Annual conference breakout session: Getting the best out of an inspection

About the session

The ‘Getting the most out of your inspection” session began with a presentation given by speakers who work within the sector. This was followed by an open discussion between the participants.

Relationship between inspector and centre staff

Participants agreed that a more positive relationship should be built up between inspector and centre staff – this could reduce the anxiety surrounding the inspection process.

Participants also discussed the need for better understanding of each others roles.

A number of suggestions were made, including:

Inspectors could visit their centres on a more informal basis to introduce themselves and to provide guidance on what inspections are etc. These visits could promote sharing, learning and informing.
Some participants liked the idea of having a photo of their inspector which they could display in the centre. This would ensure that all staff know who their inspector is.

Several participants spoke about the need for the relationship between inspector and centre staff to be handled carefully and emphasised that it is important that the inspectors respond to queries from the centre in a timely manner.

The new Compliance Cycle will mean that there will be more inspection contact between centre and inspector as there will be ongoing assessment of the centres general performance indicators and follow up on deadlines of any required improvements.

Support needed for new centres

The group discussed whether centres new to regulation need further support. It was suggested that inspectors could visit the new centres prior to their initial inspection.

What an inspection involves

Participants talked about their own experiences of inspection and stated that there is often a lack of clarity about what an inspection involves. Suggestions included:

The centre is sent an agenda for the inspection 10 working days before the inspection and that the agenda is discussed with either the Person Responsible or delegated inspection coordinator to ensure the right staff are on duty at the time they are required;
It was proposed that this could be put into the inspector’s standard operating procedure for inspection planning.
It was suggested that a pre-inspection meeting between the lead inspector and the PR would ensure there is a clear agenda, document/evidence availability, staff availability and a plan for the inspection.
In order to have a better understanding of the inspection, any inspection documentation should be available to the centres before the inspection: either on a individual inspection basis or available to clinic staff on the HFEA website, e.g.
- Standard Operating Procedures for inspection
- Inspection notebooks
- Inspection audit tools
- Draft agenda/template for renewal and interim inspection
The inspectors should consider accepting other audit evidence or quality management systems such as ISO or BIS as evidence of compliance and not duplicate work.
In principle this appears to be a way forward in order to avoid unnecessary burden for the centres and there is ongoing work within the HFEA to assess the feasibility of this and how the external schemes would meet the requirements of the HFE Act, Licence Conditions and Code of Practice.
It was suggested that an inspection training video could be commissioned for the centres to use with new staff or staff who had not taken part in an inspection before.
The inspector should provide a date when the draft report would be returned to the person responsible and/or the person coordinating the inspection in order to ensure it could be reviewed, commented on and returned as soon as possible. The report should also be copied to another member of the centre team to ensure that if the PR was away someone would pick it up.

New inspection report format

Participants shared their experiences with the old style of inspection report with some stating that sometimes the positive feedback given at the end of the inspection is not reflected in the inspection report.
Participants suggested that reports should reflect positive feedback. Participants were reminded that a new format of inspection report will be in use from 1 October 2009 and this does include areas to highlight compliance.
Participants asked whether PRs could be given longer to respond to the inspection report. A participate stated that there is a short time frame for response at the moment and this could be difficult to meet if the PR is on annual leave etc. Participant asked if they could have three weeks to respond to report.
The HFEA is responding to the request from the sector that reports are turned around much faster. There are processes in place to meet the standard already set. Work will continue on a more efficient method of ascertaining the PR response to a report.

Training of inspectors

Participants were interested in what training an inspector participates in. It was explained that a mentor led training programme for inspectors is in place and that some inspectors have completed a inspector training course led by the European Union Standards and Training in the Inspection of Tissue Establishments (EUSTITE) course.
Another participant shared their concerns about the change in approach to inspection, in particular the move towards centres having to think about what evidence to provide to show compliance. The HFEA reassured the participants that prompts will be given to staff.

HFEA and Care Quality Commission (CQC)

Participants asked if the HFEA and CQC work closer together as this would reduce the burdens for centres.
The HFEA representatives at the session stated that they appreciated the amount of inspections some centres have, but stated that the HFEA and CQC look at different areas and a mapping exercise would be required to bring the two processes under one.
Recent organisational changes at the CQC has interrupted discussions between the two organisations. These discussions will restart as soon as practicably possible.

Page last updated: 30 October 2009

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