General Practitioners
The requirement for GP practices to register with the Care Quality Commission (“CQC”) since 2013 has added an additional layer of complexity to the task of running a successful practice. Balancing and juggling competing demands whilst maintaining high quality patient care can be tough.
The CQC has extensive powers to inspect practices, request information and take civil and criminal enforcement action should it feel that the care is falling short of the relevant regulations. Such interventions can have a significant knock-on effect for GPs and the surgeries including referrals to, and action taken by, the GMC, NHS England and other relevant stakeholders. It can even result in the closure of the surgery itself.
At Ridouts we understand the CQC, its powers and how to shape an effective case against action it seeks to take.
Here, you will find information on:
- Inspections and Ratings
- Suspension, Cancellation & Imposition of Conditions on Registration (including Notice of Proposal and Notice of Decision)
- Warning Notice and Fixed Penalties
- Training
We have also compiled a set of Useful Resources for GPs in need of legal guidance.
Inspections of GP practices can be both announced and unannounced. Comprehensive inspections lead to the practice being rated which, if poor, can lead to reputational damage, being placed in Special Measures, and increased scrutiny.
Inspections are informed, amongst other sources of information, by Provider Information Collection calls and Provider Information Returns. It is imperative that this information puts forward the practices best position and Ridouts can assist in presenting key evidence and documentation.
Providers have the opportunity to challenge factually inaccurate reports and the resulting ratings. Whilst providers may consider it makes for an easier life not to challenge factually inaccurate reports, a succession of reports showing non-compliances can lead to significant enforcement action by the CQC. In addition, any report published will be taken by the reader as being accurate and a true representation of your practice. All providers in the health and social care sector must make sure of the factual accuracy of the report so that the contents truly reflect their service. Ridouts has significant experience of preparing responses to draft reports for providers, frequently achieving amendments.
Timescales for making representations to these reports can be very limited with only a few days to respond. The Ridouts team of specialist lawyers has vast experience of working swiftly and comprehensively to present well evidenced representations supported by evidence. Our lawyers not only challenge the factual accuracy of reports but also the rationale behind the judgements. This includes detailed reviews of the CQC’s own guidance as well as considering the approach taken by inspector’s during their inspection.
Ridouts also has experience in initiating further action against the CQC by way of a Rating Review, complaints or pre-action protocol letters where comments to inspection reports have not been thoroughly or properly considered. This often leads to further amendments to reports; re-gradings; and sometimes the removal of the report in its entirety and the service re-inspected.
The CQC has the power to suspend or cancel a GP practices’ registration.
It also has the power to impose conditions on a practice’s registration. Failure to comply with such conditions is a criminal offence and CQC can prosecute a provider for non-compliance.
Conditions can be ‘positive’, requiring a practice to do something, such as sending the CQC weekly action plans or ‘negative’, requiring a practice to not do something, for example, not accept any new patients.
Either way, they can be burdensome and negatively impact the practice.
Whether the CQC is seeking to suspend, cancel or amend your registration it can be done one of two ways. First of all it can be done via a “slow” process which can take a number of months before the proposed action takes effect. Alternatively it can be done through urgent powers. How the CQC does this, depends on the configuration of a practices’ registration. Either the CQC must go to a magistrates’ court to get an order, or it can simply serve a notice on you. When urgent action is taken it takes effect immediately and to carry on operating without a valid registration is a criminal offence.
Over recent years, the CQC has engaged these enforcement powers and practices have closed as a result.
The CQC can serve various documents on you, at different stages of enforcement. These can be a Notice of Proposal (NOP); a Notice of Decision (NOD); or a Magistrates’ Court Order. Sometimes the CQC will give providers an opportunity to reassure them that suitable action is being taken to mitigate risks, by serving a Letter of Intent.
You should seek legal advice if you receive any of these.
Providers often have the right to make detailed representations and provide action plans to mitigate the chance of such enforcement action being taken or have the right to appeal decisions to the First-Tier Tribunal (Care Standards) Tribunal.
Submissions need to be compelling and strong in order to avoid the action.
However, action needs to be taken early and swiftly to help prevent matters progressing further, or enable providers to put forward the best case possible. Deadlines are short and must not be missed.
The Ridouts team has an enviable success rate of challenging regulator proposals and decisions both at the representation stage and on appeal to the Tribunal.
Ridouts acted for an NHS GP Surgery who had received a Warning Notice (and a negative draft inspection report), in which the CQC raised concerns over delays in upgrades to the Providers’ IT systems. The CQC alleged that this demonstrated ineffective systems and processes to ensure regulatory compliance, in breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The inspection to which these related took place at a time when the Provider was in the middle of a significant IT switchover which had to be brought forwards at speed to meet developing requirements from the relevant Local Authority bodies. This was at a time when all GP surgeries – and, indeed the whole health and social care sector – were already having to adapt extremely quickly to change, and deal with a number of unprecedented pressures brought about by the pandemic.
Ridouts were able to assist the Provider in making submissions to the CQC which demonstrated that by the time the Warning Notices were issued, if not earlier, delays in the IT systems upgrade posed no risk to patient safety, or to the provision of safe care and treatment at the Practice and that effective systems and processes were in place to ensure compliance with the relevant requirements. The Provider was able to demonstrate that there were justifications for the delays and in any event, appropriate monitoring, oversight and auditing had been in place, and mitigated any potential risk until the Provider had been able to compete the necessary switchover. Further, it was not necessary, proportionate or in the public interest to either issue the Warning Notice, or to publish it.
The CQC accepted the submissions on the Warning Notice and it was withdrawn before publication. This was a good result for the Provider because they do not now have a non-compliance on their regulatory record, and they have avoided the potential commercial and reputational damage which can attach to a Warning Notice.
Further, the CQC accepted that further understanding of the IT systems would be beneficial, and allow them to better understand the Provider’s service, and more accurately report on it. The Provider was able to engage positively and proactively with the CQC inspection team, and the CQC decided to re-inspect, to assist it in better understanding the Provider’s IT systems, and better engage with it on inspection and monitoring activity in future.
We have seen an uptake in CQC enforcement activity over the past few months. Warning Notices are at the lower end of the scale of seriousness of the CQC’s enforcement powers. However, Providers should not assume that Warning Notices (or indeed other enforcement notices, or threats of enforcement) either have merit or should be accepted just because the CQC say so. They can do damage and if there is good grounds to do so, robust submissions in response can change the outcome.
If Providers receive Warning Notices, they should not ignore them. In almost all cases it is worth making submissions to challenge the CQC’s position, or at the very least, challenge publication. There are tight timescales in which to do so and well-prepared, evidence-based and credible submissions can make all the difference. It does not have to become adversarial as this case study shows, but Providers should not accept Warning Notices where they are not warranted, or factually correct.
Ridouts can assist Providers who receive (or who are informed they will receive) a Warning Notice and can advise GP surgeries on a range of other regulatory and legal matters. Time is often of the essence. For further information, please contact Ridouts Professional Services on 0207 317 0340.
Ridouts can provide in-house training; for example, we can help your business prepare for an inspection and guide the provider on the steps they can take to help achieve the best outcome.
When you undertake a training session from the Ridouts team, we will liaise with you in order to tailor the instruction to the particular needs of the staff at the service. Our team are vastly experienced in speaking to health and social care providers and explaining issues in both a clear and practical way.
Many of our clients have noted that the training provided by Ridouts, particularly in respect of preparing for inspection, has proven very beneficial to them and has enabled staff to fully understand the inspection process and empowered them to do themselves and their service justice.
Get in touch using the form below to find out how Ridouts can help your business.
Case Studies
Inspections of GP practices can be both announced and unannounced. Comprehensive inspections lead to the practice being rated which, if poor, can lead to reputational damage, being placed in Special Measures, and increased scrutiny.
Inspections are informed, amongst other sources of information, by Provider Information Collection calls and Provider Information Returns. It is imperative that this information puts forward the practices best position and Ridouts can assist in presenting key evidence and documentation.
Providers have the opportunity to challenge factually inaccurate reports and the resulting ratings. Whilst providers may consider it makes for an easier life not to challenge factually inaccurate reports, a succession of reports showing non-compliances can lead to significant enforcement action by the CQC. In addition, any report published will be taken by the reader as being accurate and a true representation of your practice. All providers in the health and social care sector must make sure of the factual accuracy of the report so that the contents truly reflect their service. Ridouts has significant experience of preparing responses to draft reports for providers, frequently achieving amendments.
Timescales for making representations to these reports can be very limited with only a few days to respond. The Ridouts team of specialist lawyers has vast experience of working swiftly and comprehensively to present well evidenced representations supported by evidence. Our lawyers not only challenge the factual accuracy of reports but also the rationale behind the judgements. This includes detailed reviews of the CQC’s own guidance as well as considering the approach taken by inspector’s during their inspection.
Ridouts also has experience in initiating further action against the CQC by way of a Rating Review, complaints or pre-action protocol letters where comments to inspection reports have not been thoroughly or properly considered. This often leads to further amendments to reports; re-gradings; and sometimes the removal of the report in its entirety and the service re-inspected.
Ridouts were instructed by a GP practice when it was served an urgent Notice of Decision (“NOD”) under Section 31 of the Health and Social Care Act 2008 by the CQC to impose five conditions on their registration. The conditions took effect immediately, which meant that if the GP practice did not comply they could be prosecuted for failing to do so.
One of the condition’s required the GP practice to undertake a review of thousands of patients’ medical records from the previous three years. Another condition required that Paramedics working in the GP Practice did not carry out any regulated activities which meant that they could not provide care and treatment to patients. These conditions were particularly onerous and they would have put considerable strain on our Client and affected the viability of the business. The CQC’s position was that the statutory threshold under Section 31 had been met and urgent action was necessary in order to prevent a person being exposed to harm or the risk of harm.
We assisted our Client with lodging an appeal to the NOD, challenging the accuracy of the CQC’s alleged findings and the proportionality of the decision to issue the NOD. This was an expedited appeals process which meant that we had to be ready to attend a First Tier (Care Standards) Tribunal hearing within two weeks of the appeal being submitted.
We assisted the GP partners in preparing witness statements which addressed the various allegations and conditions. Three days prior to the hearing taking place, the CQC carried out another inspection of the GP practice and made an open offer to settle the matter by removing three of the imposed conditions and amending the other two conditions. The two remaining conditions were far less onerous than the original conditions and our Client was happy to accept these conditions in order to settle the matter. Our Client and the CQC made a joint application to the Tribunal asking for the appeal to be disposed of on the basis that the parties had reached a settlement.
A satisfactory conclusion for all parties was reached.
Ridouts acted for a GP practice that had been issued with a Warning Notice by the CQC.
A Warning Notice is a form of civil enforcement action and if a provider does not comply with it they can be prosecuted.
Following inspection of the practice, the CQC sent our Client a copy of the draft inspection report and issued a Warning Notice alongside it. The Warning Notice closely mirrored the content of the draft inspection report and alleged a breach of Regulation 17 of the Health and Social Care Act 2008. Regulation 17 is concerned with the Governance and Leadership of a service.
Ridouts submitted written representations to the CQC contending that the Warning Notice should be withdrawn and not published on the basis that the Notice did not demonstrate that the GP Practice had failed to comply with the relevant requirements. The evidence relied on by the CQC in the Notice did not support its conclusion that our Client was in breach of Regulation 17 and therefore no Notice was required. We contended that the Warning Notice was based on inaccurate facts and for the CQC to publish the Warning Notice would be both unfair and damaging to our Client’s reputation.
The CQC withdrew the Warning Notice on the basis that it contained factual errors. As a result, this meant that the Provider did not have this enforcement action noted on its record. The CQC did not publish a press release on its website and did not publish a summary of Warning Notice in the inspection report which could have negatively impacted the practice’s reputation. This was a great outcome for our Client.
Warning notices have been steadily on the increase and is an enforcement power that the CQC is using against GPs.
Ridouts acted for an NHS GP Surgery who had received a Warning Notice (and a negative draft inspection report), in which the CQC raised concerns over delays in upgrades to the Providers’ IT systems. The CQC alleged that this demonstrated ineffective systems and processes to ensure regulatory compliance, in breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The inspection to which these related took place at a time when the Provider was in the middle of a significant IT switchover which had to be brought forwards at speed to meet developing requirements from the relevant Local Authority bodies. This was at a time when all GP surgeries – and, indeed the whole health and social care sector – were already having to adapt extremely quickly to change, and deal with a number of unprecedented pressures brought about by the pandemic.
Ridouts were able to assist the Provider in making submissions to the CQC which demonstrated that by the time the Warning Notices were issued, if not earlier, delays in the IT systems upgrade posed no risk to patient safety, or to the provision of safe care and treatment at the Practice and that effective systems and processes were in place to ensure compliance with the relevant requirements. The Provider was able to demonstrate that there were justifications for the delays and in any event, appropriate monitoring, oversight and auditing had been in place, and mitigated any potential risk until the Provider had been able to compete the necessary switchover. Further, it was not necessary, proportionate or in the public interest to either issue the Warning Notice, or to publish it.
The CQC accepted the submissions on the Warning Notice and it was withdrawn before publication. This was a good result for the Provider because they do not now have a non-compliance on their regulatory record, and they have avoided the potential commercial and reputational damage which can attach to a Warning Notice.
Further, the CQC accepted that further understanding of the IT systems would be beneficial, and allow them to better understand the Provider’s service, and more accurately report on it. The Provider was able to engage positively and proactively with the CQC inspection team, and the CQC decided to re-inspect, to assist it in better understanding the Provider’s IT systems, and better engage with it on inspection and monitoring activity in future.
We have seen an uptake in CQC enforcement activity over the past few months. Warning Notices are at the lower end of the scale of seriousness of the CQC’s enforcement powers. However, Providers should not assume that Warning Notices (or indeed other enforcement notices, or threats of enforcement) either have merit or should be accepted just because the CQC say so. They can do damage and if there is good grounds to do so, robust submissions in response can change the outcome.
If Providers receive Warning Notices, they should not ignore them. In almost all cases it is worth making submissions to challenge the CQC’s position, or at the very least, challenge publication. There are tight timescales in which to do so and well-prepared, evidence-based and credible submissions can make all the difference. It does not have to become adversarial as this case study shows, but Providers should not accept Warning Notices where they are not warranted, or factually correct.
Ridouts can assist Providers who receive (or who are informed they will receive) a Warning Notice and can advise GP surgeries on a range of other regulatory and legal matters. Time is often of the essence. For further information, please contact Ridouts Professional Services on 0207 317 0340.
Ridouts were instructed by a GP practice after it received a request from the CQC for information and documentation under Section 64 of the Health and Social Care Act 2008.
Failure to comply with a request under Section 64 is an offence punishable with a fine. The CQC issued the Section 64 letter two days after an unannounced inspection on the basis that there were alleged concerns about the provision of care to patients.
The CQC requested various documentation from our Client in relation to patient records and staff DBS checks. The CQC also requested a weekly action plan from our Client to provide assurances that the issues and concerns identified during the inspection were being addressed.
We assisted our Client in collating documentation that evidenced the action that the GP practice was taking to address the CQC’s concerns. There was a lot of information to work through. We helped our Client to draft the action plan, linking the action plan to the concerns raised in the Section 64 letter. We ensured that the information in the action plan was presented to the CQC in a clear and logical format and that it captured what was required and did not go beyond.
We also drafted an accompanying letter to the action plan which explained to the CQC what documentation was being provided and why. Where our Client was unable to supply the requested information we provided explanations for this.
As a result of the action plan and covering letter, the CQC did not take any further enforcement action.
