How are you going to ensure that the improvements have been made and are sustainable? What measures are going to put in place to check this? Online training company provides personal portfolios for all staff which are regularly accessed and reviewed to ensure that these are up to date. Internal training records also managed through practice spreadsheet records which are reviewed monthly. Who is responsible? Maxine Cox What resources (if any) are needed to implement the change(s) and are these resources available? External training facility accessed and training undertaken by team members Date actions will be completed: Completed 15.8.16 How will people who use the service(s) be affected by you not meeting this regulation until this date? Not applicable all actions completed to achieve regulation standard compliance – Regulated Regulation activity(ies) Diagnostic and Regulation 15 HSCA (RA) Regulations 2014 Premises and screening equipment procedures Family planning How the regulation was not being met: services Surgical Regulation 15(1)(a) procedures We did not find the required documentation under the control of Maternity and substances hazardous to health for cleaning equipment. midwifery services Regulation 15(1)d 15(1)e Treatment of disease, disorder or We found fire alarm testing was undertaken on an ad-hoc basis and injury. emergency lighting was not properly checked by the practice. We found staff had not had recent updates in regard to fire safety and had not undertaken fire evacuation practice. The practice did not provide a mains electrical system testing certificate on request. Regulation 15(2)
How are you going to ensure that the improvements have been made and are sustainable? What measures are going to put in place to check this? Online training company provides personal portfolios for all staff which are regularly accessed and reviewed to ensure that these are up to date. Internal training records also managed through practice spreadsheet records which are reviewed monthly. Who is responsible? Maxine Cox What resources (if any) are needed to implement the change(s) and are these resources available? External training facility accessed and training undertaken by team members Date actions will be completed: Completed 15.8.16 How will people who use the service(s) be affected by you not meeting this regulation until this date? Not applicable – all actions completed to achieve regulation standard compliance Regulated activity(ies) Regulation Diagnostic and screening procedures Family planning services Surgical procedures Maternity and midwifery services Treatment of disease, disorder or injury. Regulation 15 HSCA (RA) Regulations 2014 Premises and equipment How the regulation was not being met: Regulation 15(1)(a) We did not find the required documentation under the control of substances hazardous to health for cleaning equipment. Regulation 15(1)d 15(1)e We found fire alarm testing was undertaken on an ad-hoc basis and emergency lighting was not properly checked by the practice. We found staff had not had recent updates in regard to fire safety and had not undertaken fire evacuation practice. The practice did not provide a mains electrical system testing certificate on request. Regulation 15(2)
Report%20on%20actions%20you%20plan%20to%20take%20to%20meet%20CQC%20essential%20standards.docx