Surgery Information

1 Introduction

1.1 Policy statement
At South Wight Medical Practice, all patients will routinely be offered a chaperone, ideally at the time of booking
their appointment. It is a requirement that, where necessary, chaperones are provided to protect and safeguard
both patients and clinicians during intimate examinations and or procedures.
All clinical staff may at some point be asked to act as a chaperone at South Wight Medical Practice. Therefore, it is
essential that clinical personnel are fully trained and aware of their individual responsibilities when performing
chaperone duties.
The importance of a chaperone should not be underestimated. Children and young people, their parents,
relatives and carers should be made aware of the policy and why this is important.1

1.2 Status
The organisation aims to design and implement policies and procedures that meet the diverse needs of our
service and workforce, ensuring that none are placed at a disadvantage over others, in accordance with the
Equality Act 2010. Consideration has been given to the impact this policy might have with regard to the individual
protected characteristics of those to whom it applies.
This document and any procedures contained within it are non-contractual and may be modified or withdrawn at
any time. For the avoidance of doubt, it does not form part of your contract of employment.

2 Policy
2.1 Raising patient awareness
Patients are to be advised that a chaperone is ‘an independent person, appropriately trained, whose role is to
observe independently the examination/procedure undertaken by the doctor/health professional to assist the
appropriate doctor-patient relationship’2
.
At South Wight Medical Practice, a chaperone poster is clearly displayed in the waiting area, in all clinical areas
and annotated in the organisation leaflet as well as on the organisation website.
2.2 Personnel authorised to act as chaperones
It is policy that any member of the organisation team can act as a chaperone only if they have undertaken
appropriate chaperone training. The GMC advises that a relative or friend of the patient is not considered to be
an impartial observer and therefore would not be considered a suitable chaperone.
1 CQC GP Mythbuster 15
2 GMC Ethical Guidance Intimate examination and chaperones
V2 Mar 23/NS 4
2.3 General guidance
All clinicians should consider using a chaperone for some or all of the consultation and not solely for the purpose
of intimate examinations or procedures. This applies whether the clinician is of the same gender as the patient or
not.
Before conducting any intimate examination, the clinician should follow this checklist:3
 Explain to the patient why the particular examination is necessary and what it entails so they can give
fully informed consent
 Record the consent discussion in the notes, along with the identity of the chaperone or if a chaperone
was offered but declined
 If possible, use a chaperone of the same gender as the patient
 Allow the chaperone to hear the explanation of the examination and the patient’s consent
During the examination, the clinician should:3
 Ensure the patient’s privacy during the examination when they are dressing and undressing, for example
by using screens and gowns/sheets
 Position the chaperone where they can see the patient and how the examination is being conducted
 Explain what they are going to do before they do it and seek consent again (if the examination is going to
differ from what the patient was previously advised)
 Avoid personal remarks
 Invite the patient to advise if the examination becomes uncomfortable.
 Watch the patient for any signs of pain or discomfort and check the patient is happy for the examination
to continue
Ensuring that the patient fully understands the why, what and how of the examination process should mitigate
the potential for confusion.
2.4 Expectations of a chaperone
All staff who undertake a formal chaperone role must have been trained so they develop the competencies
required. Training can be delivered externally or provided in-house by an experienced member of staff so that all
formal chaperones understand the competencies required for this role.1
At South Wight Medical Practice, chaperone training will include:
 What is meant by the term chaperone
 What an intimate examination is
 Why chaperones need to be present
 The rights of the patient
 The role and responsibilities of the chaperone. Chaperones must place themselves inside the screened off
area rather than outside of the curtains/screen
 The policy and mechanism for raising concerns
3 MDU Chaperones
V2 Mar 23/NS 5
Training will be provided externally and updated on Bluestream Academy. The practice training co-ordinator will
provide information on this training.
Additionally, at South Wight Medical Practice chaperones will adhere to the GMC guidance which states
chaperones should:1

 Be sensitive and respect the patient’s dignity and confidentiality
 Reassure the patient if they show signs of distress or discomfort
 Be familiar with the procedures involved in a routine intimate examination
 Stay for the whole examination and be able to see what the doctor is doing, if practical
 Be prepared to raise concerns if they are concerned about the doctor’s behaviour or actions
For most patients and procedures, respect, explanation, consent and privacy are all that is needed. These take
precedence over the need for a chaperone. A chaperone does not remove the need for adequate explanation and
courtesy. Neither can a chaperone provide full assurance that the procedure or examination is conducted
appropriately.1
2.5 Disclosure and Barring Service (DBS) check
Clinical staff who undertake a chaperone role at South Wight Medical Practice will already have a DBS check. Nonclinical staff who carry out chaperone duties may need a DBS check. This is due to the nature of chaperoning
duties and the level of patient contact. Should South Wight Medical Practice decide not to carry out a DBS check
for any non-clinical staff, then a clear rationale for this decision must be given, including an appropriate risk
assessment.1
2.6 When a patient refuses a chaperone
When a patient is offered but does not want a chaperone, it is important the organisation has records and codes
in the record:1
 Who the chaperone was
 Their title
 That the offer was made and declined
2.7 When a chaperone is unavailable
If the patient has requested a chaperone and none is available, the patient must be able to reschedule within a
reasonable timeframe. If the seriousness of the condition means a delay is inappropriate, this should be explained
to the patient and recorded in their notes. A decision to continue or not should be reached jointly. Special
consideration needs to be given to examinations performed during home visits or online, video or telephone
consultations.1
2.8 Using chaperones during a video consultation
Many intimate examinations will not be suitable for a video consultation. When online, video or telephone
consultations take place, GMC guidance explains how to protect patients when images are needed to support
V2 Mar 23/NS 6
clinical decision making. This includes the appropriate use of photographs and video consultations as part of
patient care.
Where intimate examinations are performed, it is important that a chaperone is offered. Documentation should
clearly reflect this. It is important to document who provided the chaperoning and this should also state what
part of the consultation they were present for.
This guidance explains how to conduct intimate examinations by video and the use of chaperones.
2.9 Practice procedure (including SNOMED codes)
If a chaperone was not requested at the time of booking the appointment, the clinician will offer the patient a
chaperone explaining the requirements:
 Contact reception and request a chaperone
 Record in the individual’s healthcare record that a chaperone is present and identify them
 The chaperone should be introduced to the patient
 The chaperone should assist as required but maintain a position so that they are able to witness the
procedure/examination (usually at the head end)
 The chaperone should adhere to their role at all times
 Post procedure or examination, the chaperone should ensure they annotate in the patient’s healthcare
record that they were present during the examination and there were no issues observed
 The clinician will annotate in the individual’s healthcare record the full details of the procedure as per
current medical records policy
Detail SNOMED CT Code4
The patient agrees to a chaperone 1104081000000107
Refusal to have a chaperone present 763380007
No chaperones available 428929009
4 SNOMED CT Browser
V2 Mar 23/NS 7
2.10 Escorting of visitors and guests (including VIPs)
There may be, on occasion, a need to ensure that appropriate measures are in place to escort visitors and guests
including Very Important People (VIPs). South Wight Medical Practice will follow the recommendations outlined
in the Lampard Report (2015)5
:
a. Ensure that any visitors are escorted by a permanent member of staff at all times throughout the
duration of their visit
b. The individual organising the visit must arrange for a suitable member of staff to act as an escort.
Furthermore, the reason for the visit must be documented, giving details of the areas to be visited and if
patients are to be contacted during the visit
c. The escort is to ensure that no visitors enter clinical areas where there may be intimate examinations or
procedures taking place. This protects and promotes the privacy, dignity and respect of patients
d. The person arranging the visit must ensure that there is sufficient time for the practice team to advise
patients of the visit and offer patients the opportunity to decline to interact with the visitor(s)
e. Given the diverse nature of the patient population, some patients may not understand or may become
confused as to why visitors or guests (including VIPs) are present. To minimise any confusion or distress,
such patients as well as the visitor(s) are to be offered an escort
f. The person arranging the visit must ensure that the visitor(s) has produced photographic ID prior to the
visit taking place
g. The escort is to accept responsibility for the visitor(s) at all times. They must also be prepared to
challenge any unacceptable or inappropriate behaviour, reporting such incidences to the practice
manager immediately
h. The escort must ensure that no patient records or other patient-identifiable information are disclosed to
the visitor(s). Escorts are to ensure that the visitor(s) is aware of the need to retain confidentiality should
they overhear clinical information being discussed. Any breaches of confidentiality are to be reported
immediately to the practice manager
i. If media interest is likely, the practice manager is to inform the NHS Hampshire and Isle of Wight
Integrated Care Board (ICB), requesting that the communication team provides guidance
j. Under no circumstances is the escort to leave the visitor(s) alone with any patient or patient-identifiable
information. This is to ensure that both the patient and visitor(s) are appropriately protected
3 Summary
The relationship between the clinician and patient is based on trust and chaperones are a safeguard for both
parties at South Wight Medical Practice.
The role of a chaperone is vital in maintaining a good standard of practice during consultations and examinations.
Regular training for staff and raising patient awareness will ensure that this policy is maintained.
5 Lampard Report (2015

Please download and view our complaints procedure below

Patient-Complaints-Leaflet-July-23-

Your Information, Your Rights
Being transparent and providing accessible information to patients about how we will use your personal
information is a key element of the Data Protection Act 2018 and the EU General Data Protection
Regulations (GDPR).

The following notice reminds you of your rights in respect of the above legislation and how your GP
Practice will use your information for lawful purposes in order to deliver your care and the effective
management of the local NHS system.
This notice reflects how we use information for:
• The management of patient records;
• Communication concerning your clinical, social and supported care;
• Ensuring the quality of your care and the best clinical outcomes are achieved through clinical
audit and retrospective review;
• Participation in health and social care research; and
• The management and clinical planning of services to ensure that appropriate care is in place for
our patients today and in the future.

Data Controller
As your registered GP practice, we are the data controller for any personal data that we hold about you.

What information do we collect and use?
All personal data must be processed fairly and lawfully, whether is it received directly from you or from
a third party in relation to your care.
We will collect the following types of information from you or about you from a third party (provider
organisation) engaged in the delivery of your care:
• Personal data meaning any information relating to an identifiable person who can be directly or
indirectly identified from the data. This includes, but is not limited to name, date of birth, full
postcode, address, next of kin and NHS Number;
• Special category / sensitive data such as medical history including details of appointments and
contact with you, medication, emergency appointments and admissions, clinical notes,
treatments, results of investigations, supportive care arrangements, social care status, race,
ethnic origin, genetics and sexual orientation.
• Confidential Patient Information – this term describes information or data relating to their health
and other matters disclosed to another (e.g. patient to clinician) in circumstances where it is
reasonable to expect that the information will be held in confidence. Including both information
‘given in confidence’ and ‘that which is owed a duty of confidence’. As described in the
Confidentiality: NHS code of Practice: Department of Health guidance on confidentiality 2003.
• Pseudonymised – The process of distinguishing individuals in a dataset by using a unique
identifier which does not reveal their ‘real world’ identity.
• Anonymised – Data in a form that does not identify individuals and where identification through
its combination with other data is not likely to take place
• Aggregated – Statistical data about several individuals that has been combined to show general
trends or values without identifying individuals within the data.

Your healthcare records contain information about your health and any treatment or care you have
received previously (e.g. from an acute hospital, GP surgery, community care provider, mental health
care provider, walk-in centre, social services). These records may be electronic, a paper record or a
mixture of both. We use a combination of technologies and working practices to ensure that we keep
your information secure and confidential.

Why do we collect this information?
The NHS Act 2006 and the Health and Social Care Act 2012 invests statutory functions on GP Practices to
promote and provide the health service in England, improve quality of services, reduce inequalities,
conduct research, review performance of services and deliver education and training. To do this we will
need to process your information in accordance with current data protection legislation to:
• Protect your vital interests;
• Pursue our legitimate interests as a provider of medical care, particularly where the individual is
a child or a vulnerable adult;
• Perform tasks in the public’s interest;
• Deliver preventative medicine, medical diagnosis, medical research; and
• Manage the health and social care system and services.

How is the information collected?
Your information will be collected either electronically using secure NHS Mail or a secure electronic
transfer over an NHS encrypted network connection. In addition physical information will be sent to
your practice. This information will be retained within your GP’s electronic patient record or within your
physical medical records.
Who will we share your information with?

In order to deliver and coordinate your health and social care, we may share information with the
following organisations:
• Local GP Practices in order to deliver extended primary care services
• NHS – IW NHS Trust, University Hospital Southampton NHS Trust, Portsmouth Hospital NHS
Trust, Hampshire Hospitals NHS Foundation
• 111 and Out of Hours Service
Mar 2024/v9/ns
• Local Social Services and Community Care services
• Voluntary Support Organisations commissioned to provide services by the Isle of Wight CCG.
• Docmail
• LumiraDx INRStar *
• General Practice Data for Planning and Research (GPDPR)
• Restore Records Management
• Accurx

Your information will only be shared if it is appropriate for the provision of your care or required to
satisfy our statutory function and legal obligations.

Your information will not be transferred outside of the European Union.
* In order to carry out a full NHS provision of General Practice, patient records are stored in accredited
healthcare secure Cloud technology facility storage, with data centres in the UK. This technological
change does not affect the Rights and Freedoms of any individual, there is continued Data Protection
legislative compliant measures in place for your data. If you require more information about the systems
the Practice uses and the geographical location of data (no processing takes place outside of the UK)
then please contact the Practice IWCCG.southwightmedical@nhs.net.
Whilst we might share your information with the above organisations, we may also receive information
from them to ensure that your medical records are kept up to date and so that your GP can provide the
appropriate care.

In addition we receive data from NHS Digital (as directed by the Department of Health) such as the
uptake of flu vaccinations and disease prevalence in order to assist us to improve “out of hospital care”.
The Practice shares your diabetes related data with the Diabetic Eye Screening Programme operated by
Health Intelligence (commissioned by NHS England). This supports your invitation for eye screening
(where you are eligible and referred by the Practice) and ongoing care by the screening programme. This
data may be shared with any Hospital Eye Services you are under the care of to support further
treatment and with other healthcare professionals involved in your care, for example your
Diabetologist.
For further information, take a look at Health Intelligence’s Privacy Notice on the diabetic eye screening
website: www.desphiow.co.uk.

How do we maintain the confidentiality of your records?
We are committed to protecting your privacy and will only use information that has been collected
lawfully. Every member of staff who works for an NHS organisation has a legal obligation to keep
information about you confidential. We maintain our duty of confidentiality by conducting annual
training and awareness, ensuring access to personal data is limited to the appropriate staff and
information is only shared with organisations and individuals that have a legitimate and legal basis for
access.

How long do we hold information for?
All records held by the Practice will be kept for the duration specified by national guidance from NHS
Digital, Health and Social Care Records Code of Practice. Once information that we hold has been
identified for destruction it will be disposed of in the most appropriate way for the type of information it
is. Personal confidential and commercially confidential information will be disposed of by approved and
secure confidential waste procedures. We keep a record of retention schedules within our information
asset registers, in line with the Records Management Code of Practice for Health and Social Care 2016.

Individuals Rights under GDPR
Under GDPR 2018 the Law provides the following rights for individuals. The NHS uphold these rights in a
number of ways.
1. The right to be informed
2. The right of access
3. The right to rectification
4. The right to erasure (not an absolute right) only applies in certain circumstances
5. The right to restrict processing
6. The right to data portability
7. The right to object
8. Rights in relation to automated decision making and profiling.

Your right to opt out of data sharing and processing
The NHS Constitution states ‘You have a right to request that your personal and confidential information
is not used beyond your own care and treatment and to have your objections considered’. For further
information please visit: The NHS Constitution

Type 1 Opt Out
This is an objection that prevents an individual’s personal confidential information from being shared
outside of their general practice except when it is being used for the purposes of direct care, or in
particular circumstances required by law, such as a public health emergency like an outbreak of a
pandemic disease. If you wish to apply a Type 1 Opt Out to their record they should make their wishes
know to the practice manager.

National data opt-out
The national data opt-out was introduced on 25 May 2018, enabling patients to opt-out from the use of
their data for research or planning purposes, in line with the recommendations of the National Data
Guardian in her Review of Data Security, Consent and Opt-Outs.

By March 2021 all health and care organisations are required to apply national data opt-outs where
confidential patient information is used for research and planning purposes. NHS Digital has been
applying national data opt-outs since 25 May 2018. Public Health England has been applying national
data opt-outs since September 2018.
The national data opt-out replaces the previous ‘type 2’ opt-out, which required NHS Digital not to share
a patient’s confidential patient information for purposes beyond their individual care. Any patient that
had a type 2 opt-out recorded on or before 11 October 2018 has had it automatically converted to a
national data opt-out. Those aged 13 or over were sent a letter giving them more information and a
leaflet explaining the national data opt-out. For more information go to National data opt out
programme .

To find out more or to register your choice to opt out, please visit www.nhs.uk/your-nhs-datamatters.
On this web page you will:
• See what is meant by confidential patient information
• Find examples of when confidential patient information is used for individual care and examples
of when it is used for purposes beyond individual care
• Find out more about the benefits of sharing data
• Understand more about who uses the data
• Find out how your data is protected
• Be able to access the system to view, set or change your opt-out setting
• Find the contact telephone number if you want to know any more or to set/change your opt-out
by phone
• See the situations where the opt-out will not apply

Right of Access to your information (Subject Access Request)
Under Data Protection Legislation everybody has the right have access to, or request a copy of,
information we hold that can identify you, this includes your medical record, there are some safeguards
regarding what you will have access and you may find information has been redacted or removed for
the following reasons;
• Does not cause harm to the patient
• That legal confidentiality obligations for the non-disclosure of third-party information are
adhered to

You do not need to give a reason to see your data. And requests can be made verbally or in writing.
Although we may ask you to complete a form in order that we can ensure that you have the correct
information you require.

Where multiple copies of the same information is required the surgery may charge a reasonable fee for
extra copies.
You will need to provide proof of identity to receive this information.
If you would like to access your GP record online click here https://systmonline.tppuk.com/2/Login?Date=20200212121448

Sharing of Electronic Patient Records within the NHS
Electronic patient records are kept in most places where you receive healthcare. Our local electronic
systems (such as SystmOne, EMIS and Eclipse) enables your record to be shared with organisations
involved in your direct care, such as:
• GP practices
• Community services such as district nurses, rehabilitation services, telehealth and out of hospital
services.
• Child health services that undertake routine treatment or health screening
• Urgent care organisations, minor injury units or out of hours services
Mar 2024/v9/ns
• Community hospitals
• Palliative care hospitals
• Care Homes
• Mental Health Trusts
• Hospitals
• Social Care organisations
• Pharmacies
In addition, NHS England have implemented the Summary Care Record which contains information
including medication you are taking and any bad reactions to medication that you have had in the past.
In most cases, particularly for patients with complex conditions and care arrangements, the shared
electronic health record plays a vital role in delivering the best care and a coordinated response, taking
into account all aspects of a person’s physical and mental health. Many patients are understandably not
able to provide a full account of their care, or may not be in a position to do so. The shared record
means patients do not have to repeat their medical history at every care setting.
Your record will be automatically setup to be shared with the organisations listed above, however you
have the right to ask your GP to disable this function or restrict access to specific elements of your
record. This will mean that the information recorded by your GP will not be visible at any other care
setting.

You can also reinstate your consent at any time by giving your permission to override your previous
dissent.

Health Risk Screening / Risk Stratification
Health Risk Screening or Risk Stratification is a process that helps your GP to determine whether you are
at risk of an unplanned admission or deterioration in health. By using selected information such as age,
gender, NHS number, diagnosis, existing long term condition(s), medication history, patterns of hospital
attendances, admissions and periods of access to community care your GP will be able to judge if you
are likely to need more support and care from time to time, or if the right services are in place to
support the local population’s needs.

To summarise Risk Stratification is used in the NHS to:
• Help decide if a patient is at a greater risk of suffering from a particular condition;
• Prevent an emergency admission;
• Identify if a patient needs medical help to prevent a health condition from getting worse; and/or
• Review and amend provision of current health and social care services.
Your GP will use computer based algorithms or calculations to identify their registered patients who are
at most risk, with support from the local Commissioning Support Unit and/or a third party accredited
Risk Stratification provider. The risk stratification contracts are arranged by your local CCG in
accordance with the current Section 251 Agreement. Neither the CSU nor your local CCG will at any time
have access to your personal or confidential data. They will only act on behalf of your GP to organise
the risk stratification service with appropriate contractual technical and security measures in place.
Your GP will routinely conduct the risk stratification process outside of your GP appointment. This
process is conducted electronically and without human intervention. The resulting report is then reviewed by a multidisciplinary team of staff within the Practice. This may result in contact being made
with you if alterations to the provision of your care are identified.
A Section 251 Agreement is where the Secretary of State for Health and Social Care has granted
permission for personal data to be used for the purposes of risk stratification, in acknowledgement that
it would overburden the NHS to conduct manual reviews of all patient registers held by individual
providers.

As mentioned above, you have the right to object to your information being used in this way. However
you should be aware that your objection may have a negative impact on the timely and proactive
provision of your direct care. Please contact the Practice Manager to discuss how disclosure of your
personal data can be limited.

Change of Details
It is important that you tell the surgery if any of your contact details such as your name or address have
changed especially if any of your other contacts details are incorrect. It is important that we are made
aware of any changes immediately in order that no information is shared in error.

Mobile telephone number
If you provide us with your mobile phone number, we may use this to send you text reminders about
your appointments or other health screening information. Please let us know if you do not wish to
receive text reminders on your mobile.

Email address
Where you have provided us with your email address, with your consent we will use this to send you
information relating to your health and the services we provide. If you do not wish to receive
communications by email please let us know.

Notification
Data Protection Legislation requires organisations to register a notification with the Information
Commissioner to describe the purposes for which they process personal and sensitive information.
We are registered as a Data Controller and our registration can be viewed online in the public register
at: http://ico.org.uk/what_we_cover/register_of_data_controllers
Any changes to this notice will be published on our website and in a prominent area at the Practice.

Data Protection Officer
Should you have any data protection questions or concerns, please contact our Data Protection Officer
via the surgery at: IWCCG.southwightmedical@nhs.net

What is the right to know?
The Freedom of Information Act 2000 (FOIA) gives people a general right of op to information held by or
on behalf of public authorities, promoting a culture of openness and accountability across the public
sector. You can request any non-personal information that the GP Practice holds, that does not fall
under an exemption. You may not ask for information that is covered by the Data Protection Legislation
under FOIA. However, you can request this under a right of access request – see section above ‘Access
to your information’.
Mar 2024/v9/ns

Right to Complain
If you have concerns or are unhappy about any of our services, please contact the Practice Manager.

For independent advice about data protection, privacy and data-sharing issues, you can contact:
The Information Commissioner
Wycliffe House
Water Lane
Wilmslow
Cheshire
SK9 5AF
Phone: 0303 123 1113
Website: https://ico.org.uk/global/contact-us

The NHS Care Record Guarantee
The NHS Care Record Guarantee for England sets out the rules that govern how patient information is
used in the NHS, what control the patient can have over this, the rights individuals have to request
copies of their data and how data is protected under Data Protection Legislation.
http://systems.digital.nhs.uk/infogov/links/nhscrg.pdf

The NHS Constitution
The NHS Constitution establishes the principles and values of the NHS in England. It sets out the rights
patients, the public and staff are entitled to. These rights cover how patients access health services, the
quality of care you’ll receive, the treatments and programs available to you, confidentiality, information
and your right to complain if things go wrong.
https://www.gov.uk/government/publications/the-nhs-constitution-for-england

Infection Control Annual Statement

Purpose

This annual statement will be generated each year in April in accordance with the requirements of The Health and
Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance. It summarises:
• Any infection transmission incidents and any action taken (these will have been reported in accordance with
our Significant Event procedure)
• Details of any infection control audits undertaken, and actions undertaken
• Details of any risk assessments undertaken for prevention and control of infection
• Details of staff training
• Any review and update of policies, procedures and guidelines

Infection Prevention and Control (IPC) Lead

The South Wight Medical Practice has two Lead(s) for Infection Prevention and Control: Emma Arnold ANP QN
and Chris Wheeler PN QN.

The IPC Leads are supported by: Amy Hopper.
Emma Arnold and Chris Wheeler have attended an IPC Lead training course in 2023 and keeps updated on
infection prevention practice.
Infection transmission incidents (Significant Events)

Significant events (which may involve examples of good practice as well as challenging events) are
investigated in detail to see what can be learnt and to indicate changes that might lead to future
improvements. All significant events are reviewed in the practice meetings and learning is cascaded to all
relevant staff.

In the past year there have been no significant events raised that related to infection control.
Infection Prevention Audit and Actions

The Annual Infection Prevention and Control audit was completed by Emma Arnold and Chris Wheeler in April
2023

As a result of the audit, the following things have been changed in South Wight Medical Practice:
• Improvement program for clinic rooms
• Improvement in consumables and storage

An audit on Minor Surgery was undertaken by Emma Arnold and Chris Wheeler in April 2023
No infections were reported for patients who had had minor surgery at the South Wight Medical Practice.
An audit on hand washing was undertaken in April 2023. This was discussed at the clinical meeting.
The South Wight Medical Practice plan to undertake the following audits in 2023:
IPC – Annual Statement
• Annual Infection Prevention and Control audit
• Minor Surgery outcomes audit
• Domestic Cleaning audit
• Hand hygiene audit

Risk Assessments
Risk assessments are carried out so that best practice can be established and then followed. In the last year
the following risk assessments were carried out / reviewed:
Legionella (Water) Risk Assessment: The practice has conducted/reviewed its water safety risk assessment to
ensure that the water supply does not pose a risk to patients, visitors or staff.

Immunisation: As a practice we ensure that all of our staff are up to date with their Hepatitis B immunisations
and offered any occupational health vaccinations applicable to their role (i.e. MMR, Seasonal Flu). We take
part in the National Immunisation campaigns for patients and offer vaccinations in house and via home visits
to our patient population.

Curtains: The NHS Cleaning Specifications state the curtains should be cleaned or if using disposable curtains,
replaced every 6 months. To this effect we use disposable curtains and ensure they are changed every 6
months. The window blinds are very low risk and therefore do not require a particular cleaning regime other
than regular vacuuming to prevent build-up of dust. The modesty curtains although handled by clinicians are
never handled by patients and clinicians have been reminded to always remove gloves and clean hands after
an examination and before touching the curtains. All curtains are regularly reviewed and changed if visibly
soiled.

Toys: We have no toys in the practice.

Training
All our staff receive annual training in infection prevention and control.
Emma Arnold has undertaken specialist training in Infection prevention and control.
Chris Wheeler has undertaken specialist update training in Infection prevention and control.

Policies

All Infection Prevention and Control related policies are in date for this year.
Policies relating to Infection Prevention and Control are available to all staff and are reviewed and updated
annually and all are amended on an on-going basis as current advice, guidance and legislation changes.
Infection Control policies are circulated amongst staff for reading and discussed at meetings on an annual
basis.

Responsibility

IPC – Annual Statement

It is the responsibility of each individual to be familiar with this Statement and their roles and responsibilities
under this.

Review date
April 2024

Responsibility for Review

The Infection Prevention and Control Leads and Natalie Stevenson are responsible for reviewing and
producing the Annual Statement.

Natalie Stevenson

Practice Manager

For and on behalf of the South Wight Medical Practice

Patient Rights & Responsibilities

Users of the National Health Service have rights. The following explains what they are. They fall into three main categories.

Legislated Rights

Rights that have been written into law by means of Parliamentary Acts or Bills. (For example, UK GDPR and DPA 2018). As a patient of the NHS you have 7 rights.

• You are entitled to receive health care on the basis of clinical need, regardless of your income.
• You are entitled to be registered with a Medical practice. You are entitled to change your practice at any time. You do not have to give a reason for your decision.
• You are legally entitled to accept or refuse treatment as you see fit. This includes examinations, tests, diagnostic procedures, medication, operations, etc.
• You can refuse to be involved in research trials. If you do not agree to be involved in research trials, you can withdraw at any time.
• You are entitled to equal treatment regardless of race, gender, age or disability.
• You have a right to information on GP practices in your area and the services they provide. All practices must provide an information leaflet.
• You have a right to confidentiality. Personal information about your health is confidential and should only be disclosed to those who need that information to provide you with effective treatment, you can consent to share with other individuals outside of the NHS

Access to your Health Records.

You have a legal entitlement to see a copy of the records held about you. All records stored on computer can be accessed. If you wish to see your records you should apply in to the practice for a Subject Access Request.

Guideline Rights

• You are entitled to have reasonable access to high quality service and facilities.
• You are entitled to information on what is wrong with you and the treatment options available. Ask questions. You should be given truthful, clear answers.
• You are entitled to ask for a second opinion on your diagnosis or treatment.
• You can ask to have someone with you (friend, relative, interpreter) at any time. You may find this beneficial, particularly if you are asking questions or need moral support.

Human Rights

It is your right to be treated as a human being by another human being and as they would wish to be treated themselves, i.e. with dignity, politeness, respect and consideration. These may not necessarily be covered legally or even be contained in guidelines, but human rights will come into many of the areas mentioned above and are certainly just as important.

Consent

A doctor, nurse, or anyone else looking after your health, has to have your agreement before they can examine or treat you. This policy applies to both children and adults. Your consent will be sought before any of your information is shared with any individual not connected with your direct health care.

Patient Responsibilities

Patients, too, have certain responsibilities:

• Keeping appointments:  Please try to arrive on time. If you are unable to attend an appointment, please inform the clinic or surgery in good time. Address. If you move house, change address or telephone number, or the postcode is changed, please inform your GP practice or outpatient clinic.
• Treat all healthcare staff in a reasonable, courteous manner.
• Use emergency services in a responsible manner. Please use the out-of-hours services for emergencies only and not for routine care.
• Take care with medicines. Medicines are for one person only and should not be shared. Keep them safely away from children and in the original container. Take any unwanted medicines to a chemist for safe disposal.

At South Wight Medical Practice, we have a Facebook page which provides a range of useful information
for our patient population.

This organisation has a duty to maintain patient confidentiality and to safeguard vulnerable patients. You
can help us to achieve this by adhering to the code of conduct outlined in this guidance.

Patients at South Wight Medical Practice are expected to always adhere to the following
code of conduct:

1. The organisation requires all users of portable devices to use them in a courteous and considerate
manner, respecting their fellow patients. Portable devices are not to be used during consultations,
except when agreed with your clinician.

2. Patients are not permitted to disclose any patient-identifiable information about other patients
unless they have the express consent of that patient.

3. Whilst not encouraged, patients may record their consultation, but this should be agreed with
your clinician. This recording will solely be for your own purpose.

4. Patients must not post any material that is inaccurate, fraudulent, harassing, embarrassing,
obscene, defamatory, or unlawful. Any such posts on the organisation Facebook page will be
deleted and the post reported.

5. Patients are not permitted to take photographs in the waiting room or areas where other patients
are present, nor are photographs of staff permitted to be taken.

6. Patients must not post comments on social media that identify any staff.

7. Patients can leave a review about the practice on southwightmedicalpractice.nhs.uk/how-are-wedoing which will enable the practice manager to respond appropriately.

8. Defamatory comments about our team are not to be shared on any social media platform. Legal
advice may be sought, and the appropriate action taken against any patient who posts defamatory
comments

This leaflet explains why South Wight Medical Practice collects information about you, how we keep it safe and private, and how we may use that information.

Why do we collect information about you?

Doctors and nurses have to keep a record about your health and any treatment that we give you. This is called your “GP record”, and helps us to really look after you.

Your GP record is only used to help doctors and nurses keep you well and make you better when you are not so well.

What do we record?

We keep a record of every time that you see someone at the surgery, as well as times that you have been seen somewhere else, such as in the Accident and Emergency department of a hospital.

We keep a record of:

· Your name, address, and info about those looking after you (such as your mum and dad)

· Your home telephone and mobile number (if you have one), and your email address if you want us to

· Details of the times that you saw a doctor or nurse, here at the surgery and at other places

· Any tests that you have had (such as an x-ray)

How we keep your information safe and private?

Your GP record is kept on a really secure computer system. Only doctors, nurses and receptionists that we give permission to can look at your information. No one else.

And it’s really, really difficult to hack into that system. We make sure of that.

If you are old enough to have a mobile phone, or an email address, then we will only use that to contact you when it’s about “medical stuff” like reminding you about an appointment that you might have to see your doctor at the surgery.

If you don’t want us to text you anything at all, then just tell us and we will make sure that doesn’t happen.

Unless you want us to, we won’t use your email address to tell you about other things happening at the surgery, like new doctors and nurses working at the surgery.

All your info is very private and we won’t tell anyone else about it unless they are also looking after you, or trying to get you better. And only then if they really need to know about it.

So, at the surgery, the doctors, nurses, and receptionists can look at your GP record, if they need to. And if they do, they are not allowed to tell anyone else about it.

And if the doctors and nurses at the surgery don’t know what’s wrong with you, we will ask someone at the hospital to see you and we will give that doctor or nurse information about you and what’s making you feel unwell.

But sometimes we have to tell other people about stuff in your GP record.

Sometimes, “it’s the law”, and we will get in big trouble if we don’t.

So, if a judge tells us to, then we will have to give them information about you.

If the police tell us to, then sometimes we have to tell them as well.

If you’re ill, and that illness could be spread to all your friends and classmates, then we might need to let the right people know so that they can try to make sure that no one else catches that illness as well.

And sometimes we have to tell other people if we are worried that you, or someone else in your family, could be in danger.

Whenever we can, we would always tell you if we were going to tell someone else about you and your GP record.

Some other medical places, such as the Accident and Emergency department at our local hospital, or other doctors and nurses that you might see when the surgery is closed, can take a peek at your GP record but only if they ask you (or your mum or dad) first.

The information in your GP record could be very helpful to them when they are trying to make you better.

You don’t have to say yes if they ask you, and you can ask the surgery not to allow anyone else to be even able to look at your GP record like this if you want.

Other computers

The doctors and nurses at the surgery can also look at some of your hospital records for example, when you went to Accident and Emergency with your broken arm. We can see what the x-ray showed. That information can be very useful to us when we see you in the surgery ourselves.

Any Questions?

If you have any questions, then please do ask someone at the surgery.

Or, you (or your mum or dad) could ask the doctor who is in charge of all this “data” stuff and “keeping things private”

General

Practice365 strives to ensure that its services are accessible to people with disabilities. Practice365 has invested a significant amount of resources to help ensure that its websites are made easier to use and more accessible for people with disabilities, with the strong belief that every person has the right to live with dignity, equality, comfort and independence.

This accessibility statement applies to websites hosted by Practice365.co.uk.

Accessibility on Practice365

We want as many people as possible to be able to use this website. For example, that means you should be able to:

• change colours, contrast levels and fonts
• zoom in up to 300% without the text spilling off the screen
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• navigate most of the website using speech recognition software
• listen to most of the website using a screen reader (including the most recent versions of JAWS, NVDA and VoiceOver)

We’ve also made the website text as simple as possible to understand.

AbilityNet has advice on making your device easier to use if you have a disability.

How accessible this website is

We know some parts of this website are not fully accessible:

• most older PDF documents are not fully accessible to screen reader software

Enabling the Accessibility Menu

Disclaimer

Practice365 continues its efforts to constantly improve the accessibility of its site and services in the belief that it is our collective moral obligation to allow seamless, accessible and unhindered use also for those of us with disabilities.

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If you are experiencing difficulty with any content on Practice365 website, widget, any of its services or require assistance with any part of our site or software, please contact us during normal business hours as detailed below and we will be happy to assist.

Contacting Us

If you wish to report a problem, have any questions or need assistance, please email us at hello@iatropartners.co.uk

Enforcement procedure

The Equality and Human Rights Commission (EHRC) is responsible for enforcing the Public Sector Bodies (Websites and Mobile Applications) (No. 2) Accessibility Regulations 2018 (the ‘accessibility regulations’). If you’re not happy with how we respond to your complaint, contact the Equality Advisory and Support Service (EASS). If you are based in Northern Ireland, please reefer to Equalities Commission for Northern Ireland (ECNI) instead of the EASS and EHRC.

Introduction

The Practice takes it very seriously if a member of staff is treated in an abusive or violent way.
The Practice supports the government’s ‘Zero Tolerance’ campaign for Health Service Staff. This states
that GPs and their staff have a right to care for others without fear of being attacked or abused. To
successfully provide these services a mutual respect between all the staff and patients has to be in
place.

Our Practice staff aim to be polite, helpful, and sensitive to all patients’ individual needs and
circumstances. They would respectfully remind patients that very often staff could be confronted with a
multitude of varying and sometimes difficult tasks and situations, all at the same time. The staff
understand that ill patients do not always act in a reasonable manner and will take this into
consideration when trying to deal with a misunderstanding or complaint.

However, aggressive behaviour, be it violent or abusive, will not be tolerated and may result in you
being removed from the Practice list and, in extreme cases, the Police being contacted.
In order for the practice to maintain good relations with their patients the practice would like to ask all
its patients to read and take note of the occasional types of behaviour that would be found
unacceptable:
• Using bad language or swearing at practice staff
• Any physical violence towards any member of the Primary Health Care Team or other patients,
such as pushing or shoving
• Verbal abuse towards the staff in any form including verbally insulting the staff
• Racial abuse and sexual harassment will not be tolerated within this practice
• Persistent or unrealistic demands that cause stress to staff will not be accepted. Requests will be
met wherever possible and explanations given when they cannot
• Causing damage/stealing from the Practice’s premises, staff or patients
• Obtaining drugs and/or medical services fraudulently
• We ask you to treat your GPs and their staff courteously at all times.

The Legal Position
As a responsible employer, the Practice has a duty as a provider of NHS healthcare to protect the health,
safety and welfare of staff under the Health & Safety at Work Act. This includes a risk assessment of
violence towards staff and taking steps to mitigate this under the Management of Health and Safety at
Work Regulations 1999.

Staff members who are victims of violent conduct or assault have the right to sue their employers for
compensation if the risk of violence could have been reduced or removed completely, but the
employers did not act upon this information.
Examples of security issues:
• Security of grounds and car parking
• Security of premises – incl. storage, “out of hours”
• CCTV
• Cash and staff – storing, handling and transferring
• Security Systems
• Security of equipment – medical devices, computers
• Communication of national security alerts
• Information records
• Contingency planning.
• Security of employees
• Staff working on their own
• (Staff can be lone workers when making domiciliary visits or within a hospital department e.g.
out of hours)

This list is not exhaustive.
For example a lone working risk assessment must provide the lone worker full knowledge of the hazards
and risks to which he or she is being exposed and what they must need to do will something go wrong.
Other responsible persons must know the whereabouts of lone workers and what they are doing;
Violence at Work

The practice acknowledges that there may be instances where violence and / or aggression forms part of a
patient’s illness. In these circumstances, the issue will be discussed with the patient and form part of their care
planning.

This information will be recorded in the patient’s medical record and flagged to ensure that members of staff are
aware. In addition, where deemed necessary, appropriate support will be put in place, e.g. staff members do not
see the patient alone.

Definition of Physical and Verbal Abuse and Violence:

Physical and verbal abuse includes:
• Unreasonable and / or offensive remarks or behaviour / rude gestures / innuendoes
• Sexual and racial harassment
• Threatening behaviour (with or without a weapon)
• Actual physical assault (whether or not it results in actual injury) includes being pushed or
shoved as well as being hit, punched or attacked with a weapon, or being intentionally struck
with bodily fluids or excrement.
• Attacks on partners, members of staff or the public
• Discrimination of any kind
• Damage to an employee’s or employer’s property

The Practice supports the Zero Tolerance stance adopted by the NHS.
The HSE (Health and Safety Executive) defines work-related violence as:
“Any incident, in which a person is abused, threatened or assaulted in circumstances relating to
their work”.

Violence and aggression towards a person may also be defined as:
“A physical contact with another person which may or may not result in pain or injury. The
contact is uninvited and is an attempt to cause harm, injury or to intimidate. Non-physical
aggression includes the use of language which causes offence or threatens the safety of a
member of staff”.

Under the Health and Safety at Work Act 1974, the practice will also undertake the following
measures to ensure a safe work environment:
• Carry our risk assessments to assess and review the duties of employees, identifying any “at risk”
situations and taking appropriate steps to reduce or remove the risk to employees, particularly if
they are working alone.
• Assess and review the layout of the premises to reduce the risk to employees where physically
possible.
• Assess and review the provision of personal safety equipment, such as alarms.
• Develop surgery policies, procedures and guidelines for dealing with physical and verbal abuse.
• Provide support and counselling for victims, or refer to suitably qualified health professionals.
• Make employees aware of risks and ensure employee involvement in suitable training courses.
• Record any incidents on a Significant Event form and take any remedial action to ensure similar
incidents are prevented in future.