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Quality Assurance

QUALITY ASSURANCE & MANAGEMENT POLICY

Statement

Monkspath Surgery aims to provide care of a consistent quality for all patients; we strive to meet the high standards expected in any clinical setting. We expect all members of our practice team to work to these standards to help us achieve our aim of providing a quality service. Our management systems define each practice member’s responsibilities when looking after you.

The policies, systems and processes in place in our practice reflect our professional and legal responsibilities and follow recognised standards of good practice.

Policy

Our aim is to achieve the best outcomes for our patients by providing good care and transparent management of our practice. We use the most appropriate policies and systems and employ appropriately trained and competent team members. We evaluate our practice and staff on a regular basis through audit, peer review, performance development and patient feedback to help us monitor the effectiveness of our quality assurance procedures.

We work with NHS organisations, such as BSol (Clinical Commissioning Group) as well as external organisations such as the British Medical Association (BMA, the trade union and professional association for doctors and medical students in the UK), the Nursing Medical Council (NMC, the regulator for nursing and midwifery professions in the UK) and other regulatory bodies, as well as local medical councils and external suppliers.

Monkspath Surgery has effective procedures for assuring and enhancing the quality of the services we provide for our patients, and we aim to;

  • Provide a safe and welcoming practice

  • Ensure all members of the practice team are appropriately trained

  • Provide information for patients about the practice and the care available

  • Ensure patients understand the terms on which care is offered

  • Explain all treatment options and agree clinical decisions with the patient, explaining the possible risks involved with each option

  • Provide treatment plans based on the agreed treatment

  • Obtain valid consent for all treatment, written or verbal

  • Refer to specialists for investigation or treatment as appropriate and without undue delay

  • Maintain contemporaneous clinical records with an up-to-date medical history for all patients

  • Provide secure storage of patient records to maintain patient confidentiality

  • Explain the procedure to follow for raising a complaint or concern

Our practice teams are the specialists that work to deliver a quality service for patients, and we support them and their development by;

  • Providing a working environment that is safe and without hazards or risks

  • Providing appropriate induction training for all new members of staff

  • Providing job descriptions and contracts of employment to all staff, which are reviewed and updated to accurately reflect the current duties and responsibilities

  • Provide ongoing training and identify opportunities for development for all employees

  • Keeping and updating staff records to ensure the following information is up to date:

    • criminal records checks are accurate and up to date

    • emergency contact details

    • relevant medical history information

    • in-house and external training

    • absence through holiday and sickness

    • performance reviews

  • Having agreements in place for any 3rd party/external contractors working at the practice which include confidentiality and safety

  • Ensure that all staff are kept up to date with all practice policies and procedures.

Practice Regulators

The Practice is regulated by the Care Quality Commission, who monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety. They publish results of their regulatory inspections, giving performance ratings to help people understand the standards of care provided by healthcare providers in England.

NHS England is the body that commissions GP practices to provide a service under contract to the NHS, and they monitor and manage GP contracts and commission other primary care services.

NHS England and Clinical Commissioning Groups (CCGs) are now responsible for Commissioning the vast majority of NHS services, with local authorities taking on new public health Commissioning responsibilities.  All GP Practices have to be members of a CCG, who have a legal and we are a member of BSol

Practice Teams – Clinical and non-clinical staff

Our practice staff will adhere to practice policies and procedures. We expect everyone working at the practice to do the following;

  • Understand our aims and objectives

  • Have an understanding of the skills and competencies required to deliver the services

  • successfully

  • Understand and participate in our quality assurance activities.

  • Dealing with emergencies, including a collapsed patient.

All clinical staff are registered with their relevant body and their registration must be kept up to date. They must meet their continuing professional development requirements and maintain records of their individual CPD activity. In addition, the practice maintains records of all training provided by the practice as well as any training provided for individual members.

Policies and Procedures

The Practice has policies and procedures in place to protect and support the staff and patients – these are reviewed on an annual basis to ensure their accuracy and relevance. These policies include;

  • Infection Control

  • Child protection

  • Protection of Vulnerable Adults

  • Confidentiality and access to patient identifiable information

  • Consent

  • Information governance and Data Protection

  • Employment policies and procedures

  • Equal Opportunities

  • Whistleblowing

  • Health and Safety & Fire Safety

  • Friends & Family Test

  • Patient feedback

  • Patient referral

  • Staff Satisfaction

  • Violent and aggressive patients / Zero Tolerance 

This list is not exhaustive, but representative of the subject matter covered by the policies in place at the practice.

The practice manager manages, collates, analyses and evaluates all information:

a) About the quality and safety of the care, treatment, support and regulatory compliance achieved by the Practice;

b) Provided by external guidance and reviews issued by national organisations;

c) About the risk(s) to people’s health, welfare and safety.

She then reviews this with the Practice Partners, who agree relevant changes which are subsequently implemented.

Practice Audit processes

Monkspath Surgery carries out regular checks and audits of our procedures to monitor the quality of our service to patients. We manage, collate, analyse and evaluate all information:

a) About the quality and safety of the care, treatment, support and regulatory compliance achieved by the Practice;

b) Provided by external guidance and reviews issued by national organisations;

c) About the risk(s) to people’s health, welfare and safety.

Clinical Audit is a way that doctors, nurses and other healthcare professionals can measure the quality of the care they provide. They can compare their performance to see how they are doing and identify opportunities for improvement. Changes can then be made and monitored by further audits to see if these changes have been successful. On a regular basis we will monitor and collect data on;

  • Number of patients seen

  • Number of patients treated

  • Number of patients who did not attend appointments (DNA)

  • Patient wait times and patient demand

  • Patient Satisfaction levels

  • Referrals to other healthcare professionals

  • Safety incidents (patient or staff) and outcome of investigations

  • Prescriptions issued and drug management

  • Clinical and non-clinical activities

Clinical Governance

The Practice follows Clinical Governance to ensure we deliver a consistent standard of care to our patients. Clinical Governance is a systematic approach to managing risk, as well as maintaining and improving the quality of patient care. It pulls together the different strands of quality improvement which includes clinical audit, clinical leadership, evidence-based practice and the dissemination of good practice, ideas and innovation and addressing poor clinical performance. In relation to clinical governance, our teams will;

  • Understand their individual and Practice responsibilities

  • Understand their role in delivering a safe service

  • Review and monitor our policies and procedures on a regular basis to stay up to date

  • Take part in our internal Audit processes

  • Take responsibility for their actions, and raise any issues

  • Take responsibility for their training and development, and actively carry out their Continuous Professional Development responsibilities

The Practice will also regularly Audit and monitor their performance and ability to deliver on the following;

  • Infection Control measures

  • Child/vulnerable patients protection

  • Prevention and public health

  • Clinical Records, patient privacy and confidentiality

  • Clinical staff training requirements and development

  • Clinical Audit and Peer Review

Patient Feedback

We care about how patients feel about the service we provide, and encourage them to let us know how we are doing by providing feedback, as well as listening and acting upon views and opinions discussed with members of our Practice Team.

We have a patient comments and complaints procedure and aim to respond promptly – we discuss positive feedback and we want to learn from any shortcomings in the service we provide.

Click here to download a copy of the above information.

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Farmhouse Way, Shirley, Solihull, West Midlands, B90 4EH
  • Telephone 0121 711 1414
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Your Neighbourhood Professionals. Just a Click Away! Set up a lasting power of attorney before you lose capacity and it Don Living with limited mobility? Want to remain independent when at home or out and about? Contact a local mobility aids supplier today Franklin Funeral Directors Ltd Linden Lodge Nursing Home Accuvision - The Eye Clinic Solihull Care Ltd Cambridge Weight Plan, Sarah Bassett Taylors Independent Family Funeral Directors The Solihull Physiotherapy Clinic Ltd
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