Gildersome Health Centre 

IS PROUD TO BE A SAFE SURGERY FOR
EVERYONE IN OUR COMMUNITY
In recognition of the barriers to healthcare access faced by people in vulnerable
circumstances, including migrants, we commit to protecting the human right to health.
We will take steps to ensure that everyone in our community may fulfill their
entitlement to quality healthcare.
In partnership with Doctors of the World UK, we will ensure that our practice offers a
welcoming space for everyone who seeks to use our services.
Mindful of our duties to uphold equality and human rights law, we will implement
patient registration policies which do not discriminate based on race, gender, sexual
orientation, immigration status or any other characteristic.
Supported by the Safe Surgeries initiative, we will ensure that our staff understand
the specific barriers faced by migrants in vulnerable circumstances and that they are
empowered to mitigate these barriers, where possible.
We will ensure that a lack of identification or proof of address, immigration status or
language do not prevent patient registration.
As a member of the Safe Surgeries community, we will endeavour to support other
Safe Surgeries and, where appropriate, provide feedback to Doctors of the World UK
to support the development of the network

POLICY STATEMENT

 

This Practice recognises, as with all other NHS bodies, the statutory duty to ensure that we make arrangements to safeguard and promote the welfare of children and young people, and to protect adults at risk.

All staff employed by the Practice, in-line with other NHS funded services and employees, have a responsibility to ensure children and adults in vulnerable circumstances are kept safe, by early detection and by responding quickly when problems are identified.

The Practice and all our staff members have a statutory responsibility to ensure we have in place safe systems to safeguard children and adults at risk; that comprehensive single and multi-agency policies and procedures reflect a need to safeguard and promote the welfare of children and protect adults at risk from abuse or the risk of abuse.

 

INTRODUCTION

All staff within health services have a responsibility to promote the safety and wellbeing of patients and colleagues. The opportunity to live a life free from harm and abuse is a fundamental human right and an essential requirement for the maintenance of health and well-being. Safeguarding is about the safety and well-being of all patients and demands that professionals adopt additional measures for those least able to protect themselves from harm or abuse, ensuring that hearing the voice of the child and adult at all times remains a key focus for professionals.

“Safeguarding means protecting people's health, wellbeing, and human rights, and enabling them to live free from harm, abuse and neglect. It's fundamental to high-quality health and social care.” (Care Quality Commission, 2016)

Safeguarding is a responsibility for all of us and cannot be achieved by a single person or organisation; it is important to understand that it is not just the business of front-line service staff, it is everyone’s business; doing nothing is not an option.

Safeguarding adults, young people and children at risk is everyone’s business and is defined as:

·         Prevention of harm and abuse through high quality care.

·         An effective response to allegations of harm and abuse, in line with multiagency   procedures.

·         Using learning to improve services to patients.

 

The Practice recognises that General Practitioners (GPs) and practice staff are often the first point of contact for those people with health problems and may represent the first and only service to have contact with an adult or child at risk, who is being abused or neglected. It is important that any response is appropriate and timely, thereby preventing the potential long-term effects of abuse and neglect. 

The Practice staff within Gildersome Health Centre are responsible for sharing concerns appropriately and referring to relevant agencies, as well as for co-operating with any subsequent safeguarding enquiries that are initiated.

Staff can access support and advice from the Named Safeguarding Leads within the practice:

Gildersome Health Centre - Safeguarding Leads-

Dr Steven D’Souza is Clinical Safeguarding Lead for children within the practice.

Dr Navneel Shahi is Clinical Safeguarding Deputy Lead for children within the practice. 

Dr Steven D’Souza is Clinical Safeguarding Lead for adults within the practice.

Dr Navneel Shahi is Clinical Safeguarding Deputy Lead for adults within the practice.

 

 

Home Visit Policy

Home Visits

If possible, please try to telephone reception before 10am if you require a home visit. On most occasions one of the doctors will be available for advice. Your GP will only visit you at home if they think that your medical condition requires it and will also decide how urgently a visit is needed.

If there is a need for a home visit a GP, an Advanced Nurse Practitioner or the community nursing team may visit you as appropriate. Below is a guide which is kept at the surgery for reference

Home Visit Policy

Home Visits are reserved for the following groups of patients: –

Terminally ill 

Would come to serious harm if moved

Patients who are severely ill in bed / bedbound

Please request visits before 10 00 hrs whenever possible. Reception staff will ask the reason for the visit. The necessity and urgency will be assessed by the Duty Doctor, Nurse, or Paramedic. On occasion another member of the team may be deemed more appropriate to visit e.g., district nurse, phlebotomist etc... You cannot insist that a GP visits you at home.

GP's are better able to assess patients in the surgery where they have access to specialist equipment, good lighting and examination facilities and it is always the preferable site for any consultation.

GPs are not obliged to visit a patient if they have assessed the patient's clinical need on the telephone and found them to be suitable for an alternative method of healthcare.

As long as a GP has provided a plan for a patient (which may be an appointment the same day, a future day, telephone advice or attendance at another healthcare site such as A&E and this is communicated to the patient then the practice will support any such decision made.

The following ARE NOT valid reasons to perform a home visit: –

Transport issues for the patient It is not the GP practice responsibility to arrange transport, or to perform home visits because the patient has difficulty arranging or funding transport. In these circumstances patients should seek transport help from relatives, friends, or taxi firms.

Childcare issues for a patient.

 If a patient has difficulty arranging for someone to care for their children whilst attending appointments, the patients are welcome to bring their children to the surgery.

Poor mobility.

Whilst it is understood that having poor mobility is inconvenient and unpleasant, GP surgeries are designed to cater for patients with restricted mobility. We have ramps and our reception team are happy to help. If patients can attend appointments at other healthcare settings, then they should also be expected to attend appointments in GP surgeries. If patients can attend social events, family gatherings etc. outside of their home then they should be expected to attend appointments at Gildersome Health Centre.

An unwell child

It is in the best interest of the child to attend the surgery where they can be properly assessed and treated. The clinician can make a more informed clinical judgment when seeing the child in surgery. If a parent believes that the child is too unwell to travel to surgery and is a medical emergency, then it would be advisable for them to seek help from the emergency services by calling 999.

We thank you in advance for respecting our policy and helping us to care for you and our other patients.

Introduction

 

This policy is designed to protect both patients and staff from abuse or allegations of abuse and to assist patients to make an informed choice about their examinations and consultations.

  

Guidelines

Clinicians (male or female) should consider whether an intimate or personal examination of the patient (male or female) is justified, or whether the nature of the consultation poses a risk of misunderstanding. 

 

• The clinician should give the patient a clear explanation of what the examination will involve.

 

•  Always adopt a professional and considerate manner - be careful with humour as a way of relaxing a nervous situation as it can easily be misinterpreted.

 

• Always ensure that the patient is provided with adequate privacy to undress and dress.

 

• Ensure that a suitable sign is clearly on display in each consulting or treatment room offering the chaperone service.

 

This should remove the potential for misunderstanding. However, there will still be times when either the clinician, or the patient, feels uncomfortable, and it would be appropriate to consider using a chaperone.  Patients who request a chaperone should never be examined without a chaperone being present. If necessary, where a chaperone is not available, the consultation/examination should be rearranged for a mutually convenient time when a chaperone can be present.

 

WHO CAN ACT AS A CHAPERONE ?

 

A variety of people can act as a chaperone in the practice. Where possible, it is strongly recommended that chaperones should be clinical staff familiar with procedural aspects of personal examination. Where suitable clinical staff members are not available then non-clinical staff can chaperone.

 

Where the practice determines that non-clinical staff will act in this capacity the patient must agree to the presence of a non-clinician in the examination, and be at ease with this. The staff member should be chaperone trained, comfortable in acting in the role of chaperone, and be confident in the scope and extent of their role. They will have received relevant training on where to stand and what to watch for.

 

CONFIDENTIALITY 

The chaperone should only be present for the examination itself, and most discussion with the patient should take place while the chaperone is not present.

Patient should be reassured that all practice staff understand their responsibility not to divulge confidential information.

PROCEDURE 

The patient will have advised Reception staff on arrival that they require a chaperone or the clinician will contact Reception to request a chaperone if the patient confirms they require one when asked for the examination. The chaperone will be a non-clinical member of staff unless a clinical member of staff is available. The patient must be made aware of this.

The clinician will record in the notes that the chaperone is present, and introduce the chaperone to the patient.

Where no chaperone is available the examination will not take place – the patient should not normally be permitted to dispense with the chaperone once a desire to have one present has been expressed.

The chaperone will enter the room discreetly and remain in the room until the clinician has finished the examination.

The chaperone will attend at the head of the examination couch and watch the procedure

To prevent embarrassment, the chaperone should not enter into conversation with the patient or GP unless requested to do so, or make any mention of the consultation afterwards.

The chaperone will make a record in the patient’s note after the examination. The record will state that there were no problems, or give details of any concerns or incidents that occurred.

The patient can refuse a chaperone, and if so this must be recorded in the patient’s medical record.

If the clinician requests a chaperone and the patient refuses then the clinician will have final say and the patient may need to rearrange the appointment for another time.

 

 

Executive Summary

 

This Policy sets out the manner in which the practice wishes to ensure a consistent approach to Data Quality, in support of legislative, regulatory, statutory and business requirements.

 

Data Quality is defined within this policy as the; accuracy, validity, reliability, timeliness, relevance, completeness and robustness of data. Everyone who is involved in the collection and recording of information is responsible for ensuring its accurate collection in order to minimise risks to the organisation or individuals.

 

Information Asset Owners (IAO’s) are responsible for ensuring documented procedures and processes are in place to ensure the accuracy of information including service user information on all systems and/or records, including those that support the provision of care in addition to being responsible for ensuring adequate training is provided to staff to ensure the accurate collection of information, including service user information and onward reporting of high quality information.

Data Quality Policy

 

Introduction

 

The Practice recognises that all of their decisions, whether health care, managerial or financial need to be based on information which is of the highest quality. Data quality is crucial and the availability of complete, accurate, relevant and timely data is important in supporting patient care, governance, management and service agreements for health care planning and accountability. 

The Practice aspires to the highest standards of clinical competence and corporate behaviour  to ensure that safe, fair and equitable procedures are applied to all organisational transactions, including relationships with patients their carers, public, staff, stakeholders and the use of public resources. 

The importance of having robust systems, processes, data definitions and systems of validation in place to assure data quality is part of this process. The quality of data can affect the reputation of the Practice and may lead to financial penalty in certain circumstances, e.g. failing to meet contractual requirements, QoF expectations and other reportable outcome measures. 

The purpose of this policy, is to provide general principles for the management of all data and guidance. This is to ensure that the Practice can take decisions based on accurate and complete data and can meet its various legal and regulatory responsibilities.

 A data quality policy and regular monitoring of data standards are a requirement of the NHS Data Security Protection Toolkit 

Information accuracy is also a legal requirement under the GDPR/Data Protection Act 2018

 This policy provides the framework to mitigate against the risk of poor data quality and enable individuals within the Practice to take direct responsibility for any data they record or omit to record.

 

Aims 

Ever-increasing use of computerised systems provides greater opportunities to store and

access large volumes of many types of data but also increases the risk of misinformation if

the data from which information is derived is not of good quality.

 

This risk applies to information for the Practice’s internal use and to information conveyed in the form of statutory returns to the national databases

 

For our information to have value, it is essential that the underlying data is consistent and

complies with national standards. NHS Practices are assessed, judged and sometimes paid for on the quality of the data they produce

.

National statistics, performance indicators and audit assessments depend on good quality data for their accuracy and include data quality amongst their number.

 

The Data Quality Policy underpins the practice’s objective to record and present data of the highest possible quality and that all users of the information can be confident about its accuracy.

Scope

This policy must be followed by all staff who works for or on behalf of the Practice including those on temporary or honorary contracts, secondments, volunteers, pool staff, students and any staff working on an individual contractor basis or who are employees for an organisation contracted to provide services to the Practice.  The policy is applicable to all areas of the organisation and adherence should be included in all contracts for outsourced or shared services. There are no exclusions.

 

This policy is applicable to all data held and processed by the Practice.

 

All data must be managed and held within a controlled environment and to a standard of accuracy and completeness. This applies to data regardless of format.

 Written procedures will be available in all relevant locations within the Practice to assist staff in collecting and recording data. These procedures will be kept up-to-date, and where appropriate will also contain information relating to national data definitions.

 Processes will be established to ensure compliance with the procedures, which will include sample checks to audit compliance. 

It should be noted that all collection, storage, processing and reporting of personal information is governed by detailed legal requirements under the GDPR/Data Protection Act 2018 and associated standards, such as the Caldicott2 guidelines and Health and Social Care Act 2012 

As the Practice generates a very wide range of information for a whole variety of uses, this policy does not provide detailed guidance for specific data items or individual areas of application. It concentrates instead on general principles of completeness, accuracy, ongoing validity, timeliness, consistency of definitions and compatibility of data items, and signposts where specific procedures or further guidelines need to exist.

 

·         Patient Care – in the delivery of effective, relevant and timely care, thereby minimising clinical risk. 

·         Good Clinical Governance – a pre-requisite for minimising clinical risk and avoiding clinical error and misjudgement. 

·         Disclosure – ensuring that clinical and administrative information provided to the patient and authorised health partners, including external partners is of the highest quality. 

·         Business planning – ensuring management can rely on the information to make informed and effective business decisions. 

·         The measurement of activity and performance to ensure effective distribution and use of Practice resources. 

·         Regulatory reporting – to ensure compliance with the standards and targets as laid down in measures such as QoF, DSP toolkit etc 

·         Good corporate governance – which, as above, has data quality as a pre-requisite to ensure effective business management. 

·         Legal compliance – ensuring that the Practice conforms to its legal obligations as laid down in relevant legislation, such as GDPR/Data Protection Act 2018. 

·         Education and Training – in the development and delivery of quality education and training provision.

 

General Guidelines and Principles of Data Quality

 

Supplying accurate data is a complicated task for a number of reasons: 

·         There are many ways for the data to be inaccurate – data entry errors and incomplete data, etc. 

·         Data can be corrupted during translation depending on who is translating it, how and with what tools/processes. 

·         Data must relate to the correct time period and be available when required.

 ·         Data must be in a form that is collectable and which can subsequently be analysed. 

To ensure an organisation achieves data quality, it must set out how :

 

·         Data is collected and co-ordinated.

·         Data is transferred between systems.

·         Data is organised.

·         Data is analysed.

·         Data is interpreted.

·         Conclusions and results drawn from the data are validated.

 The following overarching principles underpin the approach to data quality:

 ·         All staff will conform to legal and statutory requirements and recognised good practice, aim to be significantly above average on in-house data quality indicators, and will strive towards 100% accuracy across all information systems. 

·         All data collection, manipulation and reporting processes by the Practice will be covered by clear procedures which are easily available to all relevant staff, and regularly reviewed and updated. 

·         All staff should be aware of the importance of good data quality and their own contribution to achieving it, and should receive appropriate training in relation to data quality aspects of their work. 

·         Teams should have comprehensive procedures in place for identifying and correcting data errors, such that information is accurate and reliable at time of use.

Validity is supported by consistency over time, systems and measures; data must be collected, recorded and utilised to the standard set by relevant requirements or controls. Any information collection, use or analytical process must incorporate an agreed validation method or tool to ensure the standards and principles outlined above are met. Validation tools will support routine data entry and analysis, as well as supporting the identification and control of duplicate records and other errors.

 

Accountability and Responsibilities

There are a number of key information governance roles and bodies that the Practice needs to have in place as part of its Information Governance Framework, these are:

 

·         DPO

·         Partnership Committee

·         Governance, Performance and Risk Committee

·         Caldicott Guardian

·         Information Asset Owner/Administrator

·         Heads of Service/department

·         All employees

 

Within the Practice there are formally documented structures of accountability for Data Quality:

 

·         Every individual that is a registered user of a Practice System is responsible for ensuring the Data Quality of records when using the system. Should individuals knowingly enter data that breaches the previously described Data Quality standards there are disciplinary procedures that can be invoked.

 

·         The Lead GP has overall responsibility for data quality systems and processes in the Practice. The Lead GP is responsible for signing off any statement of assurance of clinical data quality

 

·         Managers are responsible for ensuring the quality of data within their teams, adhering to this policy and implementing the associated Data Quality Management Procedure.

·         All staff have a responsibility to ensure the data they enter onto any system – electronic or manual is of good quality and follow Practice and local procedures for the validation of data.

 Data quality is a key part of any information system that exists within a Practice. All staff members will be in contact at some point with a form of information system, whether paper or electronic. As a result, all staff members are responsible for implementing and maintaining data quality and are obligated to maintain accurate information legally (Data Protection Act), contractually (contract of employment) and ethically (professional codes of practice).

 It is the responsibility of all managers to ensure that, where appropriate, systems are in place to validate the completeness, accuracy, relevance and timeliness of data/information. Also managers must ensure that all staff are fully aware of their obligations in this area. In certain circumstances, to support equality and diversity, line managers will need to consider individual requirements of staff to support good practice in complying with this policy.

 Ultimate responsibility for maintaining accurate and complete data and information lies with the Lead GP but all staff who record information, whether on paper or by electronic means, have a responsibility to take care to ensure that the data is accurate and as complete as possible. Individuals with responsibility for data quality must have this clearly stated in their job descriptions.

 

External Sources of Data

 

Where possible validation processes should use accredited external sources of information e.g. using Patient Demographic Service (PDS) to check NHS numbers, . Staff involved with recording data need to ensure that it is performed in a timely manner and that the details being recorded are checked with the source at every opportunity.

 The NHS number is the main patient identifier and must be recorded correctly and in all systems where patient information is present. The NHS number should be used in all referral forms and letters. The Data Security and Protection  Toolkit requires evidence outlining the NHS number is used and there is a mandatory NHS number field in all documentation and systems.

 

Procedure for data quality management 

individuals listed in the “Accountability and Responsibilities” section  will adhere to published procedures, or standard operating procedures, as indicated in order to discharge this policy in their domain.

 

Training

 

The importance of data quality will be included in: 

The Practice’s mandatory training and induction programme

 General Clinical System  training offered to all staff

 Training issues with systems and/or other specific processes should be addressed on an individual basis as they arise.

 

Process for monitoring compliance with this policy

 

Data quality is ultimately the responsibility of department leads where the specific data are being generated. Processes for ensuring high data quality will differ between teams and should be implemented and reviewed locally.

Associated documents

 

This policy should also be considered in conjunction with all the policies and legislation, especially those highlighted below:

 

Confidentiality Code of Conduct

Information Governance Policies

Records Retention Schedule