1. Care Quality Commission (CQC) Registration

2. Background The Care Quality Commission (CQC) is the health and social care regulator for England. From 1 April 2010, NHS trusts which carry out regulated activities including primary care trusts as providers, must be registered with CQC

3. Single System For All Registration Single system of registration Single set of standards Strengthened and extended enforcement powers 1 2 3 Adult Social Care NHS Independent healthcare The old The new

4. Declare compliance/non compliance for each activity at each location against each of the relevant 28 Regulations in the Health & Social Care Act How is it different? Standards for Better Health Registration One declaration for HCHC against 44 standards Each HCHC location where a regulated activity takes place is registered Regulation based on outcomes for people in terms of a quality experience of care Standards focussed on the systems, processes and policies

5. E.g. Nutrition

6. Linking it to the patient experience

7. Our registered Locations Sites from which in-patient services are provided - 11 Community Hospitals Sites from which community services are managed - Tatchbury Mount

8. Our regulated Activities Personal care Accommodation for people who require nursing or personal care Accommodation for people who require treatment for substance misuse Accommodation and nursing or personal care in the further education sector Treatment of disease, disorder or injury Assessment or medical treatment for people detained under the Mental Health Act 1983 Surgical procedures Diagnostic and screening procedures Management of supply of blood and blood derived products Transport services, triage and medical advice provided remotely Maternity and midwifery services Termination of pregnancies Services in slimming clinics Nursing care Family planning services.

9. Online Registration Registered Location: Lymington & NF Hospital Activity: Treatment of disease Surgical procedures Diagnostic and screening Regulation 1 e.g. Consent Compliant Regulation 2 e.g. Nutrition Compliant Regulation 3 E.g. Medicines Compliant Regulation 4 E.g. Staffing Compliant EtcNot CompliantPartially Compliant Regulation 28 E.g. Infection Compliant

10. Collecting our evidence Best evidence: examples of positive patient experience or quality service e.g. patient surveys, audits, patient leaflets, focus groups and information, compliments and plaudits, details of service improvements implemented Next-best evidence: examples of the systems and processes we have in place to provide a quality service and good patient experience e.g. policies and procedures, leaflets, notes of meetings, training records, action plans, etc.

11. How we will be collecting evidence Each Community Hospital – will collect evidence for their in-patient activities Community teams (including Children’s and Dental) – will collect evidence per team Policies, strategies, guidelines, etc – will be collated centrally

12. When will we collect evidence? All year Phased throughout the year to make it manageable Review and refresh annually

13. Our Registration HCHC declared full compliance against all Regulations in all Activities & Locations with the exception of: Regulation 23 (Outcome 14) “Supporting Workers” in all activities/location Regulation 24 (Outcome 6) “ Co-operating with other Providers” for Locations where treatment, surgery and diagnosis takes place e.g. community hospitals and community services

14. If we are not compliant Registered with ‘conditions’. Action plans in place Must demonstrate actions completed by the deadline agreed with CQC CQC can take enforcement action – i.e. warning notices, imposition or variation of conditions, suspension of registration to provide certain services, fines, prosecution or cancellation of registration – if actions not completed

15. How CQC monitor compliance Monitor compliance of registered providers on an ongoing basis – this is our Quality & Risk Profile (QRF) People who use services, their families and carers Other Regulatory Bodies e.g. Audit Commission, Monitor HCHC Quality & Risk Profile Providers themselves Partner Organisations e.g. Ombudsman, commissioners Staff & other professionals

16. CQC’s ongoing role Registration - continuous monitoring: Responsive Review – selected outcomes Planned Review – all outcomes Assessments of Quality: Periodic Reviews – quality of services/ assessments against indicators (TBC) Special Reviews – aspects of care e.g. nutrition, safe surgery, mortality Will involve evidence review May involve site visits All findings will be published

17. Review Scenario? Planned Review: all aspects of our Registration across all locations Responsive Review: Visit to Petersfield following serious incident where patient died Quality Assessment: Visit to Lymington as part of national review of Safe Surgery Quality Assessment: Evidence requested following submission of data against CQC quality indicators

18. Infection Control Inspection 09-10 Unannounced inspection in 4 community hospitals in May 2010 Inspected wards & equipment, talked to staff, reviewed documents and observed practice Interviewed Director responsible for infection control Identified areas for improvement Commented on positive reception they received from staff in all hospitals

19. “Be ready for anything!”

20. More information Julie Jones Associate Director – Governance Tatchbury Mount Tel: 07786 975 601 Email: julie.jones@hchc.nhs.uk Tracey Rich Governance & Risk Management Lead Tatchbury Mount Tel: 07789 272282 Email: tracey.rich@hchc.nhs.uk