cqc inspection - nhs providers · cqc inspection preparation •visited other trusts who had...
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CQC INSPECTION
Ann Marr
Chief Executive
July 2016
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Introduction to the Trust
• Acute District General Hospital, with obstetrics and paediatrics, major provider of non-elective services, regional burns and plastics centre
• 887 beds, 4200 FTE staff, £309 million turnover • New PFI estate, opened 2010 • Ancient and long-serving CEO with stable,
talented Executive Team • CQC Inspection August 2015
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CQC INSPECTION PREPARATION
• Visited other Trusts who had recently been inspected • Staff handbook – hard copies and available on the intranet • Dedicated intranet pages – with the CQC presentations and
handbook • Staff briefings, including sessions with student nurses,
therapy teams, junior doctors induction, Clinical Senate, Clinical Directors Forum, Grand Round, housekeepers, ward administrators and individual directorates based on the data pack issued by the CQC
• Weekly meetings with Matrons and Ward Managers • Team brief – monthly updates
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CQC INSPECTION PREPARATION
• Staff magazine • Operational planning group • Regular progress reports to Executive Committee and to
Board • Mock CQC inspections with initial assessment,
development of action plan and reassessment • Internal service level assessments and action plans • Corporate assessment and action plans, e.g. reviewing all
policies, patient information and website • Ward visits by Executive team and Non-Executive Directors
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CQC INSPECTION PREPARATION
• Lanyards for all staff with the Trust’s vision • Personalising the Trust vision – “what does it mean to
me?” displayed as boards throughout the Trust and on the intranet
• Board briefings for those being interviewed • Mock interviews for service leads – Directorate Managers
and Matrons, and for Executives, Chairman and Chair of Quality Committee
• Lots of anticipating and preparing for the information requests
• Identified a separate data lead and logistics lead
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The ‘149’ moment
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A state of mind……….
1 x 1 = 1 2 x 2 = 4 3 x 3 = 9 4 x 4 = 15
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About the Trust
• Ever increasing numbers of patients are choosing the Trust for their care
• Provides acute, paediatric and maternity care
• Top class facilities – “one hospital on two sites”
• Optimal configuration of services
• 887 beds
• Out-patients and ambulatory care at St Helens
• £309m turnover
• 4200 FTE staff
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Clinical and quality performance
Quality indicator 2013/14 2014/15
Mortality (HSMR) 98.6 98.1
Safety Thermometer (new harm free care) 95.2% 98%
Stroke Achieved Achieved
MRSA 4 2
C-Diff Achieved 33 Avoidable
Targets for Cancer waiting times Achieved Achieved
A&E Access (4 Hours) Achieved 94.2%
Referral to treatment targets Achieved
Achieved
Diagnostic waiting time targets Achieved
Achieved
% of patients treated 28 days following cancellation Achieved Achieved
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Consistent messages
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What we are most proud of
• Best patient experience in the NHS
• First nationally for PLACE
• 4th in national cancer survey
• First for Advancing Quality in 2014
• Top 20% scores for staff survey
• “Exceptional” medical engagement – top quintile
• Highest for flu vaccination rates
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What we are most proud of
• No never events since May 2013
• 98-99% harm-free care in 2014/15
• NHS Litigation Authority Level 3 for Maternity Services
• Reductions in numbers of falls and pressure ulcers
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Our staff say…
Staff Survey % Score
% above average
Care of patients is the organisation’s top priority 79 +12
The organisation acts on patients’ concerns 82 +13
Recommending the organisation as a place to work
72 +17
Happy with the standard of care for a relative 78 +16
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Current challenges
• Activity pressures
– Discharges
– A&E 4 hour target
– Outliers
– Readmissions
– Length of stay
– Bed occupancy
• C- Difficile
• Incidence of falls
• Recruitment hotspots
• Complaints response times
• Finance
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“Massive thank you to
A&E and the Surgical
team. Cannot fault the care
that Joe received from you
all. You are a credit to the
NHS and we as a family
will never forget how lovely
you all were.
C, D and Jx
What our patients say
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Tips on managing the inspection itself
• Look after the inspection team • Bright orange lanyards for easy identification • Debrief after every interview, and at the end of
every day • Implement a system for logging and responding to
information requests via a central point • Respond to factual accuracy challenges with
evidence • Act swiftly on any issues raised – shows you are
capable
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(Our) key ingredients of
“outstanding”
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Clear, consistent vision translated into Trust objectives and different staff roles
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“….ensuring that every decision the
Trust takes truly puts patients first”
Ann Marr Chief Executive
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Meaningful values and behavioural standards
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Genuinely putting patients first
(through actions not just words)
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A happy ending…..