Wigan CCGGP LCS Post
Payment Verification and
Quality Audit Report
Dicconson Group Practice
Tuesday 28th April – 9:30am
Contents
1. Fitness to Practice
2. Patient Experience
3. Anti-Coagulation
4. Asylum Seekers
5. Choose & Book
6. Continuing Care
7. End of Life Care - EOL
8. Near Patient Testing
9. Ring Pessary
10. Proactive Screening for Patients Aged Over 75
11. CSU Post Audit Recommendations
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Practice Name
Dicconson Group Practice
Practice Number
P92003
Practice Address
Boston House, Wigan Health Centre, Frog Lane,
Wigan, WN6 7LB
Practice Telephone Number
01942 482070
Lead GP Name
Dr P Southern
Practice Manager
Janette Cooper (Practice Manager)& Gail
Harrison (Deputy Practice Manager)
CSU Team Member
Job Title
Amy Durrant
Contract Support Assistant
RAG Rating
Rationale
Red
Doesn’t meet the expected standard, action required.
Amber
Partially meets the expected standard, improvement required.
Green
Expected standard has been observed, no action required.
1. Fitness to Practice
1
GMC GNMC
Registration
Renewal Date
Professional
Indemnity
Renewal Date
Name
Role
Dr P Southern
Lead GP
No.xxxxx
01/08/2015
MPS No.xxxxx
31/05/2015
Dr K Hosie
GP
No. xxxxx
04/08/2015
Dr L Hosie
GP
Dr J Davies
Evidence of CPD
Date of Safeguarding Training
Safeguarding Adults refresher –
12/03/2015, Child Abuse training –
07/08/2013
DBS Status
No. xxxx - 08/04/15
Full and up to date training
record observed.
MPS No.xxxxx
31/05/2015
Child Abuse training – 12/09/2014
No. xxxx 31/03/2015
Full and up to date training
record observed.
Noxxxxxx
01/08/2015
MPS No. xxxxxx
31/05/2015
Safeguarding Adults refresher –
14/03/15, Mental Capacity Act
training – 19/03/15
No. 0xxxxx
23/03/2015
Full and up to date training
record observed.
GP
No.xxxxx
01/08/2015
MPS No.xxxxx
31/05/2015
Child Abuse training – 17/07/2012
DBS has recently
been applied for
Full and up to date training
record observed.
Dr J Graham
GP
Noxxxxx
01/08/2015
MPS No.xxxxx
31/05/2015
Child Abuse training – 17/07/2012
DBS has recently
been applied for
Full and up to date training
record observed.
Dr A Tolba
GP
No. xxxxx
04/08/2015
MDDUS –
31/05/2015
Safeguarding Adults Level 3 –
16/03/15, Child Abuse Training –
16/03/15
DBS has recently
been applied for
Full and up to date training
record observed.
Sister Carole Mason
Practice Nurse
31/07/2015
AVIVA No.
Oxxxxx
Child Abuse Training – 30/03/15
Sister Clare Twist
Practice Nurse
30/09/2015
AVIVA No. Oxxxx
Child Abuse Training – 13/03/15
DBS has recently
been applied for
No. xxxxxx27/07/12
Full and up to date training
record observed.
Full and up to date training
record observed.
Public Liability
Renewal Date
AVIVA No. xxxxx
CQC Registration
Status
Registered
CQC Inspection
Status
Not yet inspected
2. Patient Experience
2.1 Patient satisfaction questionnaire
2.2 Complaints log and action record.
RAG Rating
Comments
Observed - received a copy of the questionnaire and results via email. The practice uses
the Friends & Family questionnaire; copies are distributed to every patient at reception
and are also available on the practice website. If a patient makes a complaint or
compliment, they will also be encouraged to complete a questionnaire. The results are
then collated by the Practice Manager (PM) and a record of performance is documented
every month; statistics of the results are also created and analysed. Comments made on
the questionnaire are also collated and discussed with the Practice Participation Group
to see if there any action points for the practice to implement. On a quarterly basis, a
sample of comments will be taken to see if there are any common themes to focus on,
and the questionnaire will be adapted accordingly. A comments board is also currently
being developed so results can be clearly displayed in the practice.
Observed - received a copy of the complaints log and action record. If a patient makes a
practical or administrative based complaint, the Deputy PM will try and resolve this at
the time of the complaint. Clinical complaints are dealt with by the PM who will organise
a meeting with the patient in the first instance. The meeting minutes and outcome are
recorded and sent to the patient within 3 working days; a full response is also given
within 10 working days. If the complaint is regarding a GP, that GP will also call the
patient to apologise. Once the investigation is complete, the patient will be telephoned
patient to see if they are happy with the resolution. If they still wish to take it further, the
details of the CCG will be passed on.
2.3 Complaints / compliments procedure is clearly
displayed for patients.
Observed – complaints and compliments procedure is clearly displayed in reception; it is
also included in the new patient pack and published on the website.
2.4 Serious Incidents are recorded and reported
Observed – received a copy of the Serious Incidents procedure via email; the practice
has not yet had any Serious Incidents.
2.5 Up to date health promotional/educational
material is made available to patients.
Observed – full and extensive range of health promotional materials are readily available
on reception.
2.6 Demonstrate that 100% of SUIs are reported to
the CCG within 72 hrs.
See section 2.6; the practice has not yet had any serious incidents, but has a procedure
in place.
3. Anti-Coagulation
3.1 Evidence that an up to- date register of all anti-coagulation monitoring service
patients is in place.
3.2 Identify what referral policies are in place to other services. E.g. WWL service
for patients requiring hospital level care
RAG Rating
Comments
Observed. The practice’s clinical system has searches that checks patients’
INR readings at 4, 8, and 12 weeks. If a patient falls out of these checks, the
Health Care Assistant will contact them; if the patient cannot be contact the
Warfarin clinic will be contacted instead. No repeat prescriptions are issued to
patients without their latest INR reading.
If patient needs treatment for an anti-coagulation related illness, they will
already be in the practice system as requiring this. If a patient has a new
diagnosis, they will be referred back to Secondary care. There are also a
couple of practices in the local area who will soon deliver Level 5 Interpractice Anti-coagulation; once these have been set up, referrals will be
made to these practices.
3.3 Ensure management plans are in place and that they are recorded in the
patient’s yellow anticoagulant record book.
Yes – each patient has an individual management plan recorded in their
yellow book. Both staff and patients know the importance of documenting
everything in there.
3.4 Evidence that an annual review of patients’ health is carried out.
Yes – all patients are on the clinical recall system, and are automatically
called in for an annual review. A dedicated member of the practice staff
checks the chronic disease recalls to ensure they are efficient and up to date.
3.6 Inter Practice Referral Anti Coagulation The following additional evidence
should be made available for assessment by providers who offer the Level 5
service:
A signed Inter Practice referral agreement between participating GP practices
N/A – the practice does not deliver Level 5 Inter Practice Anti Coagulation.
3.7 A call and recall system is in place that is able to operate across practice
boundaries
N/A – see above
3. 8 A single IT anti - coagulant management system is in place which has the
functionality outlined within the service specification
N/A – see above
3.9 Clinic sites are used which provide easy access to patients registered with
any practice in the collaboration
N/A – see above
3.10 Post payment verification audit to include: a number of patients
Invoices and supported documentation verified and reconciled for: Quarter 4
2014/15 – 114 patients:
4. Asylum Seekers
4.1 Evidence that a provider offers a period of time to allow registration to be
completed outside of the clinical process
RAG Rating
Comments
Yes - many Asylum Seeker patients will not turn up for their new patient
check, so on their initial appointment they are given a new patient pack
and offered another appointment for their new patient check to include
extra time for registration within that week. The practice has dedicated
slots for Asylum Seeker patients every week that are 20 minutes longer
than normal appointments. If it is clear a patient needs urgent help, they
will be automatically referred to a GP.
4.2 Evidence that a comprehensive mental and physical assessment to
identify any serious ongoing problems and the physical or mental effects of ill
treatment is undertaken
Yes – the new patient check includes a comprehensive mental and
physical assessment; if any serious issuesare flagged up, the patient will
be directed and referred appropriately.
4.3 Provide an up-to-date register of all patients eligible for the asylum
seeker service.
Yes – observed a copy of this. The practice’s clinical system will also
flag up patients that have not had their new patient checks, therefore
could be eligible for this service.
4.4 Evidence that records are maintained of the performance and result of
the service provided. Ensure that all clinical information related to this
service is recorded in the patient’s own GP held lifelong record.
Yes – observed performance records of this service. Full clinical records
are made for each patient.
4.5 The Provider must ensure that all staff involved in providing any aspect
of care under this Enhanced Service have the necessary training and skills
to do so E.g. General awareness raising training of issues affecting Asylum
seekers / Equality & Diversity
Observed – Equality & Diversity Tier 1 training certificate for Dr L Hosie
– 27/01/14
4.6 Post payment verification audit to include: a number of patients
Invoices and supported documentation verified and reconciled for:
Quarter 2 2014/15 - 1 patient:
5. Choose & Book
5.1 Evidence that a Referring Clinician, normally the patient’s GP,
initiates a choice offer and discusses the clinical aspects of choice with
patients.
RAG Rating
Comments
Yes – if the referral is to a speciality clinic or provider, patients will be offered a
full and comprehensive choice of prospective places. The GP will have a
discussion of preference of location and private providers, and give the patient a
list of choices within a 50 mile radius of the practice. If a patient wishes to be
referred to a provider that cannot be found on Choose &Book, the practice will
contact the provider directly to enquire if the patient can be referred there.
5.2 Evidence that patients are given access to meaningful information to
support their choice decision e.g. signposting to provider website / NHS
Choices or Leaflets
Yes – observed a copy of provider information that is given to the patient.
Information of all suitable providers is presented to patient to aid their decision.
5.3 Ensure that all Provider Staff are suitably qualified and competent.
Internal arrangements must be in place for maintaining and updating
relevant skills and knowledge base
Yes – all staff are competently trained and qualified in order to deliver this
service.
5.4 Post payment verification audit to include a sample number of
referrals are made via Choose and Book
Observed documents of every referral made via C&B; for example: 16/02/15 –
11 Choose & Book referrals, 17/02/15 – 1 Choose & Book referral, 18/02/15 –
4Choose & Book referrals
6. Continuing Care
RAG Rating
Comments
6.1 Any provider falling below performance level C (see below table)
will receive a 40% reduction in payment.
Practice unsure of what needs to be evidenced; CSU to clarify with CCG.
6.2 Post payment verification audit to include: a number of patients
To follow.
Key Performance
Indicator
CHC
Description
The number of multi-disciplinary meetings attended as
a percentage of GP Pro-formas completed
Performance Level
A
B
C
95%
80% <80%
7. EOL – End of Life Care
RAG Rating
Comments
7.1 Evidence that practices have received in-house education on
Advance Care Planning and that Advance Care Planning
document/leaflets have been received.
Observed copies of the Advanced Care Planning documents.
7.2 Evidence that the provider has the minimum end of life care
data set.
Observed the minimum data set on the practice’s clinical system; the
practice is currently in the process of ensuring all patients are correctly
coded for this service. The practice also has meetings to discuss the data
set.
7.3 Maintain and keep up to date EPaCCS for all patients with life
limiting palliative care condition.
N/A – EpaCCS has currently not been implemented by the CCG.
7.4 Ensure that all clinical information related to the use of
EPaCCS is recorded in the patient’s own GP held lifelong record,
including the completion of any Adverse Incidents;
N/A – see above.
7.5 Evidence that the practice has at least one named GP
coordinator for Palliative and End of Life Care.
Yes – Dr LHosie.
7.6 Post payment verification audit to include: a number of patients
The practice has yet to make a claim for this service; Advanced Care
Planning training invoice observed for all GPs.
8. Near Patient Testing - NPT
8.1 Ensure an up-to-date register is in place that includes an
individual management plan for each patient.
RAG Rating
Comments
Observed a copy of the NPT register – searches are set up in the practice’s
clinical system corresponding to each of the NPT drugs that show a list of all
patients receiving that drug and what blood tests are needed. The HCA will
monitor the NPT patients in the same way as they monitor the AntiCoagulation patients (see section 3.1).
8.2 Evidence that patients received advice on the importance and
frequency of blood test monitoring and are informed of how to
access relevant information.
Yes – all patients receive written and verbal information on the importance of
frequent blood test monitoring.
8.3 Post payment verification audit to include: a number of patients
Invoices and supported documentation verified and reconciled for: Quarter 4
2014/15 – 30 patients -
9. Ring Pessary
RAG Rating
Comments
9.1 Evidence that staff delivering the service have appropriate
clinical experience and training
The practice GPs satisfy at revalidation that they have the necessary experience
and training to deliver this service. The practice nurse is currently undertaking a
gynaecological course.
9.2 Evidence that consent is asked for from any patient
repatriated from secondary care
The practice is currently not repatriating any patients from secondary care; the GP
is currently waiting for any patients from secondary care to stabilise before they
are seen at the practice.
9.3 Evidence that the provider issues a clinical discharge letter
informing the patients registered practice of the care delivered
to the patient (Inter Practice referrals received only).
N/A – the practice does not receive any Inter Practice referrals.
9.4 Evidence that Read Codes are used for each
procedure/patient and attached to any correspondence to the
patient’s registered GP Practice.
Yes – observed a copy of the register; all patients are correctly read coded.
9.5 Post payment verification audit to include: a number of
patients
Invoices and supported documentation verified and reconciled for: 1 Aug 2014 – 1
Feb 2015: 18 patients -
10. Proactive Screening for Patients Aged Over 75
10.1 Evidence that call and recall processes are established to support
screening all patients aged 75 and over registered with the practice.
RAG Rating
Comments
Observed – the PM runs a report on all patients over 75 that excludes
patients on admission avoidance, housebound patients and patients with a
chronic disease. Dedicated staffwill look through this report weekly to
determine who needs to be called and recalled for this service. Patients
called in for this service will be seen by the nurses; if a patient is attending
for their diabetic annual review, extra time will be added on to their
appointment. If a GP needs to see a patient, they will have an allocated
appointment time for patients on this service. For anything urgent, the
practice has a duty doctor system; the patient will see a nominated GP on
that particular day to deal with acute problems.
10.2 All patients who are screened should have a Read Code placed into their
notes that will enable the CCG to monitor the healthcare utilisation of patients
prior to and after being screened.
Yes – observed a copy of the patient register with the Geriatric Health
Screening code.
10.3 Evidence that patients are subject to GP referral and follow up
irrespective of their Edmonton Frailty score when changes to their medical
condition are identified via the supplementary health questions or Urinalysis.
Observed – see section 10.1.
10.4 Evidence of what approach/tool is taken to review patients with
Polypharmacy issues
Yes – patients with Polypharmacy issues are subject to a full medications
review with their GP.
10.5 Post payment verification audit to include: a number of patients
Invoices and supported documentation verified and reconciled for: 1st
September 2014 - 31st January 2015:
11. CSU Post Audit Recommendations
Issue Identified
Recommendation

No CSU recommendations.
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