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					Clinical Governance - QiO based and in addition to contract monitoring                                       DRAFT
Standard           Questions relating to standards           Evidence source            Red standard           Amber standard         Green standard         RAG status   Notes
 Level 1                    Mandatory
                                                                                                                                 Policy available -
             Does the practice operate an equal
C7e                                                        Visit / policy        No Policy available         Policy available    evidence that
             opportunities employment policy?
                                                                                                                                 understood by all staff
             Has the practice been informed of a                                                                                 Policy available -
C14c         managing poor performance policy in           Visit / policy        No Policy available         Policy available    evidence that
             effect in the area?                                                                                                 understood by all staff
                                                                                                             Not fully
                                                                                                                                Fully accessible or
                                                                                 Not fully accessible for    accessible,
             Does the practice offer services to all       Visit and evidence                                                   recent review with
C18                                                                              disabled and no evidence of evidence of review
             patients equitably?                           of review                                                            evidence of appropriate
                                                                                 review                      but not fully
                                                                                                                                actions
                                                                                                             actioned
                                                                                                                                No or Yes with
             Does the practice keep patient records in                                                       Yes, back up made systematic back up and
C24                                                        Visit / policy        Yes, no back up made
             a paperless, electronic format?                                                                 on ad hoc basis    evidence of a policy in
                                                                                                                                place

Level 2      Best Practice
             Are all practitioners aware of NICE                                                             Aware of existence Full knowledge and
                                                           Knowledge /
C3           guidance relating to AMD, Refractive                                No knowledge                and how to access evidence is available to
                                                           information sheet
             Laser Surgery and Glaucoma?                                                                     information        share with others
                                                                                                            Multi use with no    Single use or Multi-use
             Does the practice use a contact tonometer
                                                                                 Multi-use with no policy / decontamination      with decontamination
C4c 1        or any other instrument in contact with the Visit
                                                                                 decontamination procedure policy and ad hoc     following College
             eye?
                                                                                                            procedures           guidelines
                                                                                                                                 No or Yes with
                                                                                                           Yes with ad hoc
             Does the practice use any special                                   Yes with no policy /                            decontamination
C4c 2                                                      Visit                                           decontamination
             diagnostic hard or RGP contact lenses?                              decontamination procedure                       following College
                                                                                                           procedure
                                                                                                                                 guidelines
             Are systems in place to ensure that
             guidance is disseminated to all                                                                                     Full provision of
                                                           Visit / information   No information or guidance Partial provision of
C5a          optometrists working in the practice?                                                                               information to share with
                                                           available             available                  information
             (shared care, direct referral, early recall                                                                         others
             etc)




          SPCT June 2009
                                                                                                              Record of points
             Does the practice record the CET and
                                                           Visit / information                                achieved available /   Full detailed record of
C5c          CPD of optometrists and dispensing                                   No information available
                                                           available                                          evidence of CPD        CET and CPD available
             opticians?
                                                                                                              available
             Does the practice have a patient consent                                                         Verbal policy only
                                                                                                                                     Written policy and
             policy for issuing repeat spectacle           Visit / policy                                     but example
C6                                                                                No policy available                                example paperwork
             prescriptions - and CL specifications if      available                                          paperwork
                                                                                                                                     available
             fitted?                                                                                          available
             Does the practice have professional                                                                                   Full provision of
             guidance and relevant codes of conduct        Visit / information                                Partial provision of information including all
C10b                                                                              No information available
             available for reference by professional       available                                          information          relevant codes of
             staff?                                                                                                                conduct
                                                                                                              Information            Information available on
             Does the practice have information                                                               available on a small   a comprehensive range
                                                           Visit / information
C16 1        available for patients on a range of                                 No information available    range of conditions    of conditions (>4) or
                                                           available
             common eye conditions?                                                                           available(less than    ability to print off as
                                                                                                              5)                     required

                                                                                                              Aware of existence
             Does the practice have the Low Vision         Visit - leaflet
C16 2                                                                             No knowledge                and how to access Leaflet available
             Leaflet available (LVL)?                      available
                                                                                                              information

                                                                                                              Aware of
             Does the practice offer copy referral letters Visit - records                                                         Records support copies
C16 3                                                                             No knowledge                requirement to offer
             to the patient?                               support                                                                 given to Px
                                                                                                              but no evidence
                                                                                                              No but patients        Yes or No but gives the
             Does the practice provide domiciliary         Visit / information    No and no information for
C18                                                                                                           advised to contact     contact details of PCT or
             services?                                     available              how to access
                                                                                                              PCT                    a provider
                                                                                                                                     Anti-microbial rub used
             If domiciliary is provided, what hand                                                            Anti-microbial rub
C18 1                                                      Visit - availability   No measures in place                               and own liquid soap and
             hygiene measures are used?                                                                       used
                                                                                                                                     hand towels available


Level 3      Aspirational
             Does the PCT include the practice in          Visit / evidence on                                Included but not       Included and kept for
C1a 1                                                                             Not included
             critical incident reporting structures?       file                                               kept on file           reference
                                                                                                              Included and           Included and evidence
             If yes to above, does the practice assess     Visit / evidence on
C1a 2                                                                             Included but no action      actioned on ad hoc     available of actions
             risks and feedback to staff?                  file
                                                                                                              basis                  taken




          SPCT June 2009
           Does the PCT include the practice in the     Visit / evidence on                                  Included but not       Included and kept for
C1b 1                                                                          Not included
           circulation of safety alerts?                file                                                 kept on file           reference
                                                                                                             Included and
           If yes to above, does the practice have a                                                                                Included, named person
                                                     Visit / evidence on                                     actioned on ad hoc
C1b 2      named person to acknowledge receipt and                             Included but no action                               and evidence available
                                                     file                                                    basis - no named
           to action such alerts?                                                                                                   of actions
                                                                                                             person
                                                                                                             Instructions
           Do practice staff have easy access to        Visit / instructions                                                        Instructions available for
C4b                                                                            No instructions available     available for some
           instructions on the use of equipment?        available                                                                   all major equipment
                                                                                                             instruments
           Do members of the clinical staff have a      Visit / PDP's                                        PDP's available but    PDP's available and up
C5c                                                                            No PDP's available
           PDP?                                         available                                            out of date            to date
                                                                                                             Named lead - no        Named lead and
           Does the practice have a named clinical
C7a                                                     Visit                  No named lead                 evidence of work in    evidence of work in this
           governance lead?
                                                                                                             this area              area
                                                                                                             Regular forum for      Regular forum for
           Are staff encouraged to share near misses Visit / evidence on
C7b                                                                            No system in place            discussion - no        discussion and evidence
           and solutions?                            file
                                                                                                             evidence on file       on file
           Does the practice monitor and improve the                                                         Evidence of audit      Evidence of audit
                                                        Visit / evidence on
C7f        quality of care provided e.g.through                                No system in place            undertaken but no      undertaken and actions
                                                        file
           clinical audit?                                                                                   actions                from this
           Do non-clinical members of staff have        Visit / PDP's                                        PDP's available but    PDP's available and up
C8b                                                                            No PDP's available
           personal development programmes?             available                                            out of date            to date
                                                                                                             CRB checks only
                                                                                                             by PCT on
           Does the practice carry out CRB checks       Visit / CRB                                                                 CRB checks carried out
C11a                                                                           No CRB checks                 performers started
           on professional staff?                       certificates                                                                on all professional staff
                                                                                                             since contracts
                                                                                                             started
           Has your PCT supplied you with leaflets or                                                        Supplied by PCT        Supplied by PCT and
                                                        Visit - evidence
C13c       posters to explain how their information                            Not supplied by PCT           but not readily        readily available /
                                                        available
           may be used?                                                                                      available or visible   displayed prominently
           Do you know how to contact the               Visit - detail                                       Known about but        Contact information
C14a                                                                           Not known
           Optometric Adviser in Sandwell?              available                                            no contact details     readily available
           Do you directly provide patients with
                                                                                                                                Choice information
           choice information when referring for        Visit - detail                                       Choice information
C16                                                                            No choice information given                      given in line with latest
           cataract surgery under local                 available                                            given
                                                                                                                                PCT preferred providers
           arrangements?
           Does the practice have access to local
                                                        Visit - information                                  Basic information      Up to date information
C19        waiting times for ophthalmology                                     No waiting times available
                                                        available                                            available              for a range of conditions
           appointments?




        SPCT June 2009
             Can staff store their possessions safely                                                         Private areas with   Private areas with
C20a                                                       Visit - secure area?   No suitable private areas
             while working?                                                                                   room for storage     lockers
                                                                                                                                   Evidence of actions after
                                                                                                              Evidence of
             Does the practice have procedures in          Visit - procedure /                                                     assessments with a
C20b                                                                              No confidentiality policy   assessment for
             place to ensure confidentiality?              policy                                                                  named lead for
                                                                                                              confidentiality
                                                                                                                                   confidentiality
             Does the practice have information on                                                                                 Suitable literature
                                                           Visit - information                                Verbal information
C23 1        smoking cessation programmes? (If                                    No information available                         available and actively
                                                           available                                          only
             available)                                                                                                            promoted
                                                                                                                                   Suitable literature
             Does the practice have information on         Visit - information                                Verbal information
C23 2                                                                             No information available                         available and advised
             nutrition and the eye?                        available                                          only
                                                                                                                                   appropriately

Level 4      Aspirational
             Does the practice have a formal training                                                         Some evidence of     Evidence of regular
                                                        Visit - evidence
C5b          programme for optical assistants or others                           No training / programme     training on an ad    formal training with
                                                        available
             carrying out delegated functions?                                                                hoc basis            updates and review
                                                                                                              Evidence of clinical
                                                                                                              audit but on an
                                                           Visit - evidence                                                        Evidence of regular
C5d 1        Does the practice undertake clinical audit?                          No audit undertaken         irregular basis or
                                                           available                                                               clinical audit
                                                                                                              plans to introduce
                                                                                                              (1st visit only)
             Does the practice periodically review         Visit - evidence                                   Evidence of review Evidence of regular
C5d 2                                                                             No review undertaken
             record keeping?                               available                                          only                 review and actions
                                                                                                                                   Procedures available
                                                                                                              Procedures
             Does the practice have a procedure for    Visit - procedure                                                           and use encouraged to
C7c                                                                               No procedure available      available but little
             raising concerns about staff performance? available                                                                   promote continuous
                                                                                                              used
                                                                                                                                   improvement
             Does the practice have a whistle-blowing      Visit / policy
C8a                                                                               No policy available                              Policy available
             policy?                                       available
                                                                                                                                  Evidence of named
                                                                                                              Evidence of regular person responsible for
             Does the practice have a system for           Visit - evidence
C8b                                                                               No system available         appraisal and some formal system of
             appraisal and ongoing development?            available
                                                                                                              development         appraisal and ongoing
                                                                                                                                  development




          SPCT June 2009
                                                                                                                           Evidence of feedback
                                                                                                       Evidence of         requested and results
          Does the practice survey Px for feedback    Visit - evidence
C17                                                                         No feedback requested      feedback            used to improve service
          on services provided?                       available
                                                                                                       requested           and advance practice
                                                                                                                           policies
                                                                                                      Evidence of
                                                                                                                                                      N/A for
                                                      Visit - presence of                             practice            Practice has a hearing
C18       Does the practice have a hearing loop?                            No hearing loop                                                          additional
                                                      loop                                            considering using a loop
                                                                                                                                                     contracts
                                                                                                      hearing loop
                                                                                                                          Evidence of advice
                                                                                                                          given and staff
                                                                                                      Evidence of advice encouraged to be
          Does the practice encourage staff to adopt Visit - evidence       No advice / encouragement
C22a                                                                                                  given to promote    healthy with practice
          healthier lifestyles?                      available              given to staff
                                                                                                      healthy living      being flexible to
                                                                                                                          accommodate healthy
                                                                                                                          lifestyle
                                                                                                      PCT has asked and
          Has the PCT asked the practice to                                                           programme           PCT has asked and
                                                      Visit - evidence
C23       participate in local disease prevention and                       Not been asked            underway but not    programme underway
                                                      available
          / or promotion programmes?                                                                  promoted            and actively promoted
                                                                                                      effectively
                                                                                                       Evidence of
                                                                                                                           Disaster recovery plan
          Does the practice have a disaster           Visit - plan                                     practice
C24                                                                         No plan                                        available with evidence
          recovery plan?                              available?                                       considering /
                                                                                                                           of review
                                                                                                       developing a plan




       SPCT June 2009

				
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