New provider application form

This is an annual, self-assessment process. The information you provide will be assessed against Care Quality Commission, British Association of Paediatric Surgeons, BMA, GMC and the Initiation Society standards. If your service does not meet these identified standards or you do not complete all relevant questions, your service will not be quality assured.

This process has been introduced for the protection of children and for the benefit of practitioners who perform non medical circumcision on children.

The information you provide will be managed by Public Health Manchester. A confidential, limited access database will be developed. For the purpose of reporting, all identifiable variables will be removed and results anonymised.

Thank you for you time.

Step 1 of 16

New User Password

Professional details

(Please give details in regards to the role of circumcision provider).

Name(Required)

Prefix First Last

Clinic name

Clinic address

Street Address Address Line 2 City County Post Code

Contact email(Required)

Contact tel no.(Required)

Profession

Specialty

GMC or other reg no.

Answer all questions in relation to infant male circumcision

1. Qualifications

List training courses and qualifications you hold that relate to infant male circumcision. This should include any training in neonatal resuscitation.

Qualifications

Course name

Place of training

Year

Supervisor’s name

Job title/Profession

HI ya

How do you ensure your skills and clinical knowledge of circumcision are kept up-to-date?

Keep up to date

2. Technique

Which of the following circumcision techniques do you use, (tick all that apply)

Technique

Plastibell

Scalpel

Other (please describe)

Technique Other

3. Experience

How long have you been performing circumcisions? (years/months)

Years

Months

How many circumcisions do you on average undertake per year?

Circumcisions do you on average undertake per year

Complication rate: How many children, in the last 12 months are you aware off who have experienced an:

Immediate complication (i.e. infection, bleeding)

Immediate complications

Admission to hospital within 48 hours

Later complications, (i.e. scarring, disfigurement, reoperation)

Later complications

4. Clinical Audit

Do you audit your circumcision activity?

Audit your circumcision activity(Required)

Yes

If yes, how often do you conduct an audit and what is the purpose of this audit?

How often do you conduct an audit

Please provide evidence of your audit activity.

5. Premises

What premises do you use to circumcise children? (tick all that apply)

Premises(Required)

Dedicated clinic

Religious venue

Other (please specify)

Premises Other(Required)

How would your service respond to parents who request a circumcision to take place in their home?

The panel requires all providers to register with the CQC if operating out of non-NHS premises, ensuring that surgical procedures are including within the scope of registration. Are you registered with the Care Quality Commission, (CQC) for this service? Please enclose a copy of your registration letter.

Care Quality Commission Registration Letter

Max. file size: 63 MB.

6. Consent

Is written consent obtained from both parents and/or those with parental responsibility?

Is written consent obtained from both parents and/or those with parental responsibility?(Required)

Yes

No, consent is required from one parent only

Explain how you obtain consent from an absent parent? (i.e. Mother or father is not present on day of procedure).

Explain how you obtain consent from an absent parent? (i.e. Mother or father is not present on day of procedure).(Required)

What information, verbal or written, do you provide to parents to reassure them and prepare them for the procedure?

What information, verbal or written, do you provide to parents to reassure them and prepare them for the procedure?(Required)

What information about complications and after-care do you provide to parents to enable them to provide informed consent? (please attach if printed)

What information about complications and after-care do you provide to parents to enable them to provide informed consent? (please attach if printed)(Required)

Informed Consent Files

Drop files here or

Max. file size: 63 MB.

Is this information available in community languages? (please specify)

Is this information available in community languages?

7. Patients Age

How old are the children you circumcise? (tick all that apply)

How old are the children you circumcise?

Under 6 months

Over 6 months- under 1 year

1 years-5 years

Over 5 years

8. Pain Management and Anaesthesia

What type of anaesthesia do you administer? (tick all that apply)

Anaesthesia

None

Local Anaesthetic (LA)

Other (please specify)

Please Specify

Anaesthesia other(Required)

If no anaesthesia is used, how do you manage the patient’s pain?

Manage patients pain(Required)

When administering LA, what method do you use? (i.e. ring block, dorsal penile block, cream or gel, please specify)

Administering LA(Required)

Do you recommend any post-procedure pain relief for the child? If so what?

Post-procedure pain relief

9. Involvement of Others

Other than you, who else are present during the circumcision and why? (e.g. nurse, parents, family members, other health professionals, faith members).

Others Present

10. Follow-Up Care

Following a circumcision, when do you allow a child to leave your direct care? (tick all that apply)

when do you allow a child to leave your direct care?

Following urination

30mins after bleeding has stopped

After a specific time period?

Other discharge criteria

Please Specify Specific Time

Specify Specific Time

Other discharge criteria, please specify

What aftercare advice do you provide to the parents about wound care and seeking medical advice? (tick all that apply)

Aftercare Advice

None

Written

Verbal

Please attach written

Written Upload(Required)

Max. file size: 63 MB.

Once the child has left your direct care, what follow-up is available? (tick all that apply)

Follow-up available

24 hour access to the surgeon via a dedicated telephone number?

Appointment

Telephone messaging or texting service

Other

Other - Please Specify

Follow up Other - Please Specify(Required)

Is this advice available in community languages?

What follow-up appointments do you provide? (tick all that apply)

What follow-up appointments do you provide?

A routine follow-up appointment is booked for all patients

Follow-up appointments are available on request

Emergency follow-up only

GP follow-up recommended

Other

Other: Please Specify

Follow up Other(Required)

What information about the circumcision do you send to the child’s GP? (tick all that apply)

Information sent to child's GP

Verbal

Written discharge letter

None

11. Safety

What arrangements are in place for children with immediate complications?

What arrangements are in place for children with later complications?

How are the reusable instruments sterilised? Please describe

What information do you gather to ensure it is safe to perform the procedure on a particular child? (for example, birth weight, jaundice, clinical history, complex and additional needs, etc) How do you verify this information?

How would your service support and advise families seeking a circumcision for a child with a disability?

12. Safeguarding Children

Describe how would you access local child protection procedures and policies?

When did you last receive a CRB check?

DD slash MM slash YYYY

When did you last complete safeguarding children related training? What was the level of safeguarding children training you received? Please enclose a copy of the relevant certificates.

Certificates

Drop files here or

Max. file size: 63 MB.

13. Equity, Diversity and Human Rights

How do you communicate with patients families whose first language may not be English?

14. Complaints

What is your procedure for dealing with complaints? Please attach a copy of your complaints policy.

What is your procedure for dealing with complaints? Please attached a copy of your complaints policy.

Complaints Policy

Max. file size: 63 MB.

15. Other comments

Are there any other factors that you would like to tell us about which may support the quality assurance process?