Report on actions you plan to take to meet CQC essential standards

Please see the covering letter for the date by which you must send your report to us and where to send it. Failure to send a report may lead to enforcement action.

Account number / Location ID 1-5088898291-508889829
Our reference / INS1-509631804
Regulated activity(ies) / Regulation
Treatment of disease, disorder or injury
Diagnostic and screening procedures
Family planning
Maternity and midwifery services
Surgical procedures. / Regulation 21(b) and (c) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.
Requirements relating to workers.
How the regulation was not being met:
The practice must ensure that copies of checks carried out by locum supply agencies are kept. This should include copies of indemnity cover, entry on the NHSE performers list, GMC registration (and any conditions) and all other items covered by this regulation and Schedule 3.
Please describe clearly the action you are going to take to meet the regulation and what you intend to achieve
The agency we use has been informed that we require all the relevant documents prior to the attendance of the locum. We use regular locums for the continuity of care.
The practice manager has always checked the GMC registration of all locums in the past. This includes:
GMC Reference Number
Full name
Gender
Primary care Qualifications
Provisional Registration Date
Full Registration date
Specialist Register
GP Register
Status
Registration and Licensing History and any Restrictions
Copies of indemnity cover and all personal documents have been vetted by the locum agency but these will be requested by the practice manager
In an emergency the locums will be requested to bring their documents with them and these will be copied and kept in locum’s record.
The Practice will make the following checks on relevant locums prior to appointment:
  • That the applicant is registered to carry out the proposed role
  • Whether the registration is subject to any current restrictions that might affect the duties proposed
  • If the applicant has investigations against them about their fitness to practise that the regulatory body has a duty to disclose.
  • Current address
  • DBS Check – Date of Certificate
Where possible, the Practice will check original documentation. In the event that this is not available, alternative methods of verification will be considered based on the importance and relevance to the qualification to the overall role.
Who is responsible for the action? / The practice manager
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?
The practice manager will be responsible for keeping these records and checking/reviewing the locums registration status.
This will be a priority for every locum used .
Who is responsible? / The practice manager
What resources (if any) are needed to implement the change(s) and are these resources available?
There are 3 key regulatory bodies relevant to general practice for disclosing fitness to practise information: The General Medical Council (GMC); The Nursing and Midwifery Council (NMC); The Health Professions Council (HPC)
The General Medical Council (GMC)
The GMC can confirm a doctor’s:
  • Full name;
/
  • Sex;

  • GMC reference number;
/
  • Current registration status;

  • Dates of registration (provisional, full, specialist or limited);
/
  • Primary medical qualification;

  • Licence to practise;
/
  • Specialist qualifications;

The Practice will check both the individual’s GMC registration status and whether they hold a licence to practise prior to engaging them to undertake any form of medical practice in the UK in one of the following ways:
  • By going onto the GMC’s online register (the List of Medical Practitioners) at
and entering the individual’s GMC reference number. This will state either that they are registered ‘with a licence to practise’ or that they are ‘registered without a licence to practice’;
  • By filling in the enquiry form at
  • By phoning the contact centre on 0161 923 6602;
  • By email, including the doctor’s name and GMC reference number, the employer’s name,
Trust and contact number, sent to ;
  • By writing to the General Medical Council, 3 Hardman Street, Manchester, M3 3AW;
  • By using ESR to verify a doctor’s GMC status.
Further information about registration requirements and revalidation can be found on the GMC website at
The Nursing and Midwifery Council (NMC)
The Practice will contact the NMC to provide the following registration status information on registered nurses:
  • Removed
  • Restored
  • Conditions of practice
  • Cautioned
  • Suspended
  • Lapsed
  • Effective.
As it will not indicate if someone is under investigation, the Practice will make contact with the NMC’s “Fitness to Practise” Department to obtain this information:
Via e-mail to or by telephoning: 0207 462 5801 / 5811
The Practice will contact the NMC to confirm registration status in one of the following ways:
  • Online at
  • Through the automated registration confirmation hotline (available 24 hours a day, seven Days a week), which generates a written report at the end;
  • By writing for confirmation to: Nursing and Midwifery Council, 23 Portland Place, London, W1B 1PZ;
  • By telephoning / emailing one of the following: or Tel: 0207 333 9333.

Date actions will be completed: / 15th January 2015
This has been ongoing procedure for all locums since the practice CQC Practice Visit on 15th January 2015 ,when is was discussed that although the locums are checked for registration and restrictions, evidence of indemnity and DBS checks must also be held at the practice and not just by the locum agency. The locum agency was made fully aware immediately.
How will people who use the service(s) be affected by you not meeting this regulation until this date?
The locum agency we use has their own regulatory checks prior to application. The practice manager has always checked the GMC registration via the website on all locums. Any restrictions would be addressed. To date the practice manager has not found any restrictions on any of the locums who have worked at Holmlands Medical Centre. The CV’s sent by the locum agency also has a photograph of the locum.
Completed by:
(please print name(s) in full) / Pamela Davies
Position(s): / Practice Manager
Date: / 7th April 2015