Contributing to a successful Care Quality Commission Inspection 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”. Taken from the CQC’s website

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) CQC inspections are in-depth. They also inspect in the evenings and at weekends when CQC know people can experience poorer care. The CQC’s unannounced visits to Colchester Hospital  carried out ahead of the formal inspection in September included an inspection at night. The inspectors use professional judgement, supported by objective measures and evidence, to assess services against five key questions:

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. The inspectors are looking to get to the heart of people’s experiences of care, the focus is on the quality and safety of services, based on the things that matter to people.

Also focus on care pathways and patient groups 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 The CQC has identified those services that they will always inspect, irrespective of risk, at every acute hospital where they are provided. These are known as the core services. However, they keep all the services provided under continuous surveillance. If they identify particular services, specialist areas or pathways of care where they have concerns, or where they believe the quality of care could be outstanding, and they are not covered by these core services, they may look at one or two of them in detail and report on them. They will not always be able to visit every ward or part of a core service. Where they sample services for inspection, they will select some on a random basis and for others they will consider various factors about risk, quality and the context of the services to help select and prioritise the areas they visit. The services may include, for example: • Those where a previous inspection, CQC intelligence or information gathered by either Monitor, the NHS Trust Development Authority, NHS England or a local clinical commissioning group, has flagged a concern or risk. • Those about which CQC have received a complaint, there has been a safeguarding alert or they have received concerns from a member of staff. • Those that they have not inspected for a long period or have not previously inspected at all. • Services that provide a quality of care that may be outstanding. CQC are also committed to including a focus on care pathways and particular patient groups as part of the inspection. This could include, for example, people with dementia or with a learning disability.

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 Staff Survey results – have to be in the top 20% for an outstanding rating

What is the process? Gathering views of people who use our services includes: Holding public listening events Holding focus groups with people who use services and those close to them Use posters to advertise the inspection to allow people an opportunity to speak to the CQC team Gather information from complaints Etc.

CQC form judgments

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

SAFE People are protected from abuse and avoidable harm. Incident reporting Training Staffing levels, skill mix & handover Infection prevention Equipment maintenance & training Ward boards Lessons learned & actions Safeguarding MEWS Medicines management Security of drugs Records management Service planning & MAJAX An opportunity to go through the 5 KLOEs and talk about what the inspectors may focus on

EFFECTIVE Aware of new NICE guidance End of life care People’s care, treatment and support achieves good outcomes, promotes a good quality of life based on the best available evidence. Aware of new NICE guidance Clinical audit Risk assessments and care plans Practice guidance Multidisciplinary working Consent End of life care Nutrition & hydration Discrimination, equality and diversity Appraisal, PDPs, training & education Mental capacity Act & DOLS

CARING Staff involve and treat people with compassion, kindness, dignity and respect. Hello my name is Personal, cultural, social & religious needs Emotional & compassionate support Confidentiality Improvements following patient feedback Patient & carer information Patient empowerment Patient, their families and carer involvement Patient privacy & dignity Pain management

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

WELL-LED Corporate & departmental induction Leadership & culture 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. 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

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 2013 Midlands & 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!