accessible and acceptable to
b)      teenagers.
        The team has an agreed policy for
        responding appropriately to requests for
c)      emergency contraception.
        The team has an agreed policy for
        prevention, investigation, management
        and referral for sexually transmitted
d)      diseases.

9.3   Rubella
      The rubella immune status of women of child-
      bearing age is established and recorded and
      those who require immunisation are offered
      it.


9.4   Breast screening


                                                      9 Womens Hlth & Family Planning      Page 19
                                                 1eb8ec1c-8429-41f1-912b-090b180abaf2.xls

      Women who do not attend for breast
      screening can be identified and are invited to
a)    do so.
      The service is aware of the rate of uptake of
b)    breast screening by their patients.


9.5    Menopause
      The team has a policy for advising and
      managing the care of women at the time of
      the menopause.




                                                       9 Womens Hlth & Family Planning      Page 20
         1eb8ec1c-8429-41f1-912b-090b180abaf2.xls




needs.




             9 Womens Hlth & Family Planning        Page 21
                                                  1eb8ec1c-8429-41f1-912b-090b180abaf2.xls



                                                                                                                Last/next
       Standard/Criteria                            Reference document for information       Where to find it   audit/review date

10     MATERNITY SERVICES
       Women receive maternity services that are based on informed patient choice, accepted professional service, and that

10.1   10.1 Antenatal care
          Ante-natal care and screening are
          offered according to current
          professional guidelines, such as the
          UKCC Midwives‟ Rules and NMC Code
a)        of Service.
          There is an agreed policy for the roles
          of the GP, community midwife, health
          visitor and hospital clinics in the
          provision of ante-natal and post-natal
          care and for communication between
b)        them.
          Women are fully informed and offered
          a choice about the place of their ante-
c)        natal care and delivery.
          Women and their partners have access
          to parent craft classes, and are
          informed about other local support
d)        groups.
           Women are encouraged to breast
e)        feed.

f)        The breast feeding rate is monitored.




                                                            10 Maternity Services                                       Page 22
                                                1eb8ec1c-8429-41f1-912b-090b180abaf2.xls



                                                                                                              Last/next
       Standard/Criteria                             Reference document for information    Where to find it   audit/review date

11     CONTINUED CARE IN THE HOME
       The team works with social services and other agencies to provide care and support in the community for patients and

11.1   Team care
         Patients requiring care in their home are
         assessed by members of the team and
         care is planned and provided to meet
a)       their needs.
         Patients and their carers are offered
         information and choice about the care
b)       they receive.
         The team works with social services and
         other agencies so that patients have a
         single assessment of needs, and well
c)       co-ordinated care.
         Team members together regularly
d)       review the care they are providing.
         The team has a system for identifying
         carers and ensures that carers receive
e)       appropriate support.




                                                        11 Continued Care in the Home                                Page 23
                                                 1eb8ec1c-8429-41f1-912b-090b180abaf2.xls




       Standard/Criteria                              Reference document for information         Where to find it

12     SERVICES FOR PEOPLE WITH DISABILITIES
       The team are aware of the needs of people with disabilities and ensure that they can access and receive a full range of services

12.1   Physical disability
       The service has taken all reasonable steps
       to remove any physical barriers to access in
       the service.

12.2   Sensory impairment
       The team has systems in place to assist
       patients with sensory impairment.

12.3   Learning disabilities.
       The team ensures that people with learning
       disabilities can access the full range of
       health services, including preventive
       services, to meet their needs.




                                                         12 People with Disabilities                                 Page 24
                            1eb8ec1c-8429-41f1-912b-090b180abaf2.xls



      Last/next
      audit/review date


a full range of services.




                                    12 People with Disabilities        Page 25
                                                 1eb8ec1c-8429-41f1-912b-090b180abaf2.xls


                                                                                                                 Last/next
                                                                                                                 audit/review
       Standard/Criteria                                 Reference document for information   Where to find it   date

13     SERVICES FOR OLDER PEOPLE
       The team provides services for older people that promote independence and choice, and do not discriminate against
       them on the grounds of age.

13.1   Non-discrimination and person centred care
         Services are provided by the team on the
a)       basis of clinical need regardless of age.
         Services provided for older people treat
         them as individuals and enable them to
b)       make choices about their own care.

         The team works with other agencies to
c)       promote health and an active life in old age.

13.2   Elderly Surveillance
         The team regularly assesses the needs of
a)       older patients.
         The care of older patients is planned and
b)       provided to meet the needs identified.
          The team identifies patients who have
         fallen, or are at most risk of falling, and
         ensures that they are assessed and any
         possible action taken to prevent further and
c)       more serious falls.




                                                              13 Older People                                       Page 26
                                                    1eb8ec1c-8429-41f1-912b-090b180abaf2.xls


                                                                                                                   Last/next
                                                                                                                   audit/review
       Standard/Criteria                                   Reference document for information   Where to find it   date

14     MINOR OPERATIONS (Only for those services doing minor operations)
       The performance of minor operations in the service conforms to accepted standards of professional service.

14.1   Premises

       The premises, equipment and arrangements
       for sterilisation of instruments are appropriate.

14.2    Procedures
       Minor operations are only performed after
       suitable training and in accordance with
       accepted guidelines.

14.3   Consent

          Patients are offered information and choice
a)        about any procedures to be performed.

          The information given and the patient‟s
b)        consent to any such procedure is recorded.

14.4   Audit
       The service keeps a record or log of their
       minor operations and audits them against
       accepted guidelines.




                                                               14 Minor Operations                                    Page 27
                                                 1eb8ec1c-8429-41f1-912b-090b180abaf2.xls


                                                                                                                Last/next
                                                                                                                audit/review
       Standard/Criteria                                Reference document for information   Where to find it   date

15     TEAM VALUES
       The primary care team works together to provide high quality continuing personal and comprehensive care to their

15.1   Commitment to patients
         Members of the team‟s first priority is to
         care for their patients and to promote their
a)       health.
         The team is committed to providing good-
         quality service and effective clinical
         service in the light of standards set by
         professional organisations and
b)       recommended clinical guidelines.
         Patients are treated with courtesy and
         respect for their privacy and dignity at all
c)       times.
          All team members maintain patient
d)       confidentiality at all times.
         Team members respect the personal
         beliefs and values of their patients, and do
         not seek to impose their own beliefs on
e)       them.
         Decisions about the allocation of
         resources are made in the way that best
f)       serves the interests of their patients.

15.2   Teamwork
       Members of the team are committed to
       working together and respect each others
       professionalism and different perspectives.

                                                              15 Team Values                                        Page 28
                                                  1eb8ec1c-8429-41f1-912b-090b180abaf2.xls


15.3   Discrimination

       The team treats all patients and staff equally
       and there is no discrimination on the grounds
       of age, race, gender or social class.

15.4   Probity
          Team members do not abuse the trust
a)        that patients have in them.
          The financial affairs of the service are
b)        honest and capable of scrutiny.
          All documents provided by the service,
          including certificates and references, are
c)        truthful and honest.

          Team members do not accept
          inappropriate gifts, favours or hospitality
          from patients, the pharmaceutical industry
          or others that might influence, or might be
          interpreted as seeking to influence, their
d)        policies, behaviour or their care.




                                                              15 Team Values                 Page 29
                                                 1eb8ec1c-8429-41f1-912b-090b180abaf2.xls


                                                                                                               Last/next
                                                                                                               audit/review
       Standard/Criteria                              Reference document for information    Where to find it   date

16     TEAMWORKING
       The organisation of the team promotes effective communication and teamwork.

16.1   Communication

          There is an effective system of
          communication between team members,
a)        including staff attached to the service.
          Mechanisms for referral and feedback
          between team members are agreed and
b)        effective.
          There is an agreed mechanism for
          informing all team members involved
          when patients are admitted to, or
c)        discharged from hospital.

16.2   Meetings
         The doctors, service staff and other
         members of the service have frequent
a)       opportunities to meet informally.
         Regular team meetings take place to
         discuss clinical issues and policies which
         all service and attached team members
b)       can attend.

          Records are kept of decisions made and
          actions to be taken at meetings and these
c)        are available to team members.

16.3   Team development
                                                             16 Teamworking                                       Page 30
                                                  1eb8ec1c-8429-41f1-912b-090b180abaf2.xls

         The team develops in response to new
         needs, subjects its work to critical self-
         scrutiny and continually maintains its skills
a)       and widens its horizons.
         All team members are able to contribute
         to the development of the team and its
b)       work.
         There are opportunities for
         multidisciplinary training for team
         members, and all team members are
c)       encouraged to take part.
         If there is protected time for learning
         provided by the PCO the team takes up
d)       the opportunities on offer.

16.4   Support
         All team members have identified sources
         of support either from within or outside
a)       the team.
         The team assists and enables team
         members to maintain their own physical
b)       and mental health
         All staff have access to occupational
         health services and are enabled to use
c)       them.




                                                              16 Teamworking                 Page 31
                                                  1eb8ec1c-8429-41f1-912b-090b180abaf2.xls


                                                                                                                    Last/next
                                                                                                                    audit/review
       Standard/Criteria                                   Reference document for information    Where to find it   date

17     CONTINUED PROFESSIONAL DEVELOPMENT
       All staff in the team are suitably qualified and continue to maintain their competence for their duties.

17.1   Qualifications
         The service manager and other staff in the
         service have appropriate qualifications and
a)       training.

           The nursing and other professional members
          of the team have appropriate qualifications
          and training and only carry out treatments
b)        which are within their competence.
          The service takes all necessary steps to
          ensure that any doctors who are employed as
          locums or assistants are qualified and
          competent to undertake the duties for which
c)        they are to be employed.

          All professionals working in the service are
d)        covered by appropriate indemnity insurance.

17.2   Professional requirements
         The doctors in the service have fulfilled their
         professionally recognised contractual
a)       educational requirements.




                                                       17 Contd Professional Developmt                                Page 32
                                                 1eb8ec1c-8429-41f1-912b-090b180abaf2.xls



          Nurses in the team identify their
          training/educational needs and update their
          professional service in accordance with NMC
b)        standards and principles of service.

17.3   Personal learning plans
         All team members including the doctors have
         an annual appraisal and a personal learning
         plan which identifies their learning needs and
a)       how they are to be met
         The service gives all members the
         opportunities and support they require to
b)       implement their personal learning plans.




                                                      17 Contd Professional Developmt       Page 33
                                                 1eb8ec1c-8429-41f1-912b-090b180abaf2.xls


                                                                                                                  Last/next
                                                                                                                  audit/review
       Standard/Criteria                                  Reference document for information   Where to find it   date

18     PATIENT AND PUBLIC INVOLVEMENT
       The team involves patients in their own care, in planning services and in developing their community.

18.1   Involvement in care
       Team members share information, decisions
       and appropriate responsibility with patients.

18.2   Planning services
       The team has effective methods of working with
       patients and their carers to plan, develop and
       implement services.

18.3   Community development
       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.




                                                        18 Patient & Public Involvement                             Page 34
                                                  1eb8ec1c-8429-41f1-912b-090b180abaf2.xls


                                                                                                                  Last/next
                                                                                                                  audit/review
       Standard/Criteria                                   Reference document for information    Where to find it date

19     QUALITY IMPROVEMENT
       The team is committed to continuous improvement in the services it offers its patients.

19.1   Quality improvement
         The team has established mechanisms for
         the continual monitoring and improvement of
a)       the services they provide.
         The team has an open and „no blame‟
b)       approach to assessing performance.

          All team members are able to raise concerns
          about policies or care in the service, and are
c)        not disadvantaged for doing so.

19.2   Audit
         The team regularly audits its work, covering a
         range of topics including clinical care,
         communication with patients, and service
a)       organisation.
         All members of the team contributing to care
b)       are involved in conducting audits.
         The team can demonstrate change as a
c)       result of their audits.
         The team reviews its performance against
d)       local and national standards.
         Patients and carers contribute to the design
e)       and conduct of audits.




                                                            19 Quality Improvement                                   Page 35
                                                  1eb8ec1c-8429-41f1-912b-090b180abaf2.xls


                                                                                                                  Last/next
                                                                                                                  audit/review
       Standard/Criteria                                  Reference document for information   Where to find it   date

20     RISK MANAGEMENT
       Risk management is seen as an integral part of the work of the team.

20.1   Risk management policies
          The responsibility for developing and
          monitoring risk management policies in the
a)        team is clearly defined.

          The team identifies possible risks to
          patients and staff, takes steps to minimise
          them, and has policies in place for
b)        responding when adverse events occur.

20.2   Significant event analysis
        Adverse incidents, and “near misses” are
a)     recorded.
       The team meets regularly to review and learn
b)     from, significant events.

20.3   Complaints procedure
         The team has an agreed procedure for
         handling complaints, and this is advertised
a)       to the patients.
          Patients who make a complaint are given
          information promptly about its investigation,
          any changes that will result, and are given
b)        an apology if Appropriate.



                                                             20 Risk Management                                      Page 36
                                                   1eb8ec1c-8429-41f1-912b-090b180abaf2.xls

          There is a policy for encouraging
          suggestions and feedback from patients,
c)        and these are recorded and discussed.

          The team responds constructively to
          suggestions and complaints and makes
d)        appropriate improvements as a result.
          The team also record and share patient
e)        compliments.

20.4   Managing under-performance
       The service protects patients as well as
       supporting a colleague if their health or
       performance puts patients at risk.




                                                             20 Risk Management               Page 37
                                                    1eb8ec1c-8429-41f1-912b-090b180abaf2.xls


                                                                                                                    Last/next
                                                                                                                    audit/review
       Standard/Criteria                                    Reference document for information   Where to find it   date

21     RECORDS, REGISTERS AND COMPUTERS
       The team keeps adequate records of the illnesses and treatments of patients, either on paper or in a computer record.




21.1   Clinical records
          Each patient contact is recorded in the
          patient‟s record, including visits and
a)        telephone advice.
          Entries in the records are complete,
b)        accurate and legible.

          The records, hospital letters and
c)        investigation reports are filed in date order.
          The medication that a patient is receiving is
d)        clearly listed in their record.
          Drug allergies and adverse reactions are
e)        prominently recorded.
          Recent, routine referral letters are
          typewritten, contain all the relevant
f)        information, and copies are on record.


21.2   Summaries
         The records contain a summary of all
a)       significant and continuing problems.
         There is an effective system for keeping the
b)       summaries updated.


                                                           21 Records,Registers & Computer                              Page 38
                                                1eb8ec1c-8429-41f1-912b-090b180abaf2.xls




21.3   Records entering the service

          There are agreed procedures for handling
a)       records when they come into the service.

         If the records are computerised there are
         mechanisms to ensure that the data is
b)       transferred when patients leave the service.


21.4   Access to records

         There is a designated individual responsible
a)       (Caldicott Guardian) for confidentiality.
         The service has a policy regarding
         confidentiality and access to the medical
         records by members of the Primary Health
b)       Care Team.
         Patients have access to their records on
         request in accordance with Data Protection
c)       Act.


21.5   Computers
         The service is registered under, and
         conforms to the provisions of the Data
a)       Protection Act.
         There are adequate measures taken to
b)       protect and back up computerised data.
         All clinical team members have access to
c)       any computerised clinical records.


                                                        21 Records,Registers & Computer    Page 39
                                                  1eb8ec1c-8429-41f1-912b-090b180abaf2.xls

          There is policy to control access to
          computerised data and to prevent
d)        unauthorised access.
          The service is developing the use of its
e)        computer system to:-
              I.           to record consultations
              II.         to store pathology results
              III.        to store a drug formulary
              IV.       to manage repeat prescribing
              V.         to carry out audits
              VI.       to access guidelines and protocols
              VII.      to provide information for patients
              VIII.    to communicate within the team

21.6   Audit
       The service regularly audits the completeness
       of the patient records, summaries and disease
       registers.




                                                       21 Records,Registers & Computer       Page 40
                                                  1eb8ec1c-8429-41f1-912b-090b180abaf2.xls


                                                                                                                     Last/next
                                                                                                                     audit/review
       Standard/Criteria                                     Reference document for information   Where to find it   date

22     SERVICE MANAGEMENT
       The team is managed effectively for the benefit of patients, team members and to meet financial statutory and other

22.1   Roles and responsibilities
       Responsibilities for management and
       administration within the team are clearly defined
       and understood by team members.

22.2   Personnel Management

          All statutory regulations in relation to staff
          employment (e.g. equal opportunities,
          harassment, national insurance, PAYE,
a)        statutory sick pay, pensions) are adhered to.
          Accurate and complete personnel records are
b)        kept.
          All staff have an up to date job description and
c)        contract of employment.
           All posts, including nursing posts, are graded
          and paid according to national guidelines, and
d)        reviewed regularly.
           There is an agreed disciplinary and grievance
          procedure that adheres to statutory
e)        requirements.
          There is an agreed procedure to respond to
f)        violence or sexual/racial harassment
          Staff have received appropriate training in
g)        responding to violence.


                                                             22 Service Management                                     Page 41
                                                  1eb8ec1c-8429-41f1-912b-090b180abaf2.xls

          The working hours of all staff and doctors
          balance the needs of patients with the needs
h)        of staff and their families.
          Staff are able to review and agree reasonable
          changes in their working patterns on a
          temporary or permanent basis as their
i)        personal circumstances change.

          All new staff receive an induction programme,
          appropriate supervision, mentoring and any
j)        necessary training and support.


22.3   Health and Safety at Work
         a) The people responsible for Health and
         Safety in the service are clearly defined, and
a)       are appropriately trained.
         b) The service has written policy for Health
         and Safety that meets the statutory
         requirements including the Health & Safety at
b)       Work Act and other Regulations covering:
             I.            Training of staff
             II.           Storage and use of hazardous
             substances (COSHH).
             III.         Storage of drugs, needles,
             prescriptions
             IV.         Immunisations for team members
             V.          Employers liability insurance
             VI.         Fire safety.
             VII.        Electrical safety
             VIII.       Protection of staff against violence
             IX.         Manual Handling
             X.          Response to needle stick injuries.

                                                           22 Service Management             Page 42
                                                   1eb8ec1c-8429-41f1-912b-090b180abaf2.xls


          All staff are aware of, and consulted on, the
c)        service H&S policies.

          The service regularly reviews its policies and
          its adherence to them, identifies areas of risk,
d)        and investigates any adverse incidents.

22.4   Infection control
       The service has a policy to protect staff and patients from infection. This includes policies for:-
a)        Hand washing and drying
b)        The use of protective gloves
c)        The protection of open wounds
           The disposal of clinical waste, sharps and
d)        contaminated linen
e)        Environmental cleaning
f)        Decontamination of equipment.

22.5   Policies and procedures
       There are written policies covering the
       administrative procedures and systems in the
a)     service.
       The policies and procedures are discussed and
       agreed by team members and are reviewed
b)     regularly.
        Information on service policies and procedures,
       and local facilities and services, is provided to
       guide registrars or locums who work in the
c)     service.


22.6   Financial management
       The responsibility for financial management in the
a)     service is clearly defined.

                                                             22 Service Management                           Page 43
                                                 1eb8ec1c-8429-41f1-912b-090b180abaf2.xls


       The service keeps full records of income,
b)     expenditure and petty cash transactions.
       The service prepares regular reports of income
c)     and expenditure.

       The service regularly monitors claims for items of
d)     service, reimbursements and other payments.
       The service produces an annual budget and
e)     monitors performance against it.
       The service can demonstrate that steps are taken
f)     to ensure the prevention of fraud

22.7   Service planning
       The service produces an annual development
       plan which contains clear objectives and
a)     timescales.
       All team members contribute to the development
b)     plan.
       The plan takes account of their Local Health and
       Modernisation Plan and other national and local
c)     priorities.
       The service reviews its performance against its
d)     plans in an annual report.

22.8   Information technology

       The service has an effective reference system to
a)     support clinical care and personal development.
       Team members have access and can use the
b)     NHS Net.




                                                            22 Service Management           Page 44
                                              1eb8ec1c-8429-41f1-912b-090b180abaf2.xls


                                                                                                                 Last/next
                                                                                                                 audit/review
       Standard/Criteria                                 Reference document for information   Where to find it   date

23     PREMISES AND EQUIPMENT
       The team has sufficient and appropriate accommodation and equipment at the service premises

23.1   Premises
       The premises are clean, warm, well lit and well
a)     maintained.
       The service premises are accessible to disabled
       people according to the provisions of the
b)     Disability Act.
       The premises allow respect for the comfort,
c)     dignity and privacy of patients.
       The premises provide a satisfactory working
d)     environment for all team members.
       e) The premises and its contents are protected
e)     by adequate security measures.


23.2   Equipment
       The team members have the necessary clinical
a)     equipment readily available.
       The service possesses the equipment and drugs
b)     required to deal with emergencies.
       The service ensures the regular inspection
       maintenance and calibration of equipment, and
c)     that emergency drugs are kept up to date.




                                                         23 Premises & Equipment                                    Page 45
                                                 1eb8ec1c-8429-41f1-912b-090b180abaf2.xls


                                                                                                                  Last/next
                                                                                                                  audit/review
       Standard/Criteria                                  Reference document for information   Where to find it   date

24     RELATIONSHIP WITH THE LOCAL PRIMARY CARE ORGANISATION
       Team members contribute to the work and policies of the local primary care organisation (PCO).

24.1   Clinical Governance
          The team has an identified member or
          members to lead Clinical Governance in the
a)        service.
          The team participates in the Clinical
          Governance activities of their PCO and is
b)        willing to share data with other teams.

24.2   Meetings and Communication
         Team members attend appropriate meetings
         of their PCO. There is a method for
         communicating information from the PCO to all
a)       team members.
         All members of the team know the relevant
         communication points within the PCO for
b)       advice, complaints and communication.
         Team members contribute to the
         commissioning process by identifying ways in
c)       which local services can be improved.


24.3   Policies and plans
         The team is aware of the Health and
         Modernisation Plan,, prescribing, referral and
         other policies of their PCO, and work within
a)       them.

                                                       24 Relationship with Local PCO                                Page 46
                                            1eb8ec1c-8429-41f1-912b-090b180abaf2.xls

     The team contributes to, and uses, joint
     guidelines and pathways with hospital trusts
b)   and social services.




                                                    24 Relationship with Local PCO     Page 47

				
DOCUMENT INFO
Description: Apology Letter Templates document sample