Inspection report. Inspection of compliance with the Ionising Radiation (Medical Exposure) Regulations 2000

Size: px
Start display at page:

Download "Inspection report. Inspection of compliance with the Ionising Radiation (Medical Exposure) Regulations 2000"

Transcription

1 Inspection report Inspection of compliance with the Ionising Radiation (Medical Exposure) Regulations 2000 Organisation Site inspected Date of inspection Date of publication County Durham and Darlington NHS Foundation Trust Cardiology Department University Hospital of North Durham, Durham 20 November 2009 August

2 This report is available to download from our website on Please contact us if you would like a summary of this report in other formats or languages. Phone our helpline on or Care Quality Commission September 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and Care Quality Commission

3 About the Care Quality Commission The Care Quality Commission is the independent regulator of health care and adult social care services in England. We also protect the interests of people whose rights are restricted under the Mental Health Act. Whether services are provided by the NHS, local authorities or by private or voluntary organisations, we make sure that people get better care by: Driving improvement across health and adult social care. Putting people first and championing their rights. Acting swiftly to remedy bad practice. Gathering and using knowledge and expertise, and working with others. Introduction enforcing the regulations In addition to its regulatory activities under the Health and Social Care Act 2008, the Care Quality Commission (CQC) is responsible for enforcing the Ionising Radiation (Medical Exposure) Regulations 2000, as amended in 2006, known as IR(ME)R. CQC assesses the compliance of health care providers with the regulations. The regulations are intended to: Protect patients from unintended, excessive or incorrect exposure to radiation and to ensure that in each case, the risk from exposure is assessed against the clinical benefit. Ensure that patients receive no more exposure than is necessary to achieve the desired benefit within the limits of current technology. The regulations also apply to exposures as part of medical or biomedical, diagnostic or therapeutic research and those undertaken for medico-legal purposes. Methodology for inspections Our inspections form part of a programme of proactive compliance inspections of cardiology X-ray departments in England. When we have identified potential candidates for inspection we write to the organisation s senior managers giving four to six weeks notice, allowing the organisation time to reallocate resources for clinics and cardiac laboratories and to allow clinical staff the opportunity to participate in the inspection. We identify who we would like to meet on the day of inspection. During the inspection, two IR(ME)R inspectors from CQC visit the organisation, meet with representatives of the clinical department and management, and assess compliance. 3

4 During all proactive IR(ME)R inspections, we also explore risk management and review any notifications made to us under regulation 4(5), of exposures much greater than intended. Three months after the inspection report is published, we ask the organisation to declare that they have complied with any recommendations that we made. Background to the inspection The County Durham and Darlington NHS Foundation Trust provides a cardiac catheterisation laboratory service from its University Hospital to a local population of approximately 250,000 in the north of County Durham. The service was established in 2004 and presently utilises 4 sessions per week from its dedicated day unit adjacent to the radiology department. We learnt that the service utilised a single plane dedicated cardiac angiography facility with a digital flat-plate detector, and digital image archiving and reporting features. Staff carry out over 500 catheterisation procedures each year. Staffing comprised one whole time equivalent (WTE) cardiac radiographer, three consultant cardiologists, an associate specialist in cardiology and a trainee specialist registrar (SpR). In addition the laboratory was staffed by cardiac nurses, physiology technicians and assistant staff. We were provided with data on equipment, staffing and service activity in advance of the inspection. We met with the trust s executive director of operations and business, the lead cardiologist, the cardiac nurse and catheter lab manager, the superintendent radiographer and radiation protection supervisor, the radiology directorate manager, the radiation protection adviser, medical physics experts, radiology radiation protection supervisor, and cardiac physiologists. We adopted a patient journey approach to the inspection, seeking evidence from written procedures, some of which had been provided in advance of the visit, and from discussions with staff on the day. We examined how procedures, processes and practice from referral through to diagnosis, treatment and evaluation, meet the requirements of IR(ME)R. In particular, we examined the identity and responsibilities of the various duty holders, the nature of referral criteria, how X-ray diagnostic exposures were justified, authorised and optimised. At the time of the inspection, the centre had not notified us of any exposures much greater than intended arising from incidents in the cardiology department. The inspection This is a summary report of the findings from our inspection of the cardiology department. 4

5 Employer s written procedures Before the inspection the trust provided us with a document entitled Radiation Protection Policy, dated November 2009, which gave an overview of radiation protection arrangements within the trust. We were also given Employers Procedures for the Cardiac Catheterisation Laboratory University Hospital of North Durham, dated October We noted that these IR(ME)R procedures were specific to cardiology and had been prepared in the immediate lead-up to the inspection. Staff confirmed that the cardiology department procedures had previously been integrated with those of the radiology department, but it had become clear that these were not specific enough to the activities in the catheter laboratory. We noted that the document followed the patient journey and addressed the IR(ME)R core elements of referral, justification and optimisation, allocating responsibilities to the duty holders involved, including referrers, practitioners and operators. We also noted that the document had been approved by the radiation safety committee; evidenced by the minutes of the committee meeting. The link to demonstrate that they were the employer s written procedures was in the Radiation Safety Policy. We examined and discussed the content of other key parts of the written procedures, including patient identification checks and the pregnancy question. These were generally satisfactory although we noted that the enquiries required of female patients to determine pregnancy status did not include an age range. We were told that they were carried out on all females irrespective of age. We were satisfied from the written procedures and from responses to questions during the inspection that the responsibilities of duty holders were understood. However, there was some uncertainty as to whether the arrangements for referral surrounding the use of the booking form, together with the identity of referrers, was fully mirrored in the written procedures. Referral criteria were observed to have been established. We were informed at the inspection that there were no cardiac catheterisation exposures performed as part of research trials. Neither were there any medico-legal exposures carried out. Duty holders and their responsibilities Although procedures described the practitioner responsibility and process of authorisation for cardiac catheterisation exposures, discussion revealed that there was uncertainty around exactly how and when this took place. Inspectors drew attention to the requirement for authorisation to take place prior to the exposure. There was also a lack of clarity reflected in procedures whether the SpR and associate specialist were entitled to act as practitioners. 5

6 Exposure protocols During the inspection we observed that exposure protocols were in place for standard cardiology examinations. These included what views were regarded as routine and the automatic exposure factors as set on the equipment. At the time of the inspection these had not yet been adopted formally by the radiation safety committee on behalf of the employer. Optimisation Regarding the need for optimisation we were informed that there had been involvement from the equipment manufacturer, medical physics and clinical staff in setting up the equipment. We heard evidence of the understanding of the range of exposure between high and low dose settings and different frame rates. Quality control measurements and dose surveys were described, including the setting of diagnostic reference levels (DRLs). We saw from reports and heard from medical physics support how these were established based on regional data. Overall, we were provided with assurance that optimisation was taking place. However, during discussion with staff we felt that there could have been a better understanding and agreement on the nature of patient dose units in terms of dose-area product (DAP). During catheterisation procedures, exposure time was used as an immediate indicator of patient dose. Several areas of work, such as those above, provided us with assurance that staff working collaboratively and that there was cooperation between duty holders across the various professional disciplines. Training We asked about the training of cardiologists. We were informed that medical qualifications and registration status were checked by trust staff. However, we were informed that not all consultant cardiologists had attended an externally-accredited IR(ME)R training course for cardiologists, as is currently required by the Royal College of Physicians (RCP) for specialist registrars in order for them to complete their training. We heard that the SpR, who was involved in catheterisation procedures, worked under supervision and was following an established professional training scheme. Overall, inspectors felt that there was a lack of clarity on what the employer had decided locally was adequate training for cardiologists, particularly as regards entitlement to act as a practitioner and whether attendance on an IR(ME)R course was required. We also drew attention to the need for continuing education and training. The training of radiographic staff including training records was examined. Staff described how they had developed a training programme for radiographers who rotated through cardiology from the radiology department and received operator training on use of the equipment and which was subject to a competence 6

7 assessment carried out by senior colleagues. Registration and qualifications were also a requirement for radiographic staff. Medical physics experts IR(ME)R requires the involvement of medical physics experts (MPE) in medical exposures. We heard how clinical staff were supported by medical physicists, based both in a nearby tertiary centre as well as on-site, and we were informed of a service level agreement which was nearing completion, serving to formalise the arrangements. Support included consultation on optimisation, radiation dose assessments, compliance with regulatory requirements and setting relevant local DRLs following regional dose surveys. We heard how regional dose data has been used across a large number of catheter laboratories in the region showed that the doses here for coronary angiography were towards the lower end of the range and below the DRL and national reference dose. Risk management and clinical audit We held discussions concerning risk management and clinical audit, including what arrangements were in place within the department for review of incidents and near misses. We noted that audit arrangements were listed in procedures and during the inspection we heard about an audit of patient identity checks and an audit of femoral versus radial approach. We also received assurances on arrangements for identifying where excessive skin doses might be received. We heard that for bariatric patients where difficulties might be anticipated, management of the patient may not include catheterisation procedures. It was reported that any high doses recorded were discussed at review meetings. It was described how the evaluation of the exposure, an integral part of the cardiologist s report after the examination or treatment, was recorded via a dedicated electronic reporting system. 7

8 Areas of concern We found no areas of serious concern on IR(ME)R compliance during the inspection. However, we did identify several topics relating to employer s procedures, protocols, authorisation and training which require action or merit review. Conclusions and recommendations On the day of the inspection, the trust provided evidence which showed that the cardiology X-ray department complied with most of the IR(ME)R requirements and its key framework of referral, optimisation and evaluation of medical exposure. The department provided the Commission with evidence and assurance that it had procedures in place that were in line with regulatory requirements, that duty holders were identified and understood their responsibilities under the procedures. We saw too that audit and MPE support was in place and that risks were being managed within the centre s governance structures. Although we found no serious concern during the inspection, we did find one or two areas where action is required to meet the requirements, in particular the need for authorisation of medical exposures, identity of referrers and consideration of cardiologist training and entitlement. We also highlighted several areas where the department could improve IR(ME)R compliance, in relation to employer s procedures, exposure protocols and dose understanding. We make the following recommendations to the trust. Regulation Regulation 4: Duties of employer Regulation 5: Duties of the practitioner, operator and referrer Recommendations 1. To review written procedures and arrangements concerned with referral to ensure that referrers are clearly identified and to ensure that practice mirrors procedure. 2. To establish a clear link from the examination protocols required under IR(ME)R, through to the chief executive or via a scheme of delegated authority to a committee or individual to formally adopt the written employer's procedures and examination protocols. 3. Procedures, entitlement and authorisation guidelines, must be reviewed to ensure clarity around the practitioner role and authorisation responsibility of the specialist registrar and associate specialist. 8

9 Regulation 6: Justification of individual medical exposures Regulation 7: Optimisation 4. To make practical arrangements reflected in procedures, for the necessary justification and authorisation of an exposure, by the practitioner or an operator working to guidelines on behalf of the practitioner, prior to the exposure taking place. 5. To review the nature of the recording and understanding of patient doses, with regard to the units used for dose-area product. Regulation 8: Clinical audit Regulation 9: MPE s Regulation 10: Equipment Inventory Regulation 11: Training No recommendation No recommendation No recommendation 6. To review training requirements of cardiologists with the aim of defining adequate training, particularly in relation to attendance at externally-accredited IR(ME)R training course. To ensure that all staff are adequately trained. 9

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Eastham Walk In Centre Eastham Clinic, Eastham Rake, Eastham,

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Vision MH - Cornerstone House Barnet Lane, Elstree, WD6 3QU

More information

CLINICAL PROTOCOL FOR X-RAYS AND CLINICAL IMAGING

CLINICAL PROTOCOL FOR X-RAYS AND CLINICAL IMAGING CLINICAL PROTOCOL FOR X-RAYS AND CLINICAL IMAGING RATIONALE The aim of this Protocol is to provide guidance and good practice recommendations for health care professionals involved in clinical imaging

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Amvale Medical Transport - Ambulance Station Unit 1D, Birkdale

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Southdowns Private Healthcare 97 Havant Road, Emsworth, PO10

More information

List of Contents Section 10, Nuclear Safety and Radiation Protection Legislation Page

List of Contents Section 10, Nuclear Safety and Radiation Protection Legislation Page List of Contents Section 10, Nuclear Safety and Radiation Protection Legislation Page Overview 1 The Radiation Protection (Medical Exposures) Directive 11 The Public Information (Radiological Emergency)

More information

Inspection of Hospitals, Care and Family Services

Inspection of Hospitals, Care and Family Services Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Allied Healthcare Lowestoft Hipperson Mews, 53a Station Road,

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Kumari Care Limited 5 Palace Yard Mews, Queen Square, Bath,

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Royal Free Hospital Urgent Care Centre Royal Free Hospital,

More information

SUMMARY OF CURRENT UK LEGISLATION AND GUIDELINES

SUMMARY OF CURRENT UK LEGISLATION AND GUIDELINES SUMMARY OF CURRENT UK LEGISLATION AND GUIDELINES Legislation There are two sets of regulations in the UK governing the use of ionizing radiation. They both form part of The Health and Safety at Work Act

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Sunrise Operations of Westbourne 16-18 Poole Road, Westbourne,

More information

Details about this location

Details about this location Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Prince George Duke of Kent Court Shepherds Green, Chislehurst,

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Borough of Poole - Civic Centre Borough of Poole, Civic Centre,

More information

Healthcare Inspectorate Wales (HIW)

Healthcare Inspectorate Wales (HIW) Basics Constitutional Aspects Membership Web site http://www.hiw.org.uk/ Geographical coverage Legal Framework/Basis Wales Healthcare Inspectorate Wales s (HIW) role is to regulate and inspect the National

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inglewood Nursing Home Deal Road, Redcar, TS10 2RG Date of Inspection:

More information

Review of compliance. Redcar and Cleveland PCT Redcar Primary Care Hospital. North East. Region: West Dyke Road Redcar TS10 4NW.

Review of compliance. Redcar and Cleveland PCT Redcar Primary Care Hospital. North East. Region: West Dyke Road Redcar TS10 4NW. Review of compliance Redcar and Cleveland PCT Redcar Primary Care Hospital Region: Location address: Type of service: Regulated activities provided: Type of review: Date of site visit (where applicable):

More information

Guidance Notes for Dental Practitioners on the Safe Use of X-Ray Equipment

Guidance Notes for Dental Practitioners on the Safe Use of X-Ray Equipment Guidance Notes for Dental Practitioners on the Safe Use of X-Ray Equipment June 2001 Membership of the Working Party for producing the Guidance Notes for dental practitioners on the safe use of x-ray equipment

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Telegraph House 97 Telegraph Road, Deal, CT14 9DF Tel: 01304369031

More information

How To Write A Radiology Referral Policy At Canterbury Hospital

How To Write A Radiology Referral Policy At Canterbury Hospital Contents Policy... 2 Purpose... 2 Scope/Audience... 3 Staff Groups... 3 Definitions... 3 Associated documents... 3 Equipment... 3 Policy details... 4 Background: Application of radiation to patients for

More information

Job Description. Radiography Services Manager

Job Description. Radiography Services Manager Job Description Radiography Services Manager Professionally accountable to: Head of Nursing and Clinical Services Key working relationships: Key reporting relationships: All Radiographers, Consultant Radiologists,

More information

Nurse Practitioner Frequently Asked Questions

Nurse Practitioner Frequently Asked Questions HEALTH SERVICES Nurse Practitioner Frequently Asked Questions The Frequently Asked Questions (FAQs) have been designed to increase awareness and understanding of the Nurse Practitioner role within the

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Prestige Nursing - Newcastle First & Second Floors, 22 Athenaeum

More information

Good Scientific Practice

Good Scientific Practice Section 1: The purpose of this document There are three key components to the Healthcare Science workforce in the UK: 1. Healthcare Science Associates and Assistants who perform a diverse range of task

More information

CLINICAL IMAGING REFERRAL PROTOCOL FOR REGISTERED HEALTHCARE PRACTITIONERS EMPLOYED WITHIN MINOR INJURY UNITS IN CORNWALL

CLINICAL IMAGING REFERRAL PROTOCOL FOR REGISTERED HEALTHCARE PRACTITIONERS EMPLOYED WITHIN MINOR INJURY UNITS IN CORNWALL CLINICAL IMAGING REFERRAL PROTOCOL FOR REGISTERED HEALTHCARE PRACTITIONERS EMPLOYED WITHIN MINOR 1. Aim/Purpose of this Guideline This Protocol applies to Registered Healthcare Practitioners in the Minor

More information

Rotherham, Doncaster and South Humber NHS Foundation Trust Great Oaks

Rotherham, Doncaster and South Humber NHS Foundation Trust Great Oaks Review of compliance Rotherham, Doncaster and South Humber NHS Foundation Trust Great Oaks Region: Location address: Type of service: Yorkshire & Humberside Ashby High Street Scunthorpe Lincolnshire DN16

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Julia Brewin - Portland Place 57 Portland Place, London, W1B

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Quince House 77 Adeyfield Road, Hemel Hempstead, HP2 5DZ Tel:

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Mid Suffolk Home First The Kingsfield Centre, Chilton Way, Stowmarket,

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Appletree Care Home 158 Burnt Oak Broadway, Burnt Oak, Edgware,

More information

Procedure for Non-Medical Staff who wish to Request MRI, Ultrasound and Imaging Examinations under IR(ME)R

Procedure for Non-Medical Staff who wish to Request MRI, Ultrasound and Imaging Examinations under IR(ME)R Procedure for Non-Medical Staff who wish to Request MRI, Ultrasound and Imaging V3.0 December 2013 Page 1 of 11 Table of Contents 1. Introduction... 3 2. Purpose of this Policy/Procedure... 3 3. Scope...

More information

Requirements and Standards for Nurse Education Programmes for Authority to Prescribe Ionising Radiation (XRay) First Edition

Requirements and Standards for Nurse Education Programmes for Authority to Prescribe Ionising Radiation (XRay) First Edition Requirements and Standards for Nurse Education Programmes for Authority to Prescribe Ionising Radiation (XRay) First Edition February 2008 Contents Preface 3 Introduction 5 Section 1: Extracts from the

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Bury DCA United Response, City View Business Centre, 9 Long

More information

SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST EXECUTIVE SUMMARY REPORT TO THE TRUST HEALTHCARE GOVERNANCE COMMITTEE

SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST EXECUTIVE SUMMARY REPORT TO THE TRUST HEALTHCARE GOVERNANCE COMMITTEE SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST EXECUTIVE SUMMARY REPORT TO THE TRUST HEALTHCARE GOVERNANCE COMMITTEE I TO BE HELD ON MONDAY 26 NOVEMBER 2012 Subject: Supporting Director: Author: Status

More information

Position Title: Nurse Practitioner Define

Position Title: Nurse Practitioner Define POSITION DESCRIPTION Practitioner Define Date Produced/Reviewed: Position Holder's Name: Position Holder's Signature :... Manager / Supervisor's Name: Manager / Supervisor's Signature :... Date :... Page

More information

JOB DESCRIPTION and PERSON SPECIFICATION

JOB DESCRIPTION and PERSON SPECIFICATION The Ridge Medical Practice JOB DESCRIPTION and PERSON SPECIFICATION 1. POST TITLE: Advanced Nurse Practitioner 2. DEPARTMENT: Nursing 3. LOCATION: All Ridge sites 4. GRADE: Equivalent to Band 8A Agenda

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Warrington Hospital Lovely Lane, Warrington, WA5 1QG Tel: 01925635911

More information

Safer recruitment scheme for the issue of alert notices for healthcare professionals in England

Safer recruitment scheme for the issue of alert notices for healthcare professionals in England Safer recruitment scheme for the issue of alert notices for healthcare professionals in England November 2006 The issue of alert notices for healthcare professionals Summary 1. NHS Employers and the Department

More information

Review of compliance. Mid Staffordshire NHS Foundation Trust Stafford Hospital. West Midlands. Region:

Review of compliance. Mid Staffordshire NHS Foundation Trust Stafford Hospital. West Midlands. Region: Review of compliance Mid Staffordshire NHS Foundation Trust Stafford Hospital Region: Location address: Type of service: Regulated activities provided: Type of review: West Midlands Mid Staffordshire NHS

More information

A fresh start for the regulation of independent healthcare. Working together to change how we regulate independent healthcare

A fresh start for the regulation of independent healthcare. Working together to change how we regulate independent healthcare A fresh start for the regulation of independent healthcare Working together to change how we regulate independent healthcare The Care Quality Commission is the independent regulator of health and adult

More information

Qualifications for those on the Early Years and Childcare Registers

Qualifications for those on the Early Years and Childcare Registers Qualifications for those on the Early Years and Childcare Registers Guidance for inspectors on assessing the qualifications of those providing childcare on the Early Years and Childcare Registers. Published:

More information

Safeguarding public health The Regulation of Software as a Medical Device

Safeguarding public health The Regulation of Software as a Medical Device Safeguarding public health The Regulation of Software as a Medical Device Dr Head of New and Emerging Technologies Medicines and Healthcare Products Regulatory Agency (MHRA) Crown Copyright 2013 About

More information

Consultation. Review of the scopes of practice for registration in the profession of medical radiation technology

Consultation. Review of the scopes of practice for registration in the profession of medical radiation technology Consultation Review of the scopes of practice for registration in the profession of medical radiation technology CONTENTS Page Consultation Information... 3 Context of the Consultation... 4-7 Legislative

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Lindsay House 110-116 Lindsay Avenue, Abington, Northampton,

More information

Mental Health Crisis Care: Shropshire Summary Report

Mental Health Crisis Care: Shropshire Summary Report Mental Health Crisis Care: Shropshire Summary Report Date of local area inspection: 26 and 27 January 2015 Date of publication: June 2015 This inspection was carried out under section 48 of the Health

More information

CURRICULUM FOR SPECIALIST TRAINING PROGRAMMES IN DENTAL AND MAXILLOFACIAL RADIOLOGY

CURRICULUM FOR SPECIALIST TRAINING PROGRAMMES IN DENTAL AND MAXILLOFACIAL RADIOLOGY CURRICULUM FOR SPECIALIST TRAINING PROGRAMMES IN DENTAL AND MAXILLOFACIAL RADIOLOGY 1 INTRODUCTION 1.1 The specialty of Dental and Maxillofacial Radiology involves all aspects of medical imaging which

More information

Review of compliance. Florence Nightingale Hospitals Limited Capio Nightingale Hospital. London. Region: 11-19 Lisson Grove Marylebone London NW1 6SH

Review of compliance. Florence Nightingale Hospitals Limited Capio Nightingale Hospital. London. Region: 11-19 Lisson Grove Marylebone London NW1 6SH Review of compliance Florence Nightingale Hospitals Limited Capio Nightingale Hospital Region: Location address: Type of service: London 11-19 Lisson Grove Marylebone London NW1 6SH Diagnostic and/or screening

More information

Review of compliance. Brico Limited t/a Bluebird Care (Guildford) Bluebird Care (Guildford) South East. Region:

Review of compliance. Brico Limited t/a Bluebird Care (Guildford) Bluebird Care (Guildford) South East. Region: Review of compliance Brico Limited t/a Bluebird Care (Guildford) Bluebird Care (Guildford) Region: Location address: Type of service: South East Unit 15, Westminster Court Hipley Street Old Woking Surrey

More information

JOB DESCRIPTION. Job Title: Macmillan Integrated Palliative Social Worker. Day Therapy department, Outpatient Service & Community

JOB DESCRIPTION. Job Title: Macmillan Integrated Palliative Social Worker. Day Therapy department, Outpatient Service & Community JOB DESCRIPTION Job Title: Macmillan Integrated Palliative Social Worker Reports to: Day Unit Therapy Lead Location: Salary: Hours of work Annual Leave: Day Therapy department, Outpatient Service & Community

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Warwickshire & Northamptonshire Air Ambulance Fire & Rescue

More information

Details about this location

Details about this location Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Manchester Private Medical Clinic 222 Wilmslow Road, Rusholme,

More information

Job Description Form POSITION DESCRIPTION

Job Description Form POSITION DESCRIPTION OTD SPC 04/04 Name of Employer Job Description Form POSITION DESCRIPTION For Area of Need Medical Practitioner Positions {Insert Date} POSITION DETAILS 1 Position Number: Position Title: Reports to: Division:

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. The Manor House Whitton Road, Alkborough, Nr Scunthorpe, DN15

More information

Accreditation standards for training providers

Accreditation standards for training providers PREVOCATIONAL MEDICAL TRAINING FOR DOCTORS IN NEW ZEALAND Accreditation standards for training providers Introduction Prevocational medical training (the intern training programme) spans the two years

More information

Care and Social Services Inspectorate Wales

Care and Social Services Inspectorate Wales Care and Social Services Inspectorate Wales Care Standards Act 2000 Inspection Report Aylecare Domiciliary Services 11 Alexandra Road Gorseinon Swansea SA4 4NW Type of Inspection Baseline Date(s) of inspection

More information

Job Description. Professionally accountable to the Medical Director with respect to Trust-wide Medicines Optimisation.

Job Description. Professionally accountable to the Medical Director with respect to Trust-wide Medicines Optimisation. Job Description JOB DETAILS Job Title: Chief of Pharmacy Band: 9 Hours: 37.5 Department / Ward: Directorate: Pharmacy Cross Site Central Clinical Services ORGANISATIONAL ARRANGEMENTS Operationally accountable

More information

Delegation of Services Agreements Change in Regulations

Delegation of Services Agreements Change in Regulations Delegation of Services Agreements Change in Regulations Title 16, Division 13.8, Article 4, section 1399.540 was amended to include several requirements for the delegation of medical services to a physician

More information

Memorandum of Understanding

Memorandum of Understanding Memorandum of Understanding between the Welsh Ministers and the Chief Inspector of the Care and Social Services Inspectorate Wales and the Chief Executive of Healthcare Inspectorate Wales December 2014

More information

JOB DESCRIPTION NURSE PRACTITIONER

JOB DESCRIPTION NURSE PRACTITIONER JOB DESCRIPTION NURSE PRACTITIONER TITLE OF POST: NURSE PRACTITIONER : GENERAL PRACTICE /OUT OF HOURS SALARY : To be negotiated HOURS OF EMPLOYMENT: To be agreed APPOINTMENT: Permanent contract RESPONSIBLE

More information

European Academy of DentoMaxilloFacial Radiology

European Academy of DentoMaxilloFacial Radiology European Academy of DentoMaxilloFacial Radiology Framework for Specialist Training in Dental and Maxillofacial Radiology Background The scope of DentoMaxilloFacial Radiology DMFR (Dental and Maxillofacial

More information

SOP #: Revision #: Current Version Implementation Date: Page #: Page 1 of 10 Last Reviewed/Update Date: Expiration

SOP #: Revision #: Current Version Implementation Date: Page #: Page 1 of 10 Last Reviewed/Update Date: Expiration Implementation Page #: Page 1 of 10 Last Reviewed/Update 1. Purpose and Scope The purpose of this document is to describe the Medical Physics and Radiation Safety program at Boston University (BU) and

More information

Quality Standards for local training and education providers

Quality Standards for local training and education providers Quality Standards for local training and education providers The standards are to be used to measure the quality of health training and education in the local education and training placement environment

More information

Quality Assurance. The selection of the equipment. Equipment Specifications. Medical Exposure Directive 97/43 Euratom. Quality Assurance Programme

Quality Assurance. The selection of the equipment. Equipment Specifications. Medical Exposure Directive 97/43 Euratom. Quality Assurance Programme Medical Exposure Directive 97/43 Euratom Quality Assurance Ministry of Health, Radiation Protection Department, Luxembourg Alexandra Schreiner Medical Physicist Quality Assurance (QA): All those planned

More information

ROLES, RESPONSIBILITIES AND DELEGATION OF DUTIES IN CLINICAL TRIALS OF MEDICINAL PRODUCTS

ROLES, RESPONSIBILITIES AND DELEGATION OF DUTIES IN CLINICAL TRIALS OF MEDICINAL PRODUCTS ROLES, RESPONSIBILITIES AND DELEGATION OF DUTIES IN CLINICAL TRIALS OF MEDICINAL PRODUCTS STANDARD OPERATING PROCEDURE NO SOP 09 DATE RATIFIED 4/7/13 NEXT REVIEW DATE 4/7/14 POLICY STATEMENT/KEY OBJECTIVES:

More information

Local Authority Adoption Services. London Borough of Hillingdon Adoption Service 855 Uxbridge Road Hayes Middlesex UB4 8HZ

Local Authority Adoption Services. London Borough of Hillingdon Adoption Service 855 Uxbridge Road Hayes Middlesex UB4 8HZ Local Authority Adoption Services London Borough of Hillingdon Adoption Service 855 Uxbridge Road Hayes Middlesex UB4 8HZ 30th November and 1st and 2nd December 2004 Commission for Social Care Inspection

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Harrow Health Limited 37 Love Lane, Pinner, Harrow, HA5 3EE

More information

Policy Statement: Licensing Policy in respect of those activities that require a permit under the Insurance Business (Jersey) Law 1996

Policy Statement: Licensing Policy in respect of those activities that require a permit under the Insurance Business (Jersey) Law 1996 Policy Statement: Licensing Policy in respect of those activities that require a permit under the Insurance Business (Jersey) Law 1996 Issued: 11 February 2011 Glossary of terms: The following table provides

More information

Victorian Public Health Sector Classification System

Victorian Public Health Sector Classification System Victorian Public Health Sector Classification System A review and development of a new classification structure was proposed in the Health Services Union of Australia Administrative Offices Victorian Public

More information

Skill Levels for Delivering High Quality Asthma and COPD Respiratory Care by Nurses in Primary Care

Skill Levels for Delivering High Quality Asthma and COPD Respiratory Care by Nurses in Primary Care Skill Levels for Delivering High Quality Asthma and COPD Respiratory Care by Nurses in Primary Care September 2007 Revised December 2009, April 2014 Author: Ruth McArthur In conjunction with the PCRS-UK

More information

M E D I C AL D I AG N O S T I C S P E C I AL I S T Schematic Code 14251 (31000081)

M E D I C AL D I AG N O S T I C S P E C I AL I S T Schematic Code 14251 (31000081) I. DESCRIPTION OF WORK M E D I C AL D I AG N O S T I C S P E C I AL I S T Schematic Code 14251 (31000081) Positions in this banded class perform skilled technical work in the administration of specialized

More information

Policy for Care Quality Commission Essential standards of quality and safety self assessment and assurance process

Policy for Care Quality Commission Essential standards of quality and safety self assessment and assurance process Policy No: RM76 Version: 1.1 Name of Policy: Essential standards of quality and safety self assessment and assurance process Effective From: 25/04/2013 Date Ratified 15/03/2013 Ratified Patient, Quality,

More information

Job Description. Nurse Consultant Cardiac Rhythm Management. Lead Nurse, Division of Cardiothoracic Services. Job purpose

Job Description. Nurse Consultant Cardiac Rhythm Management. Lead Nurse, Division of Cardiothoracic Services. Job purpose Job Description Position: Accountable To: Responsible To: Hours of Duty: Location: Nurse Consultant Cardiac Rhythm Management Director of Nursing Lead Nurse, Division of Cardiothoracic Services 37 ½ hours

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Watford House Residential Home 263 Birmingham Road, Shenstone

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Bluebird Care (Milton Keynes) Suite 107, Interchange Business

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Pellon Care Centre 200 Pellon Lane, Halifax, HX1 5RD Tel: 01422342002

More information

LISTER MEDICAL CENTRE

LISTER MEDICAL CENTRE LISTER MEDICAL CENTRE TITLE OF POST: NURSE PRACTITIONER : GENERAL PRACTICE SALARY : TBC HOURS OF EMPLOYMENT : TBC APPOINTMENT : Permanent contract RESPONSIBLE TO: PARTNERS ACCOUNTABLE TO: PARTNERS JOB

More information

Summary of the role and operation of NHS Research Management Offices in England

Summary of the role and operation of NHS Research Management Offices in England Summary of the role and operation of NHS Research Management Offices in England The purpose of this document is to clearly explain, at the operational level, the activities undertaken by NHS R&D Offices

More information

1.1 Terms of Reference Y P N Comments/Areas for Improvement

1.1 Terms of Reference Y P N Comments/Areas for Improvement 1 Scope of Internal Audit 1.1 Terms of Reference Y P N Comments/Areas for Improvement 1.1.1 Do Terms of Reference: a) Establish the responsibilities and objectives of IA? b) Establish the organisational

More information

NURSE PRACTITIONER: Out of Hours Service. Permanent contract. Probation period 3 months

NURSE PRACTITIONER: Out of Hours Service. Permanent contract. Probation period 3 months JOB DESCRIPTION TITLE OF POST NURSE PRACTITIONER: Out of Hours Service SALARY To be agreed HOURS OF EMPLOYMENT Zero Hours Contract. Shifts to be booked according to the rota rules APPOINTMENT Permanent

More information

www.gdc-uk.org Standards for Education Standards and requirements for providers of education and training programmes

www.gdc-uk.org Standards for Education Standards and requirements for providers of education and training programmes www.gdc-uk.org Standards for Education Standards and requirements for providers of education and training programmes November 2012 GDC Standards for Education The Standards for Education and the requirements

More information

INFORMATION SHARING AGREEMENT. Multi-Disciplinary Team (MDT): Service Information Sharing

INFORMATION SHARING AGREEMENT. Multi-Disciplinary Team (MDT): Service Information Sharing INFORMATION SHARING AGREEMENT Multi-Disciplinary Team (MDT): Service Information Sharing SCOPE NAME OF LEAD Multi-Disciplinary Team (MDT) for high risk people: this agreement is for the patient and management

More information

CLINICAL GUIDELINE FOR ADVANCED NURSE PRACTITIONER HEPATOLOGY (GASTROENTEROLOGY) 1. Aim/Purpose of this Guideline:

CLINICAL GUIDELINE FOR ADVANCED NURSE PRACTITIONER HEPATOLOGY (GASTROENTEROLOGY) 1. Aim/Purpose of this Guideline: CLINICAL GUIDELINE FOR ADVANCED NURSE PRACTITIONER HEPATOLOGY (GASTROENTEROLOGY) 1. Aim/Purpose of this Guideline: 1.1. This protocol applies to Advanced Nurse Practitioners (Hepatology) employed by RCHT

More information

Harness Care Cooperative Ltd Quality primary care services provided through local cooperation Company registration: 06584450

Harness Care Cooperative Ltd Quality primary care services provided through local cooperation Company registration: 06584450 Harness Care Cooperative Ltd Quality primary care services provided through local cooperation Company registration: 06584450 Job Description Job title: Nurse Practitioner /Lead Nurse ACCOUNTIBILITY The

More information

Clinical Trials - Insurance and Indemnity

Clinical Trials - Insurance and Indemnity Policy Directive Clinical Trials - Insurance and Indemnity Document Number PD2011_006 Publication date 25-Jan-2011 Functional Sub group Corporate Administration - Governance Clinical/ Patient Services

More information

JOB DESCRIPTION. Senior Nurse Cardiology/Clinical Director Cardiology. Organisational Chart. Director of Nursing

JOB DESCRIPTION. Senior Nurse Cardiology/Clinical Director Cardiology. Organisational Chart. Director of Nursing JOB DESCRIPTION Title of Post: Location: Specialist Nurse Cardiac Rhythm Management (CRM) XXX Hospital Department/Specialty: Division of Cardiothoracic Services Grade: AFC Band 7 Responsible to: Accountable

More information

Specialist Surgical Pathologist

Specialist Surgical Pathologist Date: October 2008 Job Title : Specialist Surgical Pathologist Department : Surgical Pathology Unit Location : North Shore Hospital Reporting To : Clinical Director, Surgical Pathology Unit Direct Reports

More information

JOB DESCRIPTION. Advanced Nurse Practitioner Professional Lead

JOB DESCRIPTION. Advanced Nurse Practitioner Professional Lead JOB DESCRIPTION JOB TITLE: RESPONSIBLE TO: LOCATION(S): JOB PROFILE: Advanced Nurse Practitioner Advanced Nurse Practitioner Professional Lead North Bristol Trust Southmead Hospital This role is to work

More information

Spillemyndigheden s Certification Programme Change Management Programme

Spillemyndigheden s Certification Programme Change Management Programme SCP.06.00.EN.2.0 Table of contents Table of contents... 2 1 Introduction... 4 1.1 Spillemyndigheden s certification programme... 4 1.2 Objectives of the change management programme... 4 1.3 Scope of this

More information

Professional Behaviour and Ethical Conduct. Code of Practice relating to:

Professional Behaviour and Ethical Conduct. Code of Practice relating to: Code of Practice relating to: Professional Behaviour and Ethical Conduct Promoting transparency and enhancing public confidence in the dental profession February 2012 Code of Practice relating to: Professional

More information

Guidelines on endorsement as a nurse practitioner

Guidelines on endorsement as a nurse practitioner Guidelines on endorsement as a nurse practitioner 7160 Introduction The National Registration and Accreditation Scheme (the National Scheme) for health professionals in Australia commenced on 1 July 2010

More information

University College Dublin An Colaiste Ollscoile, Baile Atha Cliath

University College Dublin An Colaiste Ollscoile, Baile Atha Cliath University College Dublin An Colaiste Ollscoile, Baile Atha Cliath UCD School of Nursing, Midwifery and Health Systems Scoil an Altranais, an Cnáimhseachais agus na gcóras Sláinte UCD NURSE PRESCRIBING

More information

Application for the Regulation of the Clinical Technologist Profession by the Health Professions Council

Application for the Regulation of the Clinical Technologist Profession by the Health Professions Council Application for the Regulation of the Clinical Technologist Profession by the Health Professions Council The Voluntary Register of Clinical Technologists Institute of Physics and Engineering in Medicine

More information

The EFGCP Report on The Procedure for the Ethical Review of Protocols for Clinical Research Projects in Europe (Update: April 2011) Denmark

The EFGCP Report on The Procedure for the Ethical Review of Protocols for Clinical Research Projects in Europe (Update: April 2011) Denmark The Procedure for the Ethical Review of Protocols for Clinical Research Projects in Europe (Update: April 2011) Denmark Question 1: What laws or regulations apply to an application for conducting a clinical

More information

PURPOSE OF THE PAPER To provide the committee with an overview of the Director of Nursing portfolio during quarter 1 of 2015-2016

PURPOSE OF THE PAPER To provide the committee with an overview of the Director of Nursing portfolio during quarter 1 of 2015-2016 ENC 10 Meeting Date 30 th July 2015 Title of Paper Lead Director Author Director of Nursing Quarterly Report Kathryn Halford, Director of Nursing Kathryn Halford, Director of Nursing PURPOSE OF THE PAPER

More information

CLINICAL DIRECTOR COMMUNITY DENTAL SERVICE

CLINICAL DIRECTOR COMMUNITY DENTAL SERVICE JOB TITLE: DEPARTMENT: BASE: HOURS OF DUTY: REPORTS TO: RESPONSIBLE TO: SENIOR DENTAL OFFICER COMMUNITY DENTAL SERVICE SWAH/ OMAGH (to be determined) 7.5 hours CLINICAL DIRECTOR COMMUNITY DENTAL SERVICE

More information

Radiologic Technology Program. Radiation Safety and Protection Program

Radiologic Technology Program. Radiation Safety and Protection Program Radiologic Technology Program Radiation Safety and Protection Program Name of Program: Charles R. Drew University of Medicine and Science College of Science and Health CA RHB Program Number: 1029 Name

More information

Job Description. Wilson Health Centre, Cranmer Road, Mitcham, Surrey, CR4 4TP. Practice Manager / Clinical Manager (Clinical Matters)

Job Description. Wilson Health Centre, Cranmer Road, Mitcham, Surrey, CR4 4TP. Practice Manager / Clinical Manager (Clinical Matters) Job Description Job Title: Job Location: Responsible to: Hours of work: Salary: Nurse Practitioner (NP) Wilson Health Centre, Cranmer Road, Mitcham, Surrey, CR4 4TP Practice Manager / Clinical Manager

More information

Spillemyndigheden s Certification Programme Change Management Programme

Spillemyndigheden s Certification Programme Change Management Programme SCP.06.00.EN.1.0 Table of contents Table of contents... 2 1 Objectives of the change management programme... 3 1.1 Scope of this document... 3 1.2 Version... 3 2 Certification... 4 2.1 Certification frequency...

More information

Specialist Occupational Therapist Band 6 (Stroke Rehabilitation) Factors Essential % Desirable %

Specialist Occupational Therapist Band 6 (Stroke Rehabilitation) Factors Essential % Desirable % PERSONNEL SPECIFICATION POST: Specialist Occupational Therapist Band 6 (Stroke Rehabilitation) DEPARTMENT: Occupational Therapy LOCATION: Western Health & Social Care Trust DATE: July 2013 Factors Essential

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Bolton Community Practice CIC Navigation Park, Waters Meeting

More information

Improving quality, protecting patients

Improving quality, protecting patients Improving quality, protecting patients Standards of proficiency for Healthcare Science Practitioners 31 July 2014 Version 1.0 Review date: 31 July 2015 Foreword I am pleased to present the Academy for

More information