1. CQC Report
March 2018

2. Context CQC Comprehensive Inspection 2015 Requires Improvement
Safeguarding
Unannounced Inspection July 2016
Warning Notice
Announced Inspection July 2017

3. CQC Well Led Inspection
Submission of Provider Information Request (PIR)
Unannounced Inspection 31st Oct and 1st/2nd Nov
Urgent and Emergency Care
Medical Care
Surgery / Theatres
Critical Care
Unannounced Inspection 6th/7th November
Learning Disabilities Community Services and Elmville
Announced Inspection 5th/ 6th/ 7th December

4. Overall Rating Requires Improvement

5. Community Services

6. Acute Services

7. MUST DOs Environment in ED for patients with mental health needs
Nutrition Assessments
WHO Surgical Checklist
Clinical Governance / Clinical Audit / Clinical Guidelines / Risk Management in Critical Care
Using audit information to improve services
Mandatory Training
Appraisals

8. What Next? Action Plan to CQC by 2nd April re Must Do issues
More robust and regular management of progress
Review of Assurance Programme
Work on Should Do issues
Possible unannounced follow up
Prepare for same in Sunderland in April / May
Prepare for same again next year

9. Well Led ?
Challenges
Management of risk inconsistent at Directorate level
Low incident reporting
Mechanisms for staff to report concerns
Gaps in strategies (but known and work in progress)
Insufficient engagement re equality and diversity
Limited sharing of information and getting views of people outside formal consultation
Need to implement accessible information standard
Financial Challenge

10. Well Led ?
Positives
Clear Vision and Values driven by quality and sustainability
Executives – experience capability and integrity to deliver strategy required and encouraged pride and positivity amongst staff.
Recognised still work to do
Information/data accurate and valid
Leaders at every level visible and approachable
Processes to support staff and promote well being
Staff overwhelmingly positive and proud to work here
Non executives and Governors felt well informed by the executive team and reported an open and honest working relationship

11. Any
Questions ?

12. Diane Palmer Assistant Director Of Nursing
Quality Strategy
Diane Palmer
Assistant Director Of Nursing

13. Introduction
In developing this strategy we aim to create a strategic framework and plan of action to improve quality by focussing on:
patient safety
patient experience
clinical effectiveness.

14. Our vision
Is to be an outstanding provider of healthcare for everyone who comes into contact with our services.

15. Our primary goals are to:
Reduce avoidable harm
Achieve the best clinical outcomes
Provide the best patient experience.

16. We aim to be recognised as one of the safest healthcare organisations both nationally and internationally
To achieve this we will:
Reduce the incidence of category 2-4 pressure ulcers which have developed in our care by 25%
Reduce the incidence of severe of harm from patient falls, such that we are in the lower quartile of reporting Trusts nationally
Improve the recognition and management of deteriorating patients by accurate and timely recording on Early Warning Scores for all (100%) of patients and a 50% reduction in the number of preventable cardiac arrests
Achieve at least 90% compliance with nutritional screening on admission to hospital and at least 90% compliance with recording of fluid input and output
To improve medicines manage by ensuring that medicines reconciliation is achieved for 95% of patients within 24 hours of admission to hospitals and by reducing the incidence of missed doses of medicine by 50%. 

17. Our goal is to improve the patient and carer/family experience, from their first contact until their discharge from our care
To achieve this we will:
Learn from patient feedback and aim to be in the top quartile in the national patient survey
Ensure that patients are involved as much as they want to be in decisions about their care and treatment by monitoring and audit
Provide a safe, secure, clean and comfortable environment for our patients and their carers/families by monitoring hand hygiene compliance and infection rates
Ensure that patients receive adequate information and support for safe discharge from hospital by monitoring and audit
Make sure that all patients receive person-centred care based on their needs and preferences and that we work within the Mental Capacity Act (2005) and consult with others where appropriate.

18. Ensure that every patient (or family) contact is a clinically effective contact
To achieve this we will:
Implement the recommendations from the National Maternity Safety Strategy
Improve the outcomes of patients with serious infection by ensuring timely identification and treatment for sepsis
Improve quality, efficiency and reduce variations in our services by implementing recommendations from the GIRFT programme
Learn and act on the results from participation in national clinical audits and the reviews of patient deaths
Comply with the four priority standards for seven day working.

19. Key enablers to achievement
Culture of Safety
Continuous Learning
Recruitment and Retention of Staff
Person-centred Care
Quality Improvement and Measurement
Research and Innovation
Leadership

20. Culture of Safety Our aim is to:
Promote a culture where openness and transparency is the comfortable norm for all of our staff
Continue to encourage our staff to report adverse events and to take action when it is needed and to seek assistance when they are concerned
Also continue with our Executive Director led Patient Safety Walk Rounds
Advance our plans to utilize human factors principles system-wide in our processes, procedures, learning and design of our services.

21. Continuous Learning Our aim is to ensure that:
The skills and competencies of our staff equip them to deliver safe, high quality, cost effective healthcare in both the hospital and community setting
We remain committed to a process of focused continuous professional development for our staff as professional capabilities and behaviours profoundly impact on the patient experience.

22. Recruitment and Retention of Staff
Our aim is to ensure that:
We have sufficient staff to care for the number and acuity of our patients
In particular, numbers of doctors, nurses and midwives are a challenge and we are committed to investing in recruitment
Where necessary we will deliver care in new ways in partnership with our patients and their carers.

23. Person-centred Care We will aim to:
Ensure that the care or treatment we provide is tailored to meet the needs and preferences of our patients and their carers
Encourage patient involvement and shared decision making in care and treatment wherever possible
Ensure that we include the patient’s abilities, resources, wishes, health and well being in our assessment and agreed plan of care
Put the patient and their family at the forefront of every decision and support them to be genuine partners in their care.

24. Quality Improvement and Measurement
It is well recognized that by applying quality improvement (QI) methodology, quality and safety can be improved and costs can be reduced.
We will promote QI principles throughout the implementation of this Quality Strategy.
We have identified our aims for improvement and every aim will be supported by a project and measurement plan and team of experts to implement and monitor changes to achieve success.
We recognize however that we will need to ensure that our staff have the necessary improvement capability to support this ambitious plan.
Where necessary we will expand the capability of our staff.

25. Research and Innovation
We are committed to using knowledge, learning and innovation to develop care and treatments
We recognize that research systems and participation brings benefits for patients and our healthcare community
We will further develop our infrastructure in relation to clinical research and innovation
In developing our research environment we will also look for opportunities to partner with commercial and academic learning institutions

26. Leadership
There is a well recognised and strong association between leadership and positive clinical outcomes.
We will foster a culture where all of our staff recognise their role as leaders in delivering our services to patients, their cares and their families.
Additionally we will ensure that our senior leaders promote involvement and participation as core values and that they are supportive, available, fair, respectful and empowering in their behaviours.

27. Any
Questions ?