BSc (Hons) MRICS
Associate Director, Healthcare
Savills Commercial Limited
Samantha specialises in all healthcare properties including new developments, and deals with valuations and provides consultancy advice for both private and institutional clients. Her experience covers valuation of property assets including annual portfolio valuations, and the valuation and appraisal of healthcare businesses and properties for lenders, investors and operators nationally, including many statutory bodies
As many practice managers will be aware, the Care Quality Commission (CQC), the independent regulatory body for healthcare, adult social care in England, was due to register all GP practices by April 2012. This deadline has been recently extended to April 2013.
The regulations that underpin CQC registration are the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, and the Care Quality Commission (Registration) Regulations 2009. The key regulations are the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 because they set out the main standards for CQC registration. Practices will still need to comply with the Care Quality Commission (Registration) Regulations 2009 (see Resource).
Under the new regime, each practice will require to be registered with the CQC and declare that they are compliant with 16 essential standards of quality and safety for the regulated activities provided at each location. Furthermore, each premises will have to be registered, whether it is the main surgery or a satellite surgery.
The 16 essential standards include Care and Welfare of People who use Services, Safeguarding People, Cleanliness and Infection Control, Management of Medicines, and Safety and Suitability of Premises. A further 12 regulations relate more to the day-to-day running of the service. Although it is only the 16 essential standards on which a practice must demonstrate compliance, practices will still be required to meet the additional 12 regulations and the CQC will check these as part of their review.
Reviews can be carried out as frequently as every three months or up to two years apart. Experience from the existing regulatory regime for the care home sector strongly suggests that careful consideration should be taken when submitting responses as, once reports have been published, the CQC is very reluctant to alter them and the reports will remain in the public domain.
If practices do not meet some of the 28 outcomes, the CQC has the power to take enforcement action. This can include warning notices, imposition or variation of conditions, suspension of regulation to provide certain services, fines, prosecution or cancellation of registration.
When the CQC inspects the premises, it is primarily looking at the suitability of the building to provide the services for which it is registered; this will include the design and layout.
Inspectors will also be looking for potential risks to be identified and information on how these risks will be managed. The main aim is to create a consistent and safe environment.
Requirements and expenditure
It is hoped that the CQC will recognise that many GPs do not have the benefit of modern, purpose-built facilities. Many practice premises are of course converted and extended properties, which have been adapted to accommodate changes that have taken place within primary care.
All existing practices should, by now, be compliant with the Disability Discrimination Act (DDA). This may have involved significant structural and non-structural alterations including provision of lifts, ramped and wheelchair access into premises, and it is likely that these works will help with the essential standard relating to Safety and Suitability.
However, the CQC is not just concerned with the essential standards but, as previously mentioned, will be inspecting to ensure that premises are 'safe' and 'suitable'. The premises should meet contractual requirements and, as far as appropriate, should reflect the Department of Health's (DH) technical memoranda and guidance on the design of surgery premises.(1) The premises will also be required to meet the requirements of: the Health and Safety at Work Act 1974; Management of Health & Safety at Work Regulations 1999 (amended 2006); Control of Substances Hazardous to Health Regulations; Regulatory Reform (Fire Safety) Order 2005; and other related health and safety legislation.
Much of the above will be non-structural and more of a cosmetic nature, but works such as improving the internal finish in order to meet the DH's requirements may entail expenditure. While these works might be relatively straightforward for owner-occupied premises, GPs who lease their premises may require consent from their landlord for the works.
The lease should be checked to ascertain whether the landlord or the tenant is responsible for carrying out works to comply with statutory requirements. If it is the tenant's responsibility, the landlord's consent in writing should be obtained to ensure the changes/improvements do not result in an increased rent at review. It is worth checking whether the service charge is likely to increase as a result of any works.
Planning permission and building regulation approval may be required. These statutory consents take time to obtain. It will be necessary to plan, design and carry out the works so as to create the least interruption to the practice. If the landlord undertakes the works, they are likely to seek an increase in the rent; if the tenant undertakes the works, it may be reflected in an increase in the rent reimbursed. The tenant should also benefit in the day-to-day running of their business.
It may be easier for owner-occupied premises to raise finance (if required) for the works, as banks will seek security by way of an extra charge over the freehold. If funding is not available for these works, the practices should try to manage any potential risks. In such instances it would be prudent to set up a maintenance and repair programme to demonstrate to the CQC the steps being taken to address the requirements in a sensible way. There are various funding options but, owing to the current financial constraints in the NHS, securing capital funding has become much harder. Any cost-effective, well-thought-out and justified solutions to adapting existing premises should, at least, be given consideration by funders.
The CQC will also consider practice security, infection control and fire safety. Practices are only required to comply as far as is practical. If you are in a vulnerable location, it may simply be a case of fixing shutters to accessible windows. As the risk increases, so do the costs.
Notwithstanding this, practices should try to ensure that risk assessments, risk management and solutions are provided to the CQC. In some cases where the building is outdated, tenants may be able to show their landlords that investment in compliance works would protect their property investment, especially if it provides value for money.
While the CQC will not be seeking to close down practices that do not meet the standards, they will be looking for consistency and quality in relation to both the premises and the services provided. Indeed, most practices will already be meeting the procedural standards, but it will be worth using the period to April 2013 to ensure that the practice building is both suitable and safe.
CQC registration shouldn't be considered as a burden – it should be considered as a mark of compliance that practices can use as a benchmark.
1. Department of Health. Health Building Notes (HBN) and Health Technical Memoranda (HTM). London: DH; 2005. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...
CQC – legislation
Your comments (terms and conditions apply):
"As an architect working on primary care health projects throughout the north, it is still very common for many Practices to be non-compliant with DDA legislation. This inevitably presents many practical problems given the predominance of patient visits from the elderly and infirm. One can understand the 'head in the sand' attitude of many GPs who are quite rightly focussed in delivering healthcare rather than the maintenance of their premises. The solution however is out there in the format of construction consultants who are geared up to 'remove the pain' of identifying and resolving these issues at all scales from installation of basic ramps all the way through to new build solutions" – Paul Wainwright, Leeds