Independent doctors provider information request Kit... · Web viewInformation request form: Inde pendent doctor service s To enable us to make the most of the inspection of your

Information request form:Independent doctor services

To enable us to make the most of the inspection of your service we require the following information prior to our visit.

There are links to guidance and notes within the questions shown. During the inspection visit, we may ask about any area of this information request and ask to see documentary evidence.

Please make sure you answer all of the questions. If you do not complete all of the questions, the information request will be returned to you for completion.

Practice/service details

Please complete all the following details about your practice/service.

Organisation name: Click here to enter text.

First name of the person completing this information request: Click here to enter text.

Middle name of the person completing this information request: Click here to enter text.

Surname of the person completing this information request: Click here to enter text.

Contact email for person completing the request: Click here to enter text.

Provider ID (you’ll find this on your registration certificate): Click here to enter text.

Location ID (you’ll find this on your registration certificate): Click here to enter text.

20160930 9001083 Independent Doctor provider information request v1 1

Staffing

1. The questions below – questions 1a) to 1i) – are to be answered by completing the table on page 3.

Please read questions 1a) to 1i) and complete the table on page 3 to provide details on each of your medical staff.

a) If a medical practitioner, or other registered healthcare professional, are they on the UK register at the General Medical Council (GMC), NMC (Nursing and Midwifery Council), HPC (Health Professions Council)?

b) If the medical staff member is on a UK specialist register e.g. do they have a specialist register qualification(s)? E.g. Obstetrics and gynaecology, psychiatry.

c) What is the staff member’s registration number?

d) What is the name of the medical staff member’s designated body if registered with the GMC?

e) Please give the date of next revalidation with the GMC for each medical staff member and NMC for each member of nursing staff.

f) Please give the date of the last appraisal?

g) Please give the date of the last adult safeguarding training for each medical staff member.

h) Please give the date of the last children’s safeguarding training for each staff member.

i) Please give the level of children’s safeguarding training for each staff member.

Please do not send us the names of your staff but use an identifier such as a number and we will cross reference when we carry out our visit to your location.


1a)Professions UK register GMC/ NMC/ HPC or other professional healthcare registration?

1b)GMC Specialist register qualification? E.g. psychiatry.

1c) GMC/ NMC/ HPC: Registration Number

1d)GMC: Name of Designated Body

1e) GMC/NMC: Date of next revalidation with the GMC/NMC

1)f Date of last appraisal?

1g) Date of last adult safeguarding training (or state ‘none’).

1h) Date of last children’s safeguarding training (or state ‘none’).

1i) Level of children’s safeguarding training.

Staff identifier: Click here to enter text.

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Click here to enter a date.



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Staff Identifier: Click here to enter text.

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1j) Do all of your medical staff have a prescribed link to a designated body with a responsible officer?

Choose an item.Choose an item.All doctors practising in the UK need a prescribed link to a designated body with a responsible officer. If you believe this does not apply to you please state why:


1k) Do you employ or contract any other staff than those listed in the table above?

Choose an item.

If yes, please give details of roles (but not names):


1l) Have all staff had a Disclosure and Barring Service (DBS) check?

Choose an item.Choose an item.

1m) Are you or any member of staff currently under investigation by a regulatory body or the police?


Provider services

2a) Have you submitted a statement of purpose to CQC?


2b) When was your statement of purpose last updated?


Note: Regulation 12 of the CQC (Registration) Regulations 2009 requires you to have a statement of purpose.

3a) Do you currently provide any NHS funded care?

Choose an item.Choose an item.3b) If yes, what type and proportion of patients treated annually are NHS funded?



3c) If yes, and this the provision of NHS primary medical services? Please select from the list below:☐Arrangements made pursuant to section 83(2) of the 2006 Act (primary medical services);

☐ A contract entered into pursuant to section 84 of that Act (general medical services contracts); or

☐ Arrangements made pursuant to section 92 of that Act (arrangements by the Board of primary medical services).

3d) If yes but not primary medical services, please state the nature of the NHS Funded services.


4) Are services provided at any satellites, (i.e. a place where services are provided but are managed from your location – your location will be a condition set out on your certificate of registration with CQC) on a regular basis?

Choose an item.Choose an item.If yes, please list the address(s) below:


5a) What would you describe as your main purpose? Please select one of the main service types from the list below:

☐ Specialist(s) providing consultation and/or treatment who are on the specialist register at the GMC or have completed further Royal College Certificate of Completion of Training (CCT) and who are not exempt from CQC registration, and who would ordinarily provide the same or similar services in an acute/community or mental health hospital.

☐ Specialist(s) solely providing consultation and/or treatment remotely, for example via the telephone or internet (including FaceTime or SKYPE), who are on the specialist register at the GMC or have completed further Royal College CCT training and who would ordinarily provide the same or similar services in an acute/community or mental health hospital.

☐ Vaccination clinic (travel or other vaccinations).

☐ Slimming clinics: where the regulated activity of `services in slimming clinics` is the main purpose.


☐ Private GP services providing consultation and/or treatment and medical staff are on the GP specialist register at the GMC.

☐ Private GP(s) solely providing consultation and or treatment remotely. For example: via the telephone or internet (including FaceTime or SKYPE). Medical staff are on the GP specialist register at the GMC.

☐ Registered medical practitioner providing consultation and/or treatment (which may include providing consultation and or treatment remotely). For example via the telephone or internet (including FaceTime or SKYPE).

☐ Medical agency that carries out visits to people in their homes or other places that they are staying such as hotels or care homes.

☐ Family planning services – only if the regulated activity of ‘family planning’ is the main purpose.

☐ Other – please give a description: Click here to enter text.


5b) Do you provide any of the following services? Please tick all boxes that apply:

☐ Consultations face to face (with or without prescribing)☐ Examinations☐ Online consultations (with or without prescribing)☐ Gynaecology, dermatology, cardiology or other healthcare or diagnostic services

that do not involve any treatment that falls under the acute or single specialty hospital category

☐ Provide any community type services – e.g. nurses for home visits☐ Wound management/dressing☐ Management of long-term conditions ☐ Treatment and care to people at the end of their life ☐ Treatment for mental health needs with or without prescribing☐ Treatment for substance misuse with or without prescribing☐ Counselling and psychotherapy☐ Slimming clinic/obesity management services☐ Immunisations including childhood☐ Travel vaccinations/travel medicine☐ Yellow fever vaccination centre☐ Sexual health services☐ Family planning☐ Antenatal and post-natal care☐ Fertility services/reproductive health☐ Health screening☐ Near patient testing (also referred to as point of care testing – tests which can be

undertaken whilst the patient is at the practice, e.g. blood glucose monitoring, INR)

☐ Invasive physiological measurement or monitoring☐ Any form of diagnostic imaging/scanning☐ Baby scanning for non-medical purposes☐ Treatment or care to people with cancer, including intravenous chemotherapy☐ Urodynamic services☐ All endoscopy such as gastroscopy, cystoscopy, hysteroscopy or colonoscopy☐ Endoscopy restricted to nasopharyngoscopy, colposcopy and use of auroscope

etc☐ Vasectomy ☐ Male circumcision for infants/children☐ Male circumcision for adults


☐ Dental treatment☐ Minor surgery ☐ Non-exempt cosmetic pre and post surgery care/treatment ☐ Non-exempt cosmetic surgery – for the purpose of completing this form, cosmetic

surgery does not include subcutaneous injection of Botox® or dermal fillers for the purpose of enhancing appearance

☐ Maternity services including child birth☐ Other – please specify (up to 250 words max): Click here to enter text.

5c) Please briefly describe the types of minor surgery that you carry out at the location. E.g. Dermatological, Gynaecological, Cryotherapy.


6a) If you are location based, what are your core opening hours? E.g. Fortnightly: Tuesday and Thursday 1-5pm.


6b) What are your outside of core hours arrangements, if any? E.g. call out service 7 days a week, hours of operation 6pm-8am.


7a) Do you offer mobile services e.g. home visits, online mobile apps?


7b) Please tick one of the following that best describes your mobile service:

☐ Offer a mobile/call out service 24 hours a day, every day☐ Offer a mobile/call out service only out of hours e.g. 6pm – 8am only☐ Other hours please specify (limit text to 200 words)

8) Do you offer a ‘walk-in’ (without appointment) service?



9) Please select all those that apply to your location:

☐ I/we prescribe controlled drugs ☐ I/we hold stocks of controlled drugs at the location or in a vehicle used for visiting patients☐ I/we use dispense medicines☐ I/we hold oxygen at the location or in a vehicle used for visiting patients☐ I/we use Patient Group Directions (PGDs)


10) If you dispense and or hold stocks of controlled drugs, have you reported any incidents regarding Controlled Drugs to the NHS England Area Teams Local Intelligence Network (LIN) within the last 12 months? Choose an item.Choose an item.

11) Do you have a prescribing protocol?

Choose an item.Choose an item.12a) Does your service hold emergency medicines, e.g. for the treatment of medical emergencies such as anaphylaxis.

Choose an item.Choose an item.12b) Please state if any medicines have been administered in an emergency to a patient at the service.


13a) Do you manufacture unlicensed medicines?

Choose an item.Choose an item.13b If you manufacture medicines, do you have a licence from the Medicines and Healthcare products Regulatory Agency (MHRA)?Choose an item.Choose an item.

14) If you carry out any surgery do you use (select all that apply):

☐ Local anaesthesia☐ General anaesthesia (NB – please note that if you use general anaesthesia you will fall under our acute hospitals methodology)☐ Intravenous sedation☐ Not applicable


15) Do you decontaminate any re-usable medical devices at the location?


16) Is your provider accredited with UKAS (United Kingdom Accreditation Service) for any of the services it offers? E.g. clinical pathology, physiological services

Patient17a) Do you offer consultations and/or treatment for:

☐ Children under the age of 18 only☐ Adults only 18years and older☐ Both children and adults

17b) What is your minimum age for consultation/treatment of children?Click here to enter text.

18a) If you are a GP practice, overall, how many registered patients do you currently have? If you are solely an online provider of GP/medical services please complete for the number of patients who are signed up to use your service.

☐ Less than 100 ☐ 100-500☐ 501-1000☐ More than 1000

18b) How many patients do you treat on a monthly basis?

☐ 1-50☐ 51-100☐ 101-200☐ 200-500☐ More than 500

18c) How many individual patients have you referred to one or more other services/professionals in the last 12 months?

☐ 0☐ 1-50


☐ 51-100☐ 101-200☐ 200-500☐ More than 500

19) If your patient is registered with an NHS GP, do you communicate with the GP?

☐ Yes – always☐ Yes – sometimes☐ Yes – rarely☐ No communication with the NHS GP

20a) Have you referred a child safeguarding concern to a local authority social care department during the last year?

Choose an item.Choose an item.20b) Have you referred an adult safeguarding concern to a local authority social care department during the last year?


21a) Do you gather patient feedback?

Choose an item.Choose an item.21b) If yes, how do you gather patient feedback?

☐ Annual patient survey☐ Comment cards☐ Survey after each consultation☐ PPG/virtual feedback☐ Other

Please specify other Click here to enter text.

Complaints and incidents

22a) How many complaints have you received in the last 12 months?



22b) Have you analysed any complaints received in the last 12 months?

Choose an item.Choose an item.22c) What changes have you made as a result?Click here to enter text

23a) Does your service have a definition of a serious incident/event?Choose an item.Choose an item.23b) If yes please provide a definition?Click here to enter text.

23c) How many serious adverse events have you had in the last 12 months?Note: These may be referred to as serious incidents or events which are unexpected or avoidable and could include near misses.


23d) Have you investigated and analysed the serious adverse events of the last 12 months.

Choose an item.Choose an item.23e) What improvements have you made to the service following your investigation and analysis?Click here to enter text.

Audit

24a) Have you completed any clinical audits in the last 12 months?


24b) If yes, please give examples of completed clinical audits and any other quality improvement activity.


25) Have you had any independent audit or peer review of your practice (excluding appraisal/revalidation) in the last 12 months?

Choose an item.


Choose an item.

Additional information

26) Is there any other information on your service that you wish to tell us in addition to the information requested above?


Returning the completed information request to us

We would prefer you to send this to us by email, please send to: pmsinspections @cqc.org.uk by <deadline date (10 working days)>.

Please include our reference number (<Inspection ID>), in any letter or email sent with the information.

If you do not complete all of the questions, the information request will be returned to you for completion.

If you have any questions, you can contact our National Customer Service Centre using the details below:

Telephone: 03000 616161

Email: pmsinspections @cqc.org.uk

If you do get in touch, please make sure you quote our reference number (<Inspection ID>) as it will assist us to respond to your query in a timely manner.


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Documents

Independent doctors provider information request Kit... · Web viewInformation request form: Inde pendent doctor service s To enable us to make the most of the inspection of your