Preparation:Care Quality Commission Inspection January 2016

Andrew MacCallum, Chief Executive

Our values:• Care + Compassion - We see the person in every patient, communicating with

honesty and compassion. We listen and act on feedback to ensure outstanding care.

• Trust + Respect - We respect and consider other people’s views and feelings. We seek consensus and respond to situations professionally and calmly.

• Working Together - We work to create a positive team spirit, recognise achievements and celebrate success. We are open, inclusive and want to continually improve.

• Inspiration + Innovation - We welcome new ideas and use our initiative to solve problems together. We value learning and research to improve services.

• Pride + Achievement - We take pride in our work and always go the extra mile. We lead by example and ensure quality is at the heart of all we do.

Our strategic aims:

Provide compassionate,

safe, effective care

Attract, develop and retain excellent

staff

Offer integrated care, as close to home as possible

Make the best use of all of our resources

Our priorities 2015/16:

n

Our vision:‘Working together to achieve outstanding care’

• Achieve the 4 hour emergency care standard

• Reduce hospital mortality

• Improve the consistency of services 24/7

• Achieve access standards for planned care

• Continue to improve patient experience

• Empower staff through ‘Listening into Action’

• Introduce new, tailored recruitment drives, enhance our Bank Team

• Implement a new clinical structure and leadership programme

• Protect time for training, and development

• Collaborate with our partners to redesign urgent care pathways

• Offer patients prompt, appropriate discharge

• Make better use of St Michaels and West Cornwall Hospitals

• Recruit more patients into trials across Cornwall

• Reduce our deficit to £3.8m

• Adopt best practice rotas to ensure safe, staffing levels

• Reduce waste, improve quality, to save £15m

• Invest £14m capital, to improve our equipment, technology, & facilities

Quality People Partnership Resources

Introduction:• The Care Quality Commission (CQC) will conduct a full inspection of our

services in January 2016.

• The CQC will be on site from 12th to 15th January but can arrive unannounced before and after that time. We will assess our readiness through a ‘mock inspection in December 2015.

• It is sensible to be prepared for the CQC inspection and ensure that we demonstrate good care. We must understand our strengths and weaknesses and be candid about both.

• The CQC will not ask trick questions, make assumptions or seek negative views. Their inspection is based on evidence, observation and what people tell them.

• A CQC inspection is a great opportunity to be proud of your services, care and plans to improve.

About the CQC inspection:It is the CQC’s role to ensure we provide safe, high quality services and to encourage improvement. They want to know our services are:

1) Safe – Do we protect and safeguard people from abuse and avoidable harm?

2) Effective – Do we achieve good clinical outcomes, promote a good quality of life and utilise the best available evidence?

3) Responsive – Do we organise services so we meet people’s needs?

4) Caring – Do we involve patients and carers, treating them with compassion, dignity and respect?

5) Well-led – Do our leaders and managers govern well and ensure high quality care through support, learning, openness and innovation?

About the CQC assessment:• The CQC combine evidence from the inspection with a range of other information

including complaints, information from stakeholders, patient and staff surveys, peer reviews and national or local data.

• CQC inspection teams include doctors, nurses, allied health professionals and managers from other hospitals. They will speak to patients, colleagues and the wider community during their time here.

• At the end of the inspection they will rate our services and sites as either:

Outstanding Good Requires improvement Inadequate

CQC current ratings:

Royal Cornwall Hospitals NHS Trust

Safe: InadequateResponsive: Requires improvement

Effective: GoodCaring: Good

Well-led: Good

How you can prepare:• Senior leaders are already sending the CQC information they have requested

about our services, standards and performance. 48 hours before their visit, the CQC will tell us about their ‘Key Lines of Enquiry’ (topics they will focus on).

• You can also prepare by thinking about the answers to these questions:

How good is the service you provide? What are you proud of? What do your patients think about your service? What quality improvements have you made this year? What new ways of working have you tried this year? What would you still like to improve and how do you plan to do this?

• The CQC do not expect perfection but they will expect you to know your service and your plans to progress.

How your team can prepare:• During the CQC inspection week, it is business as usual. We can utilise the

opportunity though to make sensible improvements.

Ensure patient records are up-to-date with individual care plans that have involved patients and carers.

Ensure staffing rotas are complete and implemented. Ensure premises are clean and tidy with all records, equipment, products

and medicines stored correctly. Ensure you know about the incidents, complaints, audits, peer reviews in

your area and the resulting actions. Ensure you are up-to-date with mandatory training. Ensure all notice boards are up-to-date. Wear your ID badge, correct uniform and say ‘Hello my name is…’

How team leaders can prepare:• The CQC will assess our services

and sites on five areas: Safe, Effective, Responsive, Caring, Well-led.

• As part of this toolkit, we will provide checklists for each of these five areas – available online.

• Team leaders should go through each checklist with their colleagues and complete their own assessment on the evidence available.

When the CQC arrive:• When the CQC arrive in your work area:

Ask to see their ID. Introduce yourself and welcome them. Show them somewhere to wait and find the person in charge. Notify your divisional lead.

Tell the inspectors about any specific safety or security issues. Offer them a place to work and refreshments. Support them to speak to patients or staff. Speak openly about your service and don’t worry if you can’t answer a

question – don’t make it up! If they want copies of documents, make a precise note of what they want

and contact Lisa Sandy in the quality and safety team to arrange delivery. Do not directly give them documents as there is an agreed process.

About RCHT:Good to know

(Good to adapt for your team)

About RCHT – CQC “must do” actions underway:

• Staffing – Consistent nursing levels, better skill mix, reduce agency reliance.

• Consistent Clinical Practice – standard management of sepsis, consistent use of assessment and treatment tools, no variable discharge planning, learning from incidents, complaints and risks, uptake of mandatory training.

• Documentation – regular audits on completeness and timeliness of records/treatment plans.

• Managing Patient Activity and Patient Pathways – improved focus on bed management, patient flow escalation and outlying patients.

About RCHT – responding positively to the CQC:

Wellington Ward and Emergency Department response to CQC inspection in June:

Wellington ward video:https://www.youtube.com/watch?v=QkjDIB6NtUU

About RCHT – CQC recognised improvements:

• Patient ambassadors carrying out point of care observations.

• Support for dementia patients.• Bite size learning for theatre staff.• Ambulatory Care Unit relieving pressure on

Medical Admissions Unit and the Emergency Department.

• Good support and care for patients with learning disabilities.

• Increased provision of critical care outreach.• Introduction of lockable storage cabinets for

patient records.• “Patients on a variety of wards were

complimentary about the care provided.”

About RCHT – How do we assure on safe care:

• Performance Assurance Framework(s).• Safety Thermometer.• Know how we are doing boards.• Safer care trigger tools e.g. QuESTT.• Safeguarding procedures with named

individuals.• Datix to record, report and respond to

incidents.• Regular audits of patient record keeping.• Use of NEWS, SBARD, Sepsis 6 Bundle.• Protocols and checks on medicine storage.

About RCHT – How do we assure on effective care:

• Patients seen with an hour of arrival.• Clear procedures on patient and staff

handovers.• Comply with NICE guidance and

updates.• Clear policy on patient consent.• Involve patients in their care plans.• Value based recruitment, induction and

appraisal.

About RCHT – How do we assure on responsive care:

• Work towards 4 hour ED standard.• Regular review of medical outliers.• System Wide Resilience Group to improve

patient pathways.• Specialist team to support dementia care and

learning disabilities – use of ‘This is me’ pack. • Dementia friendly environments.• Services and support in ED for homeless and

mental health patients.• Regular equipment audits and environment

checks, including for paediatrics.• Patient Ambassadors and PALS team help

ensure patient voice is heard.

About RCHT – How do we assure on caring:

• CARE campaign.• Hello my name is…campaign.• Values based recruitment.• Involve patients and carers in end of life

care and Treatment Escalation Plans.• Excellent palliative care and bereavement

team. • Access to telephone translation service.• Ensure good discharge letter and

processes.

About RCHT – How do we assure on well-led care:

• Leaders being visible and living our values.• Clear clinical strategies and priorities. • Trust Board Assurance Framework, Governance

Committee and Risk Register.• Listening into Action supporting clinical

leadership.• Access to appraisals and learning &

development.• Support for leaders from HR Business Partners. • Promote duty of candour.

Author: Andrew MacCallum, Chief ExecutiveReview Date: January 2017