1. Contributing to a successful Care Quality Commission Inspection
An opportunity to shine…………
Contributing to a successful
Care Quality Commission Inspection

2. Overview
Who are the CQC?
What is the process?
How does this affect WSFT?
How does this affect me?
What are we all doing to prepare?

3. Who are the CQC?
The Care Quality Commission (CQC) is the independent regulator of health and adult social care in England
“We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find, including performance ratings to help people choose care. We set out what good and outstanding care looks like and we make sure services meet fundamental standards below which care must never fall. Where we find poor care, we will use our powers to take action”.
Taken from the CQC’s website

4. What is involved? Planned inspection as part of a national programme
Multi-disciplinary – patients, clinicians, managers (20-30) on site for 3 days
Formal and informal (‘conversations’)
Pre visit data request – Addenbrookes 276 documents returned
CQC announced visit 3 months notice
Possible unannounced CQC visits around time of planned, evening and early morning (smaller numbers)
Will assess using Key Lines of Enquiries (KLOEs)
CQC inspections are in-depth.
They also inspect in the evenings and at weekends when CQC know people can experience poorer care.
The CQC’s unannounced visits to Colchester Hospital  carried out ahead of the formal inspection in September included an inspection at night.
The inspectors use professional judgement, supported by objective measures and evidence, to assess services against five key questions:

5. Five Key Lines of Enquiry (KLOEs)
Inspectors ask the following five questions. Are we:
Safe: people are protected from abuse and avoidable harm.
Effective: people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence.
Caring: staff involve and treat people with compassion, kindness, dignity and respect.
Responsive: services are organised so that they meet people’s needs.
Well-led: leadership, management and governance of the organisation assures the delivery of high quality person-centred care, supports learning and innovation, and promotes an open and fair culture.
The inspectors are looking to get to the heart of people’s experiences of care, the focus is on the quality and safety of services, based on the things that matter to people.

6. Also focus on care pathways and patient groups
Core Services
Maternity & gynaecology
Services for children & young people
Critical care
Surgery
Medical care incl. older people’s care
End of life
Outpatients
Emergency department
Trust wide ( support services, estates, diagnostics. HSDU/CSSD, mortuary, corporate and Trust Board
Also focus on care pathways and patient groups
The CQC has identified those services that they will always inspect, irrespective of risk, at every acute hospital where they are provided. These are known as the core services.
However, they keep all the services provided under continuous surveillance. If they identify particular services, specialist areas or pathways of care where they have concerns, or where they believe the quality of care could be outstanding, and they are not covered by these core services, they may look at one or two of them in detail and report on them.
They will not always be able to visit every ward or part of a core service. Where they sample services for inspection, they will select some on a random basis and for others they will consider various factors about risk, quality and the context of the services to help select and prioritise the areas they visit. The services may include, for example:
• Those where a previous inspection, CQC intelligence or information gathered by either Monitor, the NHS Trust Development Authority, NHS England or a local clinical commissioning group, has flagged a concern or risk.
• Those about which CQC have received a complaint, there has been a safeguarding alert or they have received concerns from a member of staff.
• Those that they have not inspected for a long period or have not previously inspected at all.
• Services that provide a quality of care that may be outstanding.
CQC are also committed to including a focus on care pathways and particular patient groups as part of the inspection. This could include, for example, people with dementia or with a learning disability.

7. What they will know… Data publically available Data we have submitted
Feedback from patients and relatives
Inpatient Survey and Staff Survey results
Harm events/current performance across services
Mortality data
Trust risk register
Ask for further information during inspection
Staff Survey results – have to be in the top 20% for an outstanding rating

8. What is the process?
Gathering views of people who use our services includes:
Holding public listening events
Holding focus groups with people who use services and those close to them
Use posters to advertise the inspection to allow people an opportunity to speak to the CQC team
Gather information from complaints
Etc.

9. CQC form judgments

10. Ratings CQC use a 4 point rating system Outstanding Good
Requires Improvement
Inadequate

11. SAFE People are protected from abuse and avoidable harm.
Incident reporting
Training
Staffing levels, skill mix & handover
Infection prevention
Equipment maintenance & training
Ward boards
Lessons learned & actions
Safeguarding
MEWS
Medicines management
Security of drugs
Records management
Service planning & MAJAX
An opportunity to go through the 5 KLOEs and talk about what the inspectors may focus on

12. EFFECTIVE Aware of new NICE guidance End of life care
People’s care, treatment and support achieves good outcomes, promotes a good quality of life based on the best available evidence.
Aware of new NICE guidance
Clinical audit
Risk assessments and care plans
Practice guidance
Multidisciplinary working
Consent
End of life care
Nutrition & hydration
Discrimination, equality and diversity
Appraisal, PDPs, training & education
Mental capacity Act & DOLS

13. CARING
Staff involve and treat people with compassion, kindness, dignity and respect.
Hello my name is
Personal, cultural, social & religious needs
Emotional & compassionate support
Confidentiality
Improvements following patient feedback
Patient & carer information
Patient empowerment
Patient, their families and carer involvement
Patient privacy & dignity
Pain management

14. RESPONSIVE Services are organised so that they meet people’s needs.
Complaints policy
Advice to patients and family how to complain
Top five types of complaints
Encourage feedback
Learn from complaints & concerns
Consider needs of different groups
Learning disabilities
Dementia
Complex needs
Timely access to care

15. WELL-LED Corporate & departmental induction Leadership & culture
Leadership, management and governance of the organisation assures the delivery of high quality person-centred care, supports learning and innovation, and promotes an open and fair culture.
Corporate & departmental induction
Leadership & culture
Our vision, values & strategy
Personal objectives
Team meetings
Current risks for the team or service
How to raise issues of concern
Whistleblowing policy

16. The Inadequates Isolation and introspection
Trusts lose sight of what good looks like
Idiosyncratic rules – we've always done it this way here
Non adherence to the rules
No personal/organisational consequence of non adherence, eg. WHO, ANTT, bare below elbow, smoking, data, etc
Problems denied/unsighted
Slow to react to changing circumstances
Argue the toss – who else to blame?
Good governance let slip – sloppiness
Poor clinical leadership models/engagement/behaviour
Poor external relations
Board/ senior leadership detached and /or distracted

17. The Outstandings: Salford Royal

18. Proud to be the best

19. We have a similar ambition Together

20. Our patients, Our hospital, Our future, together

21. Our values
Developed with staff and patients :
Focused on patients
Integrated
Respectful
Staff focused
Two-way communications  

22. We are an award winning hospital
Dr Foster Trust of the Year 2013
Midlands & East of England

23. Our quality reflects our training & education 0ur brilliant Education Centre

25. Divisional Service Quality Improvement Group
Model piloted in the Surgical division
Roll out to the other Divisions
Led by the senior team in the Division
One KLOE at a time, consider
What do we do well?
What could we do better?
What do we need to do to make our practice move from ‘Requires improvement’ to ‘Good’ or from ‘Good’ to ‘Outstanding’?

26. An opportunity to shine
We are not doing this “to pass the exam” or “to get a certificate”
We have a fantastic, high performing hospital and together we can show that we meet and in many cases exceed the CQC fundamental standards
A chance to demonstrate how good we are, and in many cases how excellent we are in the care we provide to our patients
Let’s show off our great achievements and what we are proud of.
Discuss honestly the areas in which we know we need to improve and our plans to do so.
We shouldn’t be afraid of these inspections but we must be prepared!