1. Care Quality Commission Mock Inspection Training Workshop 2014

2. Introductions Anne Leitch: Clinical Compliance Lead

3. Introductions Name Where you work What your role is Experience of CQC inspections What you would like to get out of this session

5. Aims and Objectives Refresher on who CQC are Enable workshop attendees to undertake mock inspections Provide information and paperwork on the process Inform what an inspection should entail What support is available from the Division

6. The Care Quality Commission (CQC), is the independent regulator of health and adult social care services in England They set the standards of quality and safety that everyone should receive when they receive care They register health and adult social care services They inspect services to check whether or not standards are being met Who are the CQC

7. Purpose of CQC Provide expert & independent information. Being targeted and responsive – taking swift action to follow up concerns Mitigate against risk by measuring systems and processes Non-compliance does not mean necessarily mean care is unsafe – it means an increasing risk of care being unsafe. The more ‘non-compliant’ a provider is, the greater the risk

8. Inspections are normally unannounced - CQC will arrive at a location and state to staff that they have come to carry out an inspection. Inspections may be Scheduled – these are inspections carried out on a rolling programme. Providers are not told the date of a scheduled inspection. What is involved in inspections?

9. Responsive – these are carried out when concerns are raised over a provider’s compliance with the standards. Themed – these are carried out when they review a particular type of service (e.g. Review of Learning Disability Services) or a specific set of standards (e.g. Dignity & Nutrition inspection programme) What is involved in inspections?

10. Demonstrates we are a quality provider of services Constant Standards Reputation Public and Commissioners confidence Compliant with contracts Able to tender/promote services positively What CQC means to Mental Health Division?

11. What you have Signed up for! Role of CQC Mock Inspector Mock Inspection Paperwork: Report templates Action Plan

12. Role of Care Quality Commission Mock Inspector Be prepared Be professional Be safe Be organised If an inspector is unable to carry out a timetabled inspection they must inform the CQC Administrator as soon as possible to arrange a possible swap or in exceptional circumstances cancel the inspection. Pressure of work is not a reason to cancel!

13. The service requests a mock inspection as a way to bench mark their service There is evidence of a negative trend – raised by CSD or Commissioners CQC, or National trend raised as an issue How services will be chosen

14. CQC essential standards Inspection template Feedback form Compliance framework Evidence Escalation information The inspectors tool box

15. Carry out an Inspection Inspection site agreed Outcomes have been chosen Relevant supporting evidence from Governance if applicable Paperwork sent to inspectors 5 working days prior to inspection – lead inspector will be identified Inspection day

16. Triangulation of evidence See, speak and observe Is it current Is it reliable Is it relevant Is it sufficient Does it demonstrate the quality of outcomes/experiences of Service Users? Does it demonstrate what processes (controls) the provider has in place?

17. Speak to as many patients/service users/families and members of staff as possible Put same questions to all the staff present to test the awareness and knowledge of the team Ask service users about their experience of the service and attitude / approach of staff Ask services users - if they have any concerns; do they feel safe; do staff listen to them; do they have opportunities to discuss their treatment and their future Questioning

18. Ask staff about how they feel about the service they provide (family & friends test) Ask staff about training they have received and support provided Ask about relevant policies and guidance Ask about how to raise concerns, complaints, whistleblowing and safeguarding Questioning cont.

19. Know your outcomes Note level of interaction between service users and staff & time spent in interactions Note the language used, tone of voice and attitudes expressed Note the appearance of service users, dress, mood and level of activity Note the environment/cleanliness Observations

20. CQC have the right to look at any documentation relating to the provision of care at the location they are inspecting – so do you Care records – e.g. care plans, RIO, risk assessments, admission, transfer & discharge records, medication administration, track and trigger Staff records – e.g. training, rosters, supervision checklist, appraisals record Secondary files and legal files Checking records

21. Following identification of concerns and assessment of potential risk, CQC will make a judgement and require action to be taken The impact to patients/service users is judged as: Minor – people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly CQC Judgements

22. Moderate – people who use the service experienced poor care that had a significant impact on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly. Major – people who use the service experienced poor care that had a serious current or long-term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly. CQC Judgements

23. Being declared non compliant means services have been assessed as being below expectable minimum standards Can result in Impact on image of Trust as a provider of quality services Impact on Monitor status Financial or legal implications Impact on contracts and commissioning – potential loss of business Lead to increased inspection and scrutiny Effect the morale of staff Non compliance

25. Time Scales Inspectors to meet Inspection takes place Write up paperwork Lead inspectors to provide verbal feedback to team Escalate serious issues to: Anne Leitch : 02380821260 / 07500 914391 or Fiona Hartfree : 02380 821250 / 07721 437930 Day 1 Day 3 Lead inspector sends completed paperwork through to Stephanie Lamb Grove House Meridians Cross Ocean Way Southampton SO14 3TJ

26. Time Scales Draft report sent to lead inspector to agree Day 8 Day 10 Lead inspector returns updated report to Stephanie Lamb Day 14 Report sent and inspected team Day 21 Team can return Day 28 Day 40 Final report sent back to team Team submit action plan Day 42 Day 50 Action plan quality check Monitoring and chasing action plan

27. CQC Case Studies

28. Review Aims and Objectives Enable workshop attendees to undertake mock inspections Provide information and paperwork on the process Inform what an inspection should entail

29. Any questions?.

30. Contact details Fiona Hartfree 02380 821250 07721 437930 Fiona.Hartfree@southernthealth.nhs.uk Anne Leitch 02380 821250 07500 914391 Anne.Leitch1@SouthernHealth.nhs.uk Lesley Stevens 02380 874309 Lesley.Stevens@southernhealth.nhs.uk Stephanie Lamb 02380 821251 Stephanie.Lamb@southernhealth.nhs.uk Arthur Green Compliance Manager 02380 874036 07500 914402 arthur.green@southernhealth.nhs.uk Tracey McKenzie Head of Compliance 02380 874288 07789 272282 tracey.mckenzie@southernhealth.nhs.uk Quality & Governance Team 6 Sterne Road Tatchbury Mount, Calmore SO40 2RZ 02380 874323

31. Care Quality Commission (CQC) Website http://www.cqc.org.uk/publichttp://www.cqc.org.uk/public Southern Health Foundation Trust http://www.southernhealth.nhs.uk Where to find further information:

32. Publications A fresh start for the regulations and inspections of mental health services (CQC) Monitoring the Mental Health Act in 2012/13 National Summary of the Results for the 2013 Community Mental Health Survey CQC Guide v3 June 2013 (trust site)

33. Good luck!