Microsoft word - new amended ophthalmic_contract_visit_form_v8_0_2011.doc

Ophthalmic Contract Visit Form
To be completed by the PCT
(References in brackets in bold italics are references to clauses of the model mandatory or additional services as
appropriate)
Voluntary information is highlighted with grey background shading Section A – All Contracts
1. Practice Details
1.1 Practice Name (66.3)
1.2 Contractor Name (If different) (66.3)
1.3 Practice / Correspondence Address (S1 pt2)
1.4 Practice Manager
1.5 Telephone (S1 pt2)
1.6 Fax (S1 pt2)

1.7 Website
1.8 Email (S1 pt2)
2. Visit Details
2.1 Date of Visit
2.2 Purpose: New application / Review Existing Practice / Other

2.3 Visited by:
3. Business Type (127-132/133-145)
3.1 Individual
3.2 Partnership
3.3 Body Corporate (BC)
Company secretary Name (BC Only) Companies House Registration (Section 28 Opticians Act 1989) (65)
4. Contracts Applied For / Held
4.1 Mandatory
4.2 Additional
5. Hours of Practice Opening (inc lunchtime closure) (66.3)
Saturday
Wednesday
Thursday
Bank Hols
6. Hours GOS Normally Provided (if different) (29 & 66.3)
Saturday
Wednesday
Thursday
Bank Hols
7. Performers in Regular Attendance (46 & 66.4)
7.1 Optometrist / 7.2 DoB / 1st
7.3 Ophthalmic
7.4 Professional
7.5 Included in
8. Other Clinical Staff Assisting in GOS(51)
8.2 Position and
8.3 DoB or 1st
8.4 Professional
8.5 Licensing
9. Staffing Procedures (51)
Yes/No Evidence produced in support
9.1 Does the contractor ensure that al clinical staff
have up to date professional registration? 9.2 Does the contractor check the references of al
registered clinical staff (including locums)? 9.3 Does the contractor check that al performers are
covered by up to date professional indemnity 9.4 Has the contractor produced evidence that al
employed optometrists and OMPs are included in a 9.5 How does the contractor ensure that the PCT is
informed of any changes to the performers providing GOS at the practice? (It is helpful for the PCT to provide a notification form for this purpose.) 9.6 Does the contractor ensure that staff assisting in
the provision of GOS are appropriately trained, and supervised for the tasks that they undertake? 9.7 Does the contractor ensure that clinical
procedures are appropriate especial y at times when a supervising practitioner is not on the premises, eg. repeat fields and pressures or child or blind or 10. Insurances and Registrations
10.1 Contractor has up to date arrangements for
cover in cases of clinical negligence (89)
10.2 Current Employers liability cover (Employers
Liability [Compulsory Insurance] Act 1969) (100)
10.3 Current Public Liability cover (90)
10.4 Medicines and Healthcare products Regulatory
(assemblers/manufacturers only) (28)
11. GOS Sight Test Application Procedures
Yes/No Evidence produced in support
readily available copies of Vouchers 11.1 Practice staff routinely undertake Point of
Service checks (37)
11.2 Practice staff understand that they must
routinely note date of last sight test (not just date of last NHS sight test) on GOS 1 and GOS 6 (37.3)
11.3 Practice staff are familiar with recommended
minimum GOS sight test intervals (as set out in the Memorandum of Understanding and reproduced in Vouchers at a Glance (37.4.1)
11.4 Contractor records reasons when sight tests are
refused to patients except in cases where a sight test is not necessary or the patient is not eligible (40)
11.5 Patient is offered a choice of performer where
appropriate (25A)
11.6 The practice offers al GOS patient groups
equal access to appointments during GOS hours (39)
11.7 The practice is aware of the ongoing
requirement to notify the PCT of changes to the times at which the contractor is wil ing to provide GOS (29)
12. Information Access and Protection
Yes/No Evidence produced in support
12.1 Contractor has an up to date freedom of
Information act statement and this is available to patients (100) (Freedom of Information Act 2005)
12.2 Registered with Information Commissioner for
Data protection (patient data held on computer or other electronic device) (100) (Data Protection Act 1998)
12.3 Name and title of person responsible for
practices and procedures relating to confidentiality (56)
12.4 The practice policy on handling patient data is
available to patients (100) (Data Protection Act 1998,
Freedom of Information Act 2000)
12.5 Staff are aware how to handle patient data
correctly (100) (Data Protection Act 1998)
12.6 Has the practice received from the PCT details
of local child protection arrangements and has the practice had regard to these? (100)
12.7 Has the practice received from the PCT details
of a recommended lone worker policy for optometry and has the practice had regard to this? (100)
12.8 Has the practice received from the PCT details
of a recommended chaperone policy for optometry and has the practice had regard to this? (100)
13. Record Keeping (52)
Yes/No Evidence produced in support
13.1 If gifts >£100 have been received does the
contractor maintain a gifts register? (92)
13.2 Patient records are securely stored. If
electronic, backups are made regularly and kept separately and securely (52)
13.3 GOS records are retained for 7 years in either
paper or electronic form. (54)
13.4 Contractor is aware of professional
recommendations to keep records for longer, ie. adults and deceased patients: 10 years; children to 13.5 The practice maintains ful and accurate
contemporaneous records for al GOS patients (52)
13.6 Each clinical record contains items from the fol owing list as appropriate to the individual patient:
1 2 3 4 5 6 7 8 9 10 0/1
Unaided vision/vision with current spectacles Ful Dispensing details (where a GOS voucher is Accurate details of repair or replacement 13.7 Record is legible
13.8 Is it easy to identify from the records which
14. Referral and Notification Procedures
Yes/No Evidence produced in support
14.1 Contractor is aware of any local protocols for
referral to GPs/ referral management or triage centre/ ophthalmology department (31)(100)
14.2 When required a written referral is made to the
centre/ophthalmology dept. and the urgency of the 14.3 Is the patient informed in writing of the reason
for their referral? (Sight Testing [Examination and
Prescription] [No. 2] Regulations 1989) (100)
14.4 Contractors ensure that patients are handed
their Prescription or Statement (33)
15. Complaints and Incidents
Yes/No Evidence produced in support
15.1 Contractor has a written NHS compliant
complaints procedure and is aware of requirement to report annual y the number of complaints received. (It is helpful for the PCT to provide a notification form for this purpose.) (103A)
15.2 The complaints procedure is available to
patients and staff (101)
15.3 Name of person responsible for dealing with
complaints (108)
15.4 Contractor maintains a separate record of al
complaints and associated paperwork for 2 years (112)
15.5 Contractor is aware and has ensured that al
staff are aware of the obligation to report adverse incidents potential y affecting the performance of the contract (66)
15.6 The contractor receives Safety Alerts from the
15.7 Contractor adheres to the requirements or
recommendations of MHRA medical device alerts (MDAs) and safety alert broadcasts (SABs) (28)
Section B –Mandatory Contracts Only
16. Premises
16.1 Type of premises
Purpose built / converted / commercial / health 16.2 Practice is on
16.3 Car parking
Own parking / on street parking / nearby public 17. Signage and Documentation
Yes/No Evidence produced in
17.1 Current Notice of eligibility for NHS eye examination
is displayed (description of services) (57)
17.2 Current Notice of eligibility for NHS voucher towards
the cost of spectacles is displayed (including voucher values) (57)
17.3 A complaints notice including the name of responsible
person and contact details is displayed (57)
17.4 Valid Certificate of Employers Liability is displayed
(Employers Liability [Compulsory Insurance] Act 1969) (100)
17.5 Details of business ownership/registered office are
displayed (Companies Act 2006) (100)
17.6 Health and Safety Poster is displayed (or copies
supplied to individual employees) (25)
17. 7 No smoking sign is displayed (Health Act 2006) (100)
18. General Health and Safety (28)
18.1 Health and safety risk assessment done (must be
documented if >5 people working there) 18.2 Contractor has Health and Safety Policy
18.3 Contractor is aware of reporting responsibilities under
RIDDOR (100) (Reporting Injuries Diseases and Dangerous
Occurrences Act 1995)
18.4 A suitable first aid kit is available and location clearly
identified (100) (First Aid Regulations 1981)
18.5 Contractor has an identified person who is
responsible for first aid arrangements (100) (First Aid
Regulations 1981)
18.6 Contractor has an accident record book (100) (First Aid
Regulations 1981)
18.7 Portable appliance and fixed instal ation electrical
(PAT) testing and/or regular visual inspection of appliances is carried out (100) (Electricity at Work Regulations
1989)
19. Fire precautions (25)(100) (Regulatory Reform [Fire Safety] Order 2006)
Yes/No Evidence produced in support
19.1 Fire Risk Assessment completed
19.2 Fire extinguishers
19.3 Fire extinguishers serviced
19.4 Fire exit signs
19.5 Fire exit clear
20. Non Clinical Areas(stairs, passageways etc) (25)
Yes/No Evidence produced in support
20.1 Clean and tidy
20.2 Adequate lighting
20.3 The area is clear of trip hazards
20.4 Traffic routes are clear of obstructions
20.5 Reasonable patient access (where applicable)
(Disability Discrimination Act 1995)
21. Reception / Waiting Area (25)
Yes/No Evidence produced in support
21.1 Clean and Tidy
21.2 Adequate lighting
21.3 The area is clear of trip hazards
21.4 Traffic routes are clear of obstructions
21.5 Reasonable patient access
(100) (Disability Discrimination Acts 1995 & 2005)
21.6 Suitable and sufficient seating
21.7 Layout respects the need for patient
21.8 There is a facility for confidential telephone
cal s to be made by the optometrist/OMP, eg for 22. Dispensing area (25)
Yes/No Evidence produced in support
22.1 Clean and Tidy
22.2 Adequate lighting
22.3 Suitable and sufficient seating
22.4The area is clear of trip hazards
22.5 Traffic routes are clear of obstructions
22.6 Reasonable patient access (100) (Disability
Discrimination Acts 1995& 2005)
22.7 Layout respects the need for patient
confidentiality (including safety of data displayed on computer terminals). Appeal case number FHS 23. Consulting Room
Yes/No Evidence produced in support
23.1 Clean and Tidy (25)
23.2 Adequate lighting (25)
23.3 The area is clear of trip hazards(25)
23.4 Traffic routes are clear of obstructions (25)
23.5 Reasonable patient access (100) (Disability
Discrimination Acts 1995 & 2005)
23.6 Suitable and sufficient seating (25)
23.7 Constructed to be suitable for confidential
consultations (25)
23.8 Adequate testing distance (25)
24. Clinical Testing Equipment (25)
A distance test chart for children / non-English / Al equipment is in working order and is fit for 25. Ophthalmic Drugs (25)
*Staining Agents (e.g. fluorescein/rose Bengal) Topical Anaesthetics (e.g. proxymetacaine / oxybuprocaine) Yes/No Evidence produced in support
Drugs are Stored appropriately and securely (e.g. proxymetacaine & chloramphenicol in a fridge) Single dose drugs (eg. Minims) are used once and * Essential to provision of GOS; others optional dependent on practice and instrumentation 26. Infection Control (28)
26.1 Access to a wash hand basin (good practice for this
to be within the consulting room) (28)
26.2 Liquid soap (28)
26.3 Paper towels (28)
26.4 Alcohol gel or alternative anti-bacterial hand rub
available (28)
26.5 Staff aware of good hand washing practice (28)
26.6 Suitable procedures in places for
decontamination of hard surfaces (28)
26.7 Suitable procedures for decontamination of
reusable equipment (28)
26.8 Appropriate use of disposable and single use
items (28)
27. Waste Disposal (100) (Section 34 Environmental Protection Act 1990)
27.1 Contractor aware of duty of care to appropriately
27.2 Contract in place for disposal of pharmaceutical
(inc name of contractor used)
waste
27.3 Record relating to medicines disposal kept for
correct time period (transfer notes 2 years, Section C - Additional Contracts only
28. Procedures and Documentation
Yes/No Evidence produced in support
28.1 Suitable patient leaflet available (57)
28.2 Is contractor aware of domiciliary code of
28.3 Is contractor aware of notification requirements
for domiciliary visits? (24)
29. Infection Control (28)
29.1 Liquid soap where this is unlikely to be
available at the premises visited or alternative means of cleaning the hands (28)
29.2 Paper towels where appropriate hand drying
facilities are unlikely to be available on the premises visited (28)
29.3 Alcohol gel or alternative anti bacterial hand rub
available (28)
29.4 Suitable procedures for decontamination of
reusable equipment (28)
29.5 Appropriate use of disposable and single use
items (28)
30. Waste Disposal (100) (Section 34 Environmental Protection Act 1990)
30.1 Contractor aware of duty of care to
30.2 Contract in place for disposal of pharmaceutical
(inc name of contractor used)
30.3 Records relating to medicines disposal kept for
correct time period (transfer notes 2 years, 31. Mobile Equipment Requirements (25)
Yes/No Evidence produced in support
A distance test chart suitable for children / non- English/learning disability Measuring Device Magnification for anterior eye examination Al equipment is in working order and is fit for 32. Ophthalmic Drugs (25)
*Staining Agents (e.g. fluorescein/rose Bengal) Topical Anaesthetics (e.g. proxymetacaine / Yes/No Evidence produced in support
Drugs are stored appropriately and securely (e.g. proxymetacaine & chloramphenicol in a fridge at Single dose drugs (eg. Minims) are used once and * Essential to provision of GOS. Others optional dependent on practice and instrumentation
Section D - Voluntary Information
Private and/or NHS Enhanced Services Provided (for information)
Low vision including the provision of aids Cataract monitoring – pre- and/or post extraction Additional Equipment Held (for information)
Section E – Action Plan
Name of Practice
Premises Inspection Date
KEY ACTIONS
Key Actions Identified from Premises
Lead Person/s
Timescale
Inspection
Responsible
NB. The timescales given in the action plan are al owances made by the PCT to al ow a contractor time to take remedial action to comply with their NHS contract on the issues listed. After the timescale given has expired an extension may be granted or a formal remedial/breach notice may be issued. This does not mean that contractors are immune from potential discipline from other public bodies during the time al owed if they are found by them to be in breach of any UK Legislation. Comments/Conclusions
Feedback from Practice
Final report agreed by:
Job Title:

Signature:
Job Title:

Signature:

PRACTICE
Job Title:

Signature:
Traffic Light System Scoring Red = Action Required from Practice/PCT - Urgent Amber = Action Required from Practice/PCT - Non-Urgent

Source: http://www.sandwell-loc.co.uk/documents/Practice_Visits/Sandwell%20Contract%20compliance%20v2.pdf