Cross Hills is a semi-rural practice on the edge of the Yorkshire Dales, located between Keighley and Skipton. Part of the Airedale Wharfedale and Craven Clinical Commissioning Group, it is a training practice with just over 12,000 patients, ten GPs, one Registrar, two advanced nurse practitioners and a full practice nursing team, as well as dedicated admin support staff.

Their CQC inspection took place at 9am on Wednesday, 11 September 2013. Charlotte Hudson spoke to the Head of Operations, Belinda Seth, to find out exactly what happened...

How did you receive notice of the inspection? 
Well it was classic: I was at my desk, 9am on the Monday morning when I took a phone call and a rather sombre voice spoke: “This is the CQC calling…I am ringing to give you your 48 hours’ notice of inspection.” It was the sort of call that would strike dread into any practice manager’s heart, especially on a Monday morning, because of course I had my whole week ahead planned (in so far as you can plan in this job!).

What was your initial reaction to the call? 
I notified the partners and pulled all the staff together for a short briefing to explain what was going to happen. I also put up notices around the building to make sure everyone was aware that the inspectors would be arriving 9am Wednesday. I tried to put people at ease. My aim was to get across to staff not to be worried because we’re doing a good job and the inspectors are not here to catch us out.

How did you prepare for the inspection?
The CQC is about making sure that practices are delivering a high standard of care in a safe environment that meets patient needs, and clearly this can only be determined by speaking to patients directly

I was less than six weeks into the role when I received the call from the CQC but the interim practice manager had done a lot of work within the practice since registering with the CQC. She had made sure that we had good controls to monitor performance against the CQC outcomes, defined process ownership and documented up to date protocols which had been discussed and cascaded throughout the organisation. We use one of the available CQC toolkits, which helps to structure and identify which protocols are relevant and what actions you need in order to be able to satisfy the different outcomes. This was helpful when it came to sourcing relevant documentation for the inspectors to look at and to focus staff’s attention prior to their arrival.

Did you let patients know about the inspection? 
No I didn’t, and this is one thing that I’ve learnt from because I should have, but wasn’t sure at the time if I was allowed to or not. You can actually advertise the fact, and put up notices in your waiting room.

That said, I did notify the PPG (Patient Participation Group) and arranged for a member of the group to be there at the time of inspection, which the inspectors found helpful.

Did the inspectors speak to patients? 
Yes, there were two inspectors: the main inspector and an accompanying expert. They were understandably very keen to get the patient point of view supporting the concept that the CQC isn’t about ticking boxes, it’s about making sure that practices are delivering a high standard of care in a safe environment that meets patient needs, and clearly this can only be determined by speaking to patients directly.

What were the inspectors like? Did they share information about their background? 
They were very friendly, professional and keen to put people at ease. They said very early on, we are not here to catch you out. I think one inspector was a former nurse who had a keen interest in our advanced nurse practitioners and how we were using that role within the practice, and the other was a practice manager.

How did you feel during the inspection?

Having been in the job less than six weeks it was a bit of a shock but, actually, because I’m an ex-auditor (though not connected with the NHS), I’m very familiar with the auditing process. Also, being new into the job I was secretly pleased that they were coming so soon after I’d started because that would help me to identify anything that I could improve upon very early on so I chose to see it as an opportunity.

What areas of the practice were inspected?

The inspectors were here from 9am until approximately 2pm and they inspected five outcomes:

• Outcome 1: Respecting and involving people who use services
• Outcome 7: Safeguarding people who use services from abuse
• Outcome 8: Cleanliness and infection control
• Outcome 14: Supporting workers
• Outcome 16: Assessing and monitoring the quality of service provision

They did look a little bit at complaints but only reported on the five outcomes.

Did you feel well prepared?

Yes, I’d looked at the outcomes beforehand and tried to take a little bit of control of the process, by scheduling time in with key people within the practice who I felt would be able to give the inspectors the information they needed for those outcomes.

"Be prepared - expect the unexpected but don’t worry about it"

What questions did they ask?

They kind of trawled the whole practice; as well as basing themselves in the waiting room and talking to patients, they also went into the office and selected a few members of staff at random and they were asking them, for example, whether the practice had a process for safeguarding and what they understood by safeguarding – it was quite thorough. We have a GP lead for safeguarding so I made sure that she was available between certain times to speak to the inspectors; for the ‘supporting workers’ outcome they ask how you induct new employees, how you appraise them and develop them, etc, and one of our advanced nurse practitioners had only recently joined the practice and therefore that experience was fresh in his mind, so again I scheduled time with him. Likewise I blocked some time with the practice nurse because of the focus on infection control – they wanted to look at the treatment rooms, etc – so the practice nurse lead for infection control was available to assist.

Did the inspectors have any specific concerns?

We were found to be compliant in all of the outcomes they inspected. They gave little hints and tips along the way but they were very clear from the outset that it was not within their remit to offer advice. They would say things like “some practices have found it useful to do X,Y,Z” but they weren’t recommending specific actions.

"Make it as easy as you can for the inspectors to get the information they need"

How long after the inspection did you receive the report?

They issued a draft report to us on 19 September, eight days after the inspection, and we were given the opportunity to make amendments or add comments to it.

How did the visit end?

Once the inspectors had finished interviewing and looking through documentation they retired to a private room, which we’d set aside for them. They spent about 40 minutes going through everything, before having a 30-minute wrap-up meeting at the end with me, where they outlined what they’d done, what their findings were and gave verbal confirmation that we had been found to be compliant, which was helpful.

What is your advice to other practices facing an inspection?

1. Be prepared – expect the unexpected but don’t worry about it; I don’t feel that they’re looking for perfection, what they’re looking for is an understanding of the CQC requirements and for you to have a mechanism for evaluating and improving your performance on an ongoing basis. If you’re not the best you can be now and you don’t have every schedule and every protocol perfect, I don’t think it matters, providing you can demonstrate that the bones are there and that as a practice you are looking at the outcomes and making progress, and
2. Make it as easy as you can for the inspectors to get the information they need. I’m an ex-auditor and I know that any kind of inspection is not an easy job as you have to navigate round different organisations and interrupt people’s work. Giving them access to a range of people, who are relevant to the outcomes they are looking at, and who can talk to them in an informed way, is helpful to them. It’s in our interests to make it easy for the inspectors and you can take steps to manage the process to minimise disruption to your practice.
3. Get your PPG involved. It is important to get the patient opinion across because at the end of the day unless you subscribe to a very cynical view, CQC inspection is about improving the quality of service and care to patients.

What is your practice doing going forward?

Even though I am delighted that we’ve been found to be compliant on the five outcomes, that doesn’t mean we can become complacent. There are many more outcomes than those they inspected and if CQC inspection stands for quality assurance, designed to prompt improvements to service and the processes that underpin them, then that’s the spirit we take it in. We will continue to review what we’re doing, to ensure all practice staff understand what is required of them and to make improvements where we can and where it is in patients’ interests to do so.

Useful links

• CQC, What to expect from an inspection: GPs and other primary medical services.
• CQC, Guidance about compliance – Essential standards of quality and safety. Visit: www.cqc.org.uk