An opportunity to shine…………

Contributing to a successful

Care Quality Commission Inspection

Overview• Who are the CQC?• What is the process?• How does this affect WSFT?• How does this affect me?• What are we all doing to prepare?

Who are the CQC?

The Care Quality Commission (CQC) is the independent regulator of health and adult social care in England“We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find, including performance ratings to help people choose care. We set out what good and outstanding care looks like and we make sure services meet fundamental standards below which care must never fall. Where we find poor care, we will use our powers to take action”.

What is involved?

• Planned inspection as part of a national programme• Multi-disciplinary – patients, clinicians, managers (20-30)

on site for 3 days• Formal and informal (‘conversations’)• Pre visit data request – Addenbrookes 276 documents

returned• CQC announced visit 3 months notice• Possible unannounced CQC visits around time of

planned, evening and early morning (smaller numbers)• Will assess using Key Lines of Enquiries (KLOEs)

Five Key Lines of Enquiry (KLOEs)

Inspectors ask the following five questions. Are we:

Safe: people are protected from abuse and avoidable harm.

Effective: people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence.

Caring: staff involve and treat people with compassion, kindness, dignity and respect.

Responsive: services are organised so that they meet people’s needs.

Well-led: leadership, management and governance of the organisation assures the delivery of high quality person-centred care, supports learning and innovation, and promotes an open and fair culture.

Core Services

• Maternity & gynaecology• Services for children & young people• Critical care• Surgery• Medical care incl. older people’s care• End of life• Outpatients• Emergency department• Trust wide ( support services, estates, diagnostics. HSDU/CSSD,

mortuary, corporate and Trust Board

Also focus on care pathways and patient groups

What they will know…

• Data publically available• Data we have submitted• Feedback from patients and relatives• Inpatient Survey and Staff Survey results• Harm events/current performance across services• Mortality data• Trust risk register• Ask for further information during inspection

What is the process?

CQC form judgments

Ratings

• CQC use a 4 point rating system– Outstanding – Good– Requires Improvement – Inadequate

SAFE

• Incident reporting• Training• Staffing levels, skill mix &

handover• Infection prevention• Equipment maintenance

& training• Ward boards

People are protected from abuse and avoidable harm.

• Lessons learned & actions• Safeguarding• MEWS• Medicines management• Security of drugs• Records management• Service planning &

MAJAX

EFFECTIVE

• Aware of new NICE guidance

• Clinical audit• Risk assessments and

care plans• Practice guidance• Multidisciplinary working• Consent

People’s care, treatment and support achieves good outcomes, promotes a good quality of life based on the best available evidence.

• End of life care• Nutrition & hydration• Discrimination, equality

and diversity• Appraisal, PDPs, training

& education• Mental capacity Act &

DOLS

CARING

• Hello my name is• Personal, cultural, social

& religious needs• Emotional &

compassionate support• Confidentiality• Improvements following

patient feedback

Staff involve and treat people with compassion, kindness, dignity and respect.

• Patient & carer information

• Patient empowerment• Patient, their families and

carer involvement• Patient privacy & dignity• Pain management

RESPONSIVE

• Complaints policy• Advice to patients and

family how to complain• Top five types of

complaints• Encourage feedback• Learn from complaints &

concerns

• Consider needs of different groups

• Learning disabilities• Dementia• Complex needs• Timely access to care

Services are organised so that they meet people’s needs.

WELL-LED

• Corporate & departmental induction• Leadership & culture• Our vision, values & strategy• Personal objectives• Team meetings• Current risks for the team or service• How to raise issues of concern• Whistleblowing policy

Leadership, management and governance of the organisation assures the delivery of high quality person-centred care, supports learning and innovation, and promotes an open and fair culture.

The Inadequates

• Isolation and introspection• Trusts lose sight of what good looks like • Idiosyncratic rules – we've always done it this way here • Non adherence to the rules • No personal/organisational consequence of non adherence, eg. WHO,

ANTT, bare below elbow, smoking, data, etc • Problems denied/unsighted • Slow to react to changing circumstances • Argue the toss – who else to blame? • Good governance let slip – sloppiness • Poor clinical leadership models/engagement/behaviour • Poor external relations • Board/ senior leadership detached and /or distracted

The Outstandings: Salford Royal

Proud to be the best

We have a similar ambition Together

Our patients, Our hospital, Our future, together

Our values

Developed with staff and patients :

Focused on patients

Integrated

Respectful

Staff focused

Two-way communications  

We are an award winning hospital

Dr Foster Trust of the Year 2013Midlands & East of England

Our quality reflects our training & education

0ur brilliant Education Centre

Divisional Service Quality Improvement Group

• Model piloted in the Surgical division• Roll out to the other Divisions• Led by the senior team in the Division• One KLOE at a time, consider

– What do we do well?– What could we do better?– What do we need to do to make our practice move

from ‘Requires improvement’ to ‘Good’ or from ‘Good’ to ‘Outstanding’?

An opportunity to shine

We are not doing this “to pass the exam” or “to get a certificate”• We have a fantastic, high performing hospital and together we

can show that we meet and in many cases exceed the CQC fundamental standards

• A chance to demonstrate how good we are, and in many cases how excellent we are in the care we provide to our patients

• Let’s show off our great achievements and what we are proud of.

• Discuss honestly the areas in which we know we need to improve and our plans to do so.

• We shouldn’t be afraid of these inspections but we must be prepared!