Associate Network Clinic Self-Audit Form

Join our network!

FitBack Physiotherapy are a leading provider of specialist Occupational Health Physiotherapy and Health and Wellbeing services to some of the UK`s leading brands.

Due to expansion, we are growing our network of associate private physiotherapy clinics across the UK. We are looking for outstanding clinics interested in receiving Occupational health physiotherapy referrals to join our growing national network.

Our patient base are employees that are either absent from work due to MSK issues or suffering with MSK issues affecting their work. Our physiotherapy interventions are work focused with an aim to returning patients back to work or full duties as quickly and safely as possible. Our associate clinics will be providing employees with treatment when they really need it which isn’t always accessible through traditional pathways.

We differ from other Physiotherapy network providers in that we don’t receive referrals from insurance companies for low level claim whiplash disorders. Furthermore, we believe our payment terms and conditions are amongst the best of the network providers.

We invite you to join our network and look forward to welcoming you on board!

Instructions (Please Allow 20-30 minutes to complete)

Please note this document is based on CSP clinical quality assurance standards audit minimum recommendations.
Please do not refresh your browser or leave the page before submitting otherwise your data will be lost.
Before completing please read through this document to ensure you have all the documentation that is necessary.
Please ensure that all sections are fully completed.
Please ensure that all documents requested are attached when submitting the form.
Following submission of your application and if successful, FitBack will contact you with payment terms and conditions.
If you have any queries prior to filling in the form please email FitBack at [email protected]

Last Saved:

1. Clinic Information
2. Policies and Procedures
3. Clinical Governance / Record Keeping
4. Documents for Upload

Clinic Information Edit
Policies and Procedures Edit
Clinical Governance / Record Keeping Edit
Documents for Upload Edit

Clinic Details

Please complete the following questions below:

Clinic Name

Please populate this field.

Clinic Owner Name

Please populate this field.

Clinic Owners First Name

Please populate this field.

Clinic Owners Surname

Please populate this field.

Number of clinics within practice

Please populate this field.

Main Address of Clinic

Please populate this field.

Clinic address second line

Clinic Town

Please populate this field.

Clinic County

Please populate this field.

Clinic Post Code

Please populate this field.

Telephone Number

Please populate this field.

Email Address

Please populate this field.

Website Address

Contact name of main contact for network clinic administration

Please populate this field.

Email address of main contact for network clinic administration

Please populate this field.

Please enter additional clinic addresses below

Please list your clinic opening hours below:

Open

Close

Monday

Please populate this field.

Please populate this field.

Tuesday

Please populate this field.

Please populate this field.

Wednesday

Please populate this field.

Please populate this field.

Thursday

Please populate this field.

Please populate this field.

Open

Close

Friday

Please populate this field.

Please populate this field.

Saturday

Please populate this field.

Please populate this field.

Sunday

Please populate this field.

Please populate this field.

Further clinic information needed:

Receptionist cover

Yes

No

Please populate this field.

Number of new patients seen in the last 12 months

Please populate this field.

How many face to face treatments have been carried out in the last 12 months?

Please populate this field.

How many full time physiotherapists work from the clinic?

Please populate this field.

How many part time physiotherapists work from the clinic?

Please populate this field.

Does your clinic use an electronic practice management/ diary software package?

Yes

No

Please populate this field.

If you selected yes, please let us know which one here:

Please populate this field.

Is there disabled access?

Yes

No

Please populate this field.

Does the clinic have a gym?

Yes

No

Please populate this field.

Does the clinic have access to a hydro pool?

Yes

No

Please populate this field.

Does the clinic run pilates classes?

Yes

No

Please populate this field.

Does the clinic provide any other exercise/ rehab classes?

Yes

No

Please populate this field.

Does the clinic offer home Visits?

Yes

No

Please populate this field.

Please select the specialities provided by the clinic:

Musculoskeletal

Orthopaedics

Neurological

Ergonomics

DSE assessments

Paediatrics

Vestibular rehab

Cardio-respiratory

Hand-therapy

Acupuncture

Other

If you selected other, please list here:

Please populate this field.

Save & Continue

Clinician Details

Please list all the clinicians working within the clinic below:

Please note that without clinician details they will not be able to assess/treat FitBack patients.

Physiotherapists Full Name

Please populate this field.

CSP Number

Please populate this field.

Confirm you have seen clinicians CPD portfolio

Yes

No

Please populate this field.

Number of years qualified

Years
Please populate this field.

HCPC Number

Please populate this field.

Add Clinician

Submitted Clinicians

CLINICIAN NAME

NUMBER OF YEARS QUALIFIED

HCPC NUMBER

CSP NUMBER

PORTFOLIO CONFIRMATION

Edit

Physiotherapists Full Name

Please populate this field.

CSP Number

Please populate this field.

Confirm you have seen clinicians CPD portfolio

Yes

No

Please populate this field.

Number of years qualified

Years
Please populate this field.

HCPC Number

Please populate this field.

Update Clinician Delete Clinician

Save & Continue to the next section
Policies and Procedures Checklist

Please note you don't need to reply 'yes' to all these questions to be accepted.

Is there an organisational policy for the following:

Fire procedures

Yes

No

Please populate this field.

Moving and Handling

Yes

No

Please populate this field.

Confidentiality

Yes

No

Please populate this field.

Safeguarding children and vulnerable adults

Yes

No

Please populate this field.

There is a health and safety policy which includes procedures to manage: Waste disposal, first aid, disposal of sharps & lone working.

Yes

No

Please populate this field.

Life support

Yes

No

Please populate this field.

Control and prevention of infection

Yes

No

Please populate this field.

Information governance

Yes

No

Please populate this field.

Chaperoning arrangements

Yes

No

Please populate this field.

There is regular servicing of medical equipment and action taken

Yes

No

Please populate this field.

Are there policies for:

The secure storage and transfer of data records in accordance with relevant legal and regulatory requirements and GDPR and the disposal of records in accordance with statutory requirements in a secure manner

Yes

No

Please populate this field.

Access to records by service users and others

Yes

No

Please populate this field.

Policies which govern the use of electronic communication to ensure it is appropriate, secure and confidential

Yes

No

Please populate this field.

Physiotherapy Care of Bariatric patients

Yes

No

Please populate this field.

A glossary describing the allowable abbreviations and their meaning

Yes

No

Please populate this field.

Ensuring staff are aware of their responsibilities under GDPR (2018)

Yes

No

Please populate this field.

Locally agreed systems for onward referral

Yes

No

Please populate this field.

Acupuncture

Yes

No

N/A

Please populate this field.

A signature book to ensure physiotherapy team members can be recognised and traced

Yes

No

Please populate this field.

Save & Continue to the next section
Clinical Governance

Is there a clinical audit programme to ensure continuous improvement of clinical quality, with clear arrangements for ensuring that clinical audit monitors the implementation of clinical effectiveness which includes:

Changes in practice are implemented as part of a clinical audit cycle, in order to rectify any deficiencies identified

Yes

No

Please populate this field.

There is evidence that action is taken as a result of the outcomes of audit

Yes

No

Please populate this field.

Is there a clear and responsive procedure for making and dealing with complaints including policies in place which ensure:

Service users have access to information about the service’s complaints procedure and their 8 individual rights under GDPR, complaints are managed within a locally defined time-scale and monitored in order to identify trends

Yes

No

Please populate this field.

Save & Continue

Record Keeping

Please confirm that within the last 3 months you have audited a minimum of 3 sets of patients notes in line with section 6 (Record Keeping and Clinical Governance) of the CSP Quality assurance standards

Yes I can confirm

No I cannot confirm

Please populate this field.

If no please add comments

Please populate this field.

Save & Continue to the next section
Documents for Upload

Please upload the following documents:

Each file must be no larger than 20MB and must be one of the following file formats: jpg, jpeg, gif, bmp, png, docx, doc, pdf, key, ppt, odt, xls, xlsx, csv, txt

Copy of Public Liability Insurance (Compulsory)

Upload file

Awaiting Upload

Please populate this field.

Copy of Employers Liability Insurance (Compulsory)

Upload file

Awaiting Upload

Please populate this field.

Please send a photo of the front of your clinic and a photo of your clinic room to [email protected] following submission of your application.

If a sole practitioner, I can confirm that I have a continuity plan should I be unable to work:

Yes i can confirm

No i cannot confirm

If no please add comments

Please populate this field.

Save & Continue to the next section
Declaration

I hereby declare that the details provided above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately.

Name

Please populate this field.

Job Role

Please populate this field.

Please ensure you only click submit once
Congratulations, your application has been submitted.

Many thanks for taking the time to complete this audit. Following submission of your completed audit form FitBack will then send contracts and terms and conditions to successful network clinics, along with a form requesting your details for payment.

Back to fitback website

Join our network!

Instructions (Please Allow 20-30 minutes to complete)

Clinic Details

Please complete the following questions below:

Please list your clinic opening hours below:

Further clinic information needed:

Please select the specialities provided by the clinic:

Clinician Details

Please list all the clinicians working within the clinic below:

Please note that without clinician details they will not be able to assess/treat FitBack patients.

Submitted Clinicians

Policies and Procedures Checklist

Please note you don't need to reply 'yes' to all these questions to be accepted.

Is there an organisational policy for the following:

Are there policies for:

Clinical Governance

Is there a clinical audit programme to ensure continuous improvement of clinical quality, with clear arrangements for ensuring that clinical audit monitors the implementation of clinical effectiveness which includes:

Is there a clear and responsive procedure for making and dealing with complaints including policies in place which ensure:

Record Keeping

Please confirm that within the last 3 months you have audited a minimum of 3 sets of patients notes in line with section 6 (Record Keeping and Clinical Governance) of the CSP Quality assurance standards

If no please add comments

Documents for Upload

Please upload the following documents:

Each file must be no larger than 20MB and must be one of the following file formats: jpg, jpeg, gif, bmp, png, docx, doc, pdf, key, ppt, odt, xls, xlsx, csv, txt

Please send a photo of the front of your clinic and a photo of your clinic room to [email protected] following submission of your application.

If a sole practitioner, I can confirm that I have a continuity plan should I be unable to work:

If no please add comments

Declaration

Congratulations, your application has been submitted.