The Care Quality Commission (CQC) is the independent regulator of health and social care services in England. It registers, monitors and inspects providers of regulated activities including GP practices. Registered providers are expected to meet the regulations set out in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and the CQC (Registration) Regulations 2009.
The system used since October 2014 as the framework for inspection of GP services is based on asking five key questions (see Box 1). We also consider how the practice tailors care to six different population groups (see Box 2). We then rate them as outstanding, good, requiring improvement or inadequate. Sometimes we have to take enforcement action under the legislation when we find that there is a significant risk to patient safety. We have published 4,093 reports on GP practices so far and rated 79.7% as good and 4% as outstanding, despite the overwhelming pressure primary care is facing.
As the national nurse advisor, my remit is to advise on how nursing in primary care should be considered within the CQC’s overall regulatory framework. The practice nurse role has some key characteristics that distinguish it from other branches of nursing. Inspection teams should be aware of this as it contributes to an understanding of the risks associated with the scope and professional autonomy of the role.
A vital part of my role is contributing to training for inspectors, both introducing people to the role and developing those who have more experience or have worked in other sectors such as hospitals and care homes. Obviously, practice nursing reflects the wider picture in primary care; it is fast paced and constantly changing.
I sometimes use the childhood immunisation schedule and the additions to it over the last few years to demonstrate the complexity of the knowledge base required. Then I explain the tight timescales that nurses operate in; from acting on the announcement of a new vaccine to consulting with a parent and baby in a 10-minute slot.
My primary care nursing experience has also been useful beyond regulation of GP services. We have recently started inspecting independent travel clinics. As pre-travel health advice (including vaccination) is often delivered by nurses in primary care, I have been able to use my experience to advise on the standards to be expected.
All the key questions we ask have relevance to the nursing service as nurses are such a key part of the wider team and crucial to delivery of all aspects of primary care. The areas we look at range from systems for storing medicines appropriately, including management of the cold chain, to the training undertaken to collect samples for the cervical screening programme, manage long-term conditions or provide first-contact care.
The provider is responsible under the regulations for ensuring staff are competent for their role. There are many ways to obtain and maintain competency and no standard entry-level training exists for the role of a practice nurse. It is therefore important for GPs, practice managers and nurses to demonstrate initial training and the different mechanisms the practice uses to ensure nurses stay up to date with evidence-based practice.
Well-organised practices support nursing teams to monitor their performance such as through audit and analysis of significant events as well as attendance at appropriate training events. Inspectors have to strike a careful balance and recognise that while no single training course may exist for the role, patient safety has to be maintained and regulation exists to underpin that principle. This is particularly true for nurses who have developed their practice into extended roles such as clinical assessment and diagnosis.
A rewarding part of my role is attending inspections and meeting the nursing and wider practice teams. It is fascinating to see the different ways practices organise care and I have certainly learned an enormous amount about efficient use of resources and nurses’ talents. It has also been evident that some of the myths and anxieties associated with CQC inspections have faded as the months have gone by, if not entirely disappeared. Although I realise news of an inspection may be greeted with apprehension, hopefully it is no longer a dreaded event and some practices take it as an opportunity to showcase the quality of their service – and deservedly so.
I always ask nurses if they have identified and addressed a particular need to enhance patient care. Often they believe these initiatives are standard practice, but it is not the case. On a recent inspection at a large practice, the nursing team was constantly alert to the possibility of undiagnosed diabetes and consequently had a higher register of patients, and therefore workload. However, they still managed to offer all patients an hour’s appointment within 10 days of diagnosis. The aim was to start the process of education and psychological adjustment that is so vital to help the patient come to terms with a life-long diagnosis.
I have particularly enjoyed meeting nurses and practice managers when I’ve been asked to speak at conferences and meetings. The main reason I chose this job was to use my primary care background to improve care. I use every opportunity to clarify expectations around the regulatory process and hopefully allay fears. I also discuss key themes that have emerged as the inspection programme has progressed and it’s clear that nurses are often the innovators. They are willing to learn from the experience of other practices, to look at their own systems and move forward to make improvements if necessary.
I’ve enjoyed contributing to the work of the CQC over the last two years and I have been very fortunate to have this opportunity to use my primary care experience. I’ve tried to ensure there is recognition of both the high standard of nursing care in GP practices and some of the inherent risks.
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