1. Care Quality Commission Mock Inspection Workshop 5 th July 2011, 1300 - 1700 Parkway Centre

2. Introductions Anne Leitch: Development Manager Sally Probert: Business Development Manager Fiona Hartfree: Directorate Lead Nurse AMH Kate Adams: Project Support Officer

4. Mock Inspectors Quiz 1.28 2.Provider Compliance Assessment 3.Safeguarding Service Users 4.Race, age, gender, disability, sexual orientation and religion/belief 5.Human Rights Act, Mental Health Act, Mental Capacity Act, Deprivation of Liberty 6.Yes 7.Issue a warning, impose concerns, prosecute for specific offences, issue a fixed penalty

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

6. Purpose of Care Quality Commission Single regulator Outcome/service user experience focused Register providers of care Monitor compliance of set standards Tackle poor quality care using risk-based regulation, to reduce the likelihood of harm

7. Purpose of Care Quality Commission 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. What CQC means to AMH Demonstrates we are a quality provider of services Consistent standards Reputation Public & Commissioner confidence (kitemark effect) Compliant with contracts Able to tender / promote services positively

9. Provider Compliance Assessments (PCA) Requested by CQC prior to visit Focus services attention on required outcomes Content – information needs to be service specific and evidence based to the service Completion – RAG rating & action plans CQC will triangulate PCAs, observations & data reports 15 PCAs bespoke to service Live documents – not for the shelf

10. How Directorate will run Mock Inspection Programme CQC Mock Inspection Schedule Pathways and timeline Directorate coordination and sustainability Tracking/reporting

11. Mock Inspection Schedule Rationale 1 inspection per Area per month 1 or 2 CMHT inspections per month 1 Inpatient inspection every 2 months PICU every 3rd month Reablement every 3 rd month CRHT every 2 months AOT every 2 months Spread specialist services Planned and unplanned CQC Mock Inspections Mock Inspector will have around four CQC Mock Inspections

12. CQC Mock Inspections Schedule Example AreaInspectorJul ’11Aug ’11 Sep ‘11 East1PICU 2EIP 3 4 CRHT West5AOT IP 6CMHT

13. Break

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

15. 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!

16. Day 1 - 45 - 910 - 1112131415 - 20 Request Information e.g. Complaints Investigations Audit reports Health & Safety reports PCAs Admission/disch arge/wait times Inspectors digest findings of information Inspectors meet to decide on focus & style of the inspection Inspection takes place & Inspectors digest findings Inspectors produce draft report Report finalised by Lead Inspector & submitted to Administrator (cc CQC Area Lead) Report reviewed by responsible CQC Officer (Lesley Stevens, Jason Brandon - Quality Leads to escalate issues and/or innovations) See "Role of CQC Mock Inspector" Mock Inspector Templates CQC Mock Inspection Final Report template See CQC Action Plan template. Area CQC Lead works with the service to draft action plan (14 day target)

17. Plan - Develop a plan for improving quality Do - Execute the plan, first on a small scale Study - Evaluate the feedback to confirm or adjust the plan Act - Make the plan permanent or study the adjustments Mock Inspection Timeline

18. Carry out an Inspection Outcomes have been chosen Relevant supporting evidence from support services Meet with peer CQC Mock Inspector Inspection day

19. Mock Inspection Evidence 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?

20. CQC Mock Inspection Final Report Evidence gathered Judgement Framework Setting the bar

21. CQC Mock Inspection Final Report Template Service Users experience Other evidence Our Judgement Submit to the CQC Administrator

22. Level of Concern Minor concern People who use the service are safe, but the provision of care may not always meet the safety and quality regulation. Moderate concern People who use the service are generally safe but there are risks. Provision of care is inconsistent. Major concern People who use the service are not protected from unsafe or inappropriate care. The provision of care does not meet safety and quality regulations.

23. Level of Concern LikelihoodLowMediumHigh Unlikely Probably never happen as there are measures and processes in place Minor Moderate Possibility May happen but is not a persistent issue MinorModerateMajor Almost certain Probably happen/recur frequently due to a breakdown in process or serious concerns about control measures ModerateMajor

24. CQC Case Studies Impact on service user Likelihood of recurring Level of concern

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

26. Questions & Evaluation

27. Good Luck!