1. CQC Inspection Ian Tombleson, Director of Corporate Governance Tracy Luckett, Director of Nursing Declan Flanagan, Medical Director Kaajal Chotai, Head of Compliance Trust Board 31 st March 2016 9-13 May 2016

2. www.moorfields.nhs.ukcompliance@moorfields.nhs.uk Presentation overview The CQC Inspection CQC inspection overviewInspection preparedness activitiesProject governancePriority themes5 weeks (and 2 days!) countdown

3. www.moorfields.nhs.ukcompliance@moorfields.nhs.uk Who are the CQC and What do they do? The CQC is the independent regulator for health and social care. The CQC monitors, inspects and regulates health care services to ensure that they are providing people with safe, caring and effective high-quality care, which is well-led.

4. www.moorfields.nhs.ukcompliance@moorfields.nhs.uk What the CQC wants to know is… Are we safe, effective, caring, responsive, and well-led? (KLoE)

5. www.moorfields.nhs.ukcompliance@moorfields.nhs.uk The Inspection is but one step on the Quality journey Compliance Compliance Assessment Framework Self-Assessment & Improvement Action Planning July 2014 May 2015March 2014 Trust-wide focus on compliance the development of an assurance model of quality and safety Ward-to-board view of organisation Discussions with wide- range of staff ‘worry-list’ used to identify areas of concern for further action (such as deep-dive reviews) Triangulation with other data Self-assessment mapped to CQC domains and KLoE Self-assessment process June – December 2015 Results in dashboard Improvement action planning October onwards CQC inspection

6. www.moorfields.nhs.ukcompliance@moorfields.nhs.uk The Inspection is but one step on the Quality journey The Inspection is Announced The Inspection Beyond the Inspection May 2016June 2016 onwardsDecember 2015 Moorfields’ Eye for Quality’ initiative launched November 2015 Inspection announced December 2015 PIR1 and PIR2 delivered on time Project management structure On-going communication Improvement activity in lead- up to inspection But, improvements are not just for the inspection Re-enforcement of existing good practice whilst addressing weaker areas Acting on the inspection outcomes Maintaining the momentum of ‘inspection-improvement’ Enhancing the CAF The commitment to quality CQC inspection

7. www.moorfields.nhs.ukcompliance@moorfields.nhs.uk Inspection sites 1.City Road 2.St Georges 3.Queen Mary Roehampton 4.Croydon 5.Purley 6.Bedford 7.Barking 8.Mile End 9.Ealing 10.Any other sites The CQC needs to inspect at least 65% of our activity to be able to rate us Our data return and onsite inspection are weighted 47% - 53% respectively Around 50 inspectors will visit 9 sites over 5 days Unannounced inspection(s) within 10 working days Can speak to any staff, any where, any time May make data requests whilst on site

8. www.moorfields.nhs.ukcompliance@moorfields.nhs.uk Preparation for inspection (commenced Q2 2015) Identifying strengths and weaknesses via self-assessment, to drive learning and improvement Listening to staff and patients to ensure we understand their needs and respond to them Informing Moorfields – innovations in communication and engagement – e.g. policy infographics The inspection experience – gathering information from other Trusts to prepare for ours Planning and governance – the CQC inspection project board and sub groups

9. www.moorfields.nhs.ukcompliance@moorfields.nhs.uk Priority Themes from the Self-assessment process The self-assessment process has identified general themes considered a priority to improve. These are: Leadership and visibility (at all levels) Behaviours (includes staff welfare and raising concerns) Patient experience (includes service flow) Communication

10. www.moorfields.nhs.ukcompliance@moorfields.nhs.uk Project Board – governance structure CQC Project Board (CEO weekly briefing) CQC Engagement and Communications Group CQC Data and Information Group CQC Onsite Inspection Readiness Group Policies and Governance work stream CQC Operational Improvement Group

11. www.moorfields.nhs.ukcompliance@moorfields.nhs.uk Sub-groups update Operational Readiness Commenced 23.02.16 Assurance for operational improvement actions and escalations Engagement & Communication Commenced 23.02.16 Focus on messaging, audiences, materials and key milestones Data and Information PIR2 received 11.02.16 Deadline 10.03.16 (+/- a few days) successfully met; issues flagged Onsite Inspection Commenced 19.02.16 Additional support recruited to brief senior staff

12. www.moorfields.nhs.ukcompliance@moorfields.nhs.uk Seven week project deliverables Engagement and Communications Onsite Inspection Readiness Data and Information Now week 6 (28.03.16 – 03.04.16) Staff pocket book to printers Manager’s inspection toolkits disseminated (released in sections for speed) Complete room bookings and technological requirements for 9 sites Staffing rotas for inspection period drafted MEH hub processes agreed Undertake a review of PIR2 submission to understand gaps Communication to staff about PIP Ensure outstanding PIR2 requests completed

13. www.moorfields.nhs.ukcompliance@moorfields.nhs.uk The walkabout process has identified some general themes: Lack of identification of senior managers Inability to describe corporate priorities Poor knowledge of the names of the safe guarding leads Poor compliance with bare below the elbows policy But overall has been quite positive

14. www.moorfields.nhs.ukcompliance@moorfields.nhs.uk Improvements and innovations from CQC inspection preparation Improved staff engagement, for example face to face team brief New quality and safety boards to put up around network Improved diligence around policies plus introduction of info graphics leading to better staff familiarity Better assurance about mandatory training levels New ways of data handling. Model developed to link HR and finance data highly commended by CQC Introduction of ‘SURE’ assurance process Local teams being more proactive in taking action

15. www.moorfields.nhs.ukcompliance@moorfields.nhs.uk Overall outcomes of CQC self-assessment process indicated that the Trust continues to aim for a ‘good’ rating and this was submitted to the CQC

16. www.moorfields.nhs.ukcompliance@moorfields.nhs.uk

17. Lots to do in: 27 days 5 weeks and 2 days 9 - 13 May 2016 Any questions?