CQC Compliance Outcome 11 Safety, Availability and Suitability of Equipment Presented By: Alex Zarneh (Dr.) Head of Medical Physics & Radiation Protection Services Medical Physics Department Mid Yorkshire Hospitals NHS Trust Incorporating Dewsbury & District, Pinderfields and Pontefract Hospitals alex.zarneh@midyorks.nhs.uk MID YORKSHIRE HOSPITALS NHS TRUST DEWSBURY AND DISTRICT HOSPITAL MEDICAL PHYSICS DEPARTMENT HALIFAX ROAD DEWSBURY WEST YORKSHIRE WF13 4HS

Take Your Seats, Sit Back, Relax And Enjoy  

Neglect or Ignorance?   This presentation gives an overview from the following points of view: - Head of Medical Physics with operational and professional responsibility - Acting as out of hours on-site duty manager - being accountable for patients not having basic kit such as Static Mattresses or Pillows

What Happened?  The Trust was inspected by Care Quality Commission Assessors 60 assessors arrived and spent one week across 3 hospitals and care closer to home premises They also came back at weekends and did unannounced inspection

What Happened?  A lot of Evidence was presented prior to their visit but was not Enough to satisfy the requirements of outcome 11!

Outcome 11 – Safety, Availability and Suitability of Equipment The registered person, the Trust must make suitable arrangements to protect service users and others who may be at risk of using unsafe equipment

Availability Of Devices   To ensure that any devices is: Properly maintained and suitable for its purpose Used correctly Is available in sufficient quantities Role of Medical Devices Library

Fit For Purpose   The Device is: Suitable for its purpose Is properly maintained Is used correctly and safely Promotes independence IN-HOUSE MANAGEMENT OF MEDICAL DEVICES POLICY!

Responsibilities?   Do You Know Who is responsible In Your Trust for: - Static / Foam Mattresses or Pillows - Wheel Chairs? How many are lying around broken? - Commodes? / Bariatric Equipment _ Pressure Relief Mattresses? - Decontamination / Cleaning of Medical Devices?

Responsibilities?  - Who is responsible for Clinical Training? - Who is responsible for managing external medical devices contracts? -Who verifies the contractors service reports? Ward clerk? - Who accepts the device back into service? Ward Clerk / Domestics?

Responsibilities?  - Who decides on the level of contract needed? -Is there a centralised database with full visibility? - Is there a replacement programme for all the devices? - What is your standardisation Policy? - Who stands up to users and clinical colleagues who are putting pressure on to purchase the “Deal of the Day”?

CQC Assessment  - Assessors spent time on the wards - Command centres were set up at each hospital site - Head of Medical Physics - Director - Matrons - Chief Nurse Deputy

Yellow Folders! - Inventory ? - Training Records? How many were in date? Some wards also created their own folders: Labeled – CQC Evidence? – Not acceptable!

CQC Assessment   We met with each other every two hours - Kept in touch via text and mobile – signal issues - Walked round the wards and corridors - Engaged with porters to move items from corridors - Lots of biscuits / Fruit and Chocolates - Created good relationship between different colleagues

Operational Issues  - Some staff not familiar with the sites - Working for the same organisation? - Making assumptions - What happened to day to day tasks? - Tired - Having spent 4 weeks collecting evidence!

CQC / Trust Expectations  - Each day requests came from CQC for information - Can you do it for now? - Remember - All Information must be credible - We had a lot of explaining to do!

CQC / Trust Expectations  What were the issues for Medical Physics? - Labeling of service dates on devices - I sent a global Email to other Trusts for comments - Received some good and some rude and ignorant Emails - Spot checking of service dates via telephone call from the assessor

CQC / Trust Expectations - CQC asked for a list of outstanding jobs - List of outstanding PVIs - High Risk, Medium Risk and Low Risk - What is the problem?

What happened Next? - The information was presented to CQC - Decision made to withdraw the “Yellow Folders”

Feedback? - No Formal feedback - Various informal questions re Inventory for various areas - !Number of NIBPs in a certain area!

What Have We Done? - Continue with achieving compliance (91%) - Debate re stickers and service lables?

Thank you for your attention 14