Presentation on theme: "STAFF BRIEFING Care Quality Commission (CQC) Essential Standards of Quality and Safety Preparing for inspection 1."— Presentation transcript:
1 STAFF BRIEFING Care Quality Commission (CQC) Essential Standards of Quality and Safety Preparing for inspection1
2 STAFF BRIEFING The purpose for this briefing is to: Help staff familiarise themselves with the new inspection modelExplain how the CQC will inspect so that the actual visit feels less dauntingShine a light on the areas of risk identified through our own quality inspectionsProvide practical advice on how to prepare
3 The role of the Care Quality Commissioner: Independent regulator of all health and social care services in EnglandThe independent regulator of all health and social care services in EnglandCare provider registrationSet National Essential Standards of Quality and SafetyCompliance monitoring and regulation of services against standards through:Data and surveillance pre inspection and at regular times during the yearDirect observations and interviews at inspectionAction – where standards are not being met.
4 St George’s CQC inspection The Care Quality Commission (CQC) inspection starts on Monday 10th February 2014It will last for one week but there could be shorter follow-up visits in the terms of unannounced inspectionsInspection will cover St George’s and Queen Mary’s Hospital and our community services40-50 inspectors divided in to 12 teams. Inspectors will be wearing colored id badgesSix teams will focus on St George’s and six will focus in the communityThe inspectors will observe care in practice, also talk to staff, patients and our key stakeholdersA rating of ‘good’ or ‘outstanding’ is required for us to continue our path to becoming a Foundation Trust.
5 CQC Inspection model 5 inspection questions Since our last inspection a new, more rigorous, inspection model has been devised by the Chief Inspector of HospitalsThe new regime and approach to inspections will be based around 5 key domainsFour point scale used for all ratings5 inspection questionsAre they safe?Are they effective?Are they caring?Are they well led?Are they responsiveOutstandingGoodRequires ImprovementInadequate
6 NEW CQC INSPECTION REGIME Chief Inspector of HospitalsDecisions on where and when to inspect will be made by using information in a more focused and open way, responding quickly to services that are failingNational and local data sources will continue to be used along with intelligence from local authority overview and scrutiny committeesA set of 118 indicators to provide information on each element of the new surveillance model. “Smoke detectors” by which they will decide where and when to inspect - which helps to develop their key lines of enquiryMortality data features highly in the proposed data set along with patient / public comments posted on various web sites.
7 CQC Inspection model During an inspection the CQC Inspectors will: Hold focus groups with people who use services (including relatives) about their experiences of receiving careHold small group meetings with leaders of key servicesHold focus groups with staff (multidisciplinary teams – including students)Interview individual directors as well as staff of all levelsObserve patient care to check that the right systems and processes are in place, and patients are treated with kindness, dignity and respect and staff work well and communicate effectively with each other and patientsLook for evidence that care is meeting national standardsLook at documentation – have observations been done, medication given, risk assessments completed, plans of careObserve staff interaction – are teams supportive and respectful of each otherLook at environment – is it clean, uncluttered and safeLook at patient information available – are notice boards up to date, relevant, tidy.
8 Promoting high-performance and excellence The CQC revisit in August found a much improved position across the St George’s Hospital siteThe majority of the patients they spoke said that they had a good experience at St George’s and were very positive about the care they received from staffDon’t forget that these inspections are an opportunity for us to nationally showcase the quality and safety of care we provideWe continue to use each inspection as a driver for quality improvement. For example CQC inspections have now become quality inspections and form part of our internal assurance processes to check that we are consistently achieving good standards of care.
9 Advice from a senior nurse It’s about flexibility because what may be important during one inspection may not be an issue at another…It’s important to remember that getting the little things right quickly accumulates into getting the big things right. It’s also worth remembering the opposite is true…Ensure all members of staff are aware of the identified areas of concern and all members of staff have a ‘voice’…Be prepared, be receptive to change and learn from any shortcomings the inspectors might raise…It’s important not to take things personally or think inspectors are nit-picking. You need to listen to what they have to say, address any issues raised…
10 If you speak to an inspector Maintain a professional manner at all times. There is no such thing as a ‘throw away’ commentThink carefully about how you speak about yourself, your colleagues and your environment. Always talk about colleagues and services in a professional mannerListen to what is being asked – ask for clarification if need be. Think about your reply. It’s ok to pause to collect your thoughtsIf you aren’t certain how to respond to a question or feel compromised by any line of questioning, or if you can’t answer a question, say so but also say that you will find out.As well as being asked about what you do or what you know you may be asked about things that concern you. It is absolutely right that you are open and honest. Try to balance your concerns with information about what is being done.Think about the positive effects your care provides to families and patients who you work with on a day-to-day basis and over the long-term.Remember, if you make a comment about the service, inspectors may check the validity of what you said against other evidence.
11 Tips for working under inspection It is a fact of life that people act/work differently whilst being observed. The following points are suggestions to help you whilst working under observationDon’t get paralysed by perfectionBe yourself, and use the inspection to showcase your workStay in the moment?- if you feel overwhelmed (like pretty much everyone) it might not be because you have so much to do rather you trying to do so much at the same time.Keep calmEven though you may feel you are being watched always consider the patient needs first
12 Are we safe?: CQC Key Lines of Enquiry Domain – SafetyNo.KLOEBe safe, we mean that people are protected from both abuse and avoidable harm and that there is an open and just culture, which promotes continual learning.S1How safe has care been in the past?S2Can the provider demonstrate that they consistently learn when things go wrong and improve standards of safety as a result?S3How reliable are systems, processes and practice?S4How safe is care today?S5How confident are we that care will be safe?What does this mean in your daily practice?
13 What does this mean in your daily practice PRACTICAL APPLICATIONComplaints postersLearning from incidentsAudits - Results and where to improveID bands in placeIC - Hand gel & hand washing/ equipmentSluice - clean and tidyCall bells near patientClutter free ward - Dump the junkHandling linenSafe surgery checklistPatient surveysPOLICES AND PROCDURESMental Capacity ActIndependent Mental CASafeguarding AdultsSafeguarding ChildrenInfection Prevention and ControlMedicine SafetyMonitoring Drug and Fridge TemperaturesHealth and SafetyWaste ManagementMedical EquipmentSafe StaffingAvailable via the intranet homepage
14 What can you do prior to inspection Consider the following questions:Do I report/act on concerns about unsafe equipment?Do I know how to report a safety incident?Do I always wash my hands or use hand gel between patients?Do I follow Trust policies in relation to medication?Do I know how to resolve or advise a patient who has concerns?Do I ensure written and electronic patient information is kept secure?Do I keep the information available to patients up to date?Do I observe the dress code or uniform policy including bare below elbowsDo encourage patients to provide feedback on our services?Do I complete all appropriate risk and document assessments ?Do you assess your patient acuity / dependency at handover and ensure you have sufficient staff to cover the required work for the shiftDo I know the procedure to follow for a patient who might have a lack of mental capacity?Do I provide bank, temporary, agency or junior staff with adequate support at the start of a shift?
15 Quality Inspections: Identified Safety Risks Not all staff are aware of how access an interpreter.Cleaning & Decontamination green labels are not always on equipment to identify it has been cleaned.Not all staff have completed 'Basic Awareness of Safeguarding Vulnerable Adults and Adult Protection', which is part of mandatory training for all staff working within the Trust.The target of 96% of VTE risk assessments to be fully completed within 24 hours of admission has not been delivered in Quarter 2. Certain divisions have performed poorly, dropping from a completion rate of 70% to 53%The outcome of the WHO Checklist Compliance has shown poor compliance rate for Briefing and Debriefing and the common reasons documented were “the team do not do the debriefing regularly”,
16 Are we effective ? CQC Key Lines of Enquiry Domain – EffectiveNo.KLOEBy effective, we mean that care and treatment provided to people is evidence based and achieves good outcomes for them, whether that is the prevention of premature death, the achievement of a good quality of life for those with long term conditions or following ill health/ injury, or indeed the achievement of a ‘good death’.E1Is care and treatment planned and delivered in line with current legislation, standards and nationally/ internationally recognised evidence-based guidance, in a manner which doesn’t just meet patient’s needs but tries to deliver the best possible outcomes for them?E2How does the provider support and facilitate multi-disciplinary working among services and organisation?E3How does the provider work with other health and social care providers and support networks (including volunteer organisations and individual carers) to manage and meet peoples’ needs?E4How does the provider ensure that staffing arrangements enable the delivery of care and treatment an do not compromise on quality?E5How does the provider monitor and improve the quality of its care and treatment?What does this mean in your daily practice?
17 What does this mean in your daily practice? PRACTICAL DEMONSTRATIONSafe storage of recordsClear documentationAccurate recordsAssessing painIncident reportingUp to date chartsLock trolleysWho is who in the trustConfidentialityKeep all informedPOLICIES AND PROCEDURESInformation GovernanceConsentRecords ManagementAccessing PoliciesAvailable via the intranet homepage
18 How to prepare for a CQC visit Consider the following questions:Is my mandatory (MAST) training up to date?Do I keep the information available to patients up to date?Do I document verbal discussions about care, treatment and support on the patient’s file?Do I link new patient records with any previous records that exist for that patient?Do I ensure that all patient records are up to date, accurate, and kept confidential?Are records stored and transferred securely according to our policy?Have I completed Record Keeping training?Do I know where to access all mandatory policies relating to quality, safety and clinical governance?
19 Quality Inspections: Identified Risks Nursing documentation to be addressed – Risk assessments incomplete or not reviewed, accuracy and completeness of observations, individualised patient care planDNAR notices are not always completedMUST assessments not always completed on all patientsEscalation as a result of an EWS score are not always well documentedCompletion of fluid balance charts and weight charts.
20 Are we caring? CQC Key Lines of Enquiry Domain – CaringNo.KLOEBy caring, we mean that people are treated with kindness and respect and are supported to manage their treatment and care with dignity.C1How are patients, their relatives and those close to them, involved as ‘partners’ in their care – taking part in decisions about their care, with support where needed?C2How do staff develop trusting relationships and communicate respectfully with people and those close to them, throughout their hospital stay?C3How are patients, their relatives and those close to them, able to understand what is going to happen to them and why, at each stage of their treatment and care?C4How are patients, their relatives and those close to them receive the support they need to cope emotionally with their treatment and hospital visit/ stay?C5How are patients made to feel safe and comfortable and treated with dignity while they receive treatment and personal care?ALL STAFFWhat does this mean in your daily practice?The CQC Inspector can and will approach any staff member including doctors, nurses, managers, hotel services, allied health professionals, administrative staffIf approached or observed by a CQC Inspector would you be able to answer these questions?Be prepared!What does this mean in your daily practice?
21 What does this mean in your daily practice? PRACTICAL DEMONSTRATIONPrivacy & dignityTone of voiceAttitudes & behaviourListen to patientsNoise at nightSupport at mealtimesLearning disability/ vulnerable patientsDementia patientsEnd of life care and DNARAccess to InterpretersIntentional roundingPOLICIES AND PROCEDURESEquality and diversityInterpreting ServiceComplaintsCommunicating effectively with patientsEnd of life care and DNARPatient InformationFriends and Family TestDNAR properly documented and communicatedAvailable via the intranet homepage
22 What can you do prior to inspection Consider the following questions:Do I give relevant information leaflets/contact details to patients?Do I involve patients in their care plans by explaining their treatment, options and care?Do I help patients to understand what is going to happen to them and whyDo I give patients information about the risks and benefits of alternative treatments?Do I effectively communicate with a patient’s relatives to ensure they are involved in the decision-making about the patients care?Do I document in the patient’s record when they have discussed their treatment options or when they have given them information?Do patients sign their care plan/assessment to confirm that they have been involved and understand their treatment?Am I up to date with my Equality and Diversity training?Does the care environment make patients/families feel safe, comfortable and private?Do I ensure multi-disciplinary team handovers include all parties to ensure consistence of care – including relatives?Do I always pull curtains properly around the bed?Do I always introduce myself ?Do I always check what patients liked to be called?
23 Quality Inspections: Identified Risks On some wards the nursing staff need to be more sympathetic when responding to patients concernsOn some wards patients felt that they had not been involved in their care plans.
24 Are they responsive? CQC Key Lines of Enquiry Domain – ResponsiveNo.KLOEBy responsive we mean that people receive the treatment and care to meet their needs, at the right time without avoidable delay, and that they are involved in a way that responds to their needs and concerns to improve the services providedR1How does the provider plan its services on the basis of the needs of the local populationR2How does the provider enable people from all its communities to access services in response to their needsR3How do staff take account of patients needs at each stage of their treatment, especially patients who are in vulnerable circumstances or who lack the capacity to communicate their needs.R4How do staff take account of patients’ needs and wishes so that they are ready to leave hospital at the right time, when they are well enough and with the right support in place?R5How does the provider involve patients, the public and their representatives, in planning its services, and routinely learns from people’s experiences, concerns and complaints to improve the quality of care?ALL STAFFWhat does this mean in your daily practice?The CQC Inspector can and will approach any staff member including doctors, nurses, managers, hotel services, allied health professionals, administrative staffIf approached or observed by a CQC Inspector would you be able to answer these questions?Be prepared!
25 What does this mean in your daily practice? PRACTICAL APPLICATIONCall bells answered in a timely wayDischarge planningClinical leadershipTeam workingDecision on mental capacityHanding over vital information from shift to shiftStaff safety forumsQuality roundsWard informationDon’t take your troubles home - resolve concerns and issues proactivelyPOLICIES AND PROCEDURESAdverse incidentsNutrition and hydrationIntentional roundingProductive wardAvailable via the intranet homepage
26 What can you do prior to inspection Consider the following questions:Do I take account of patients’ needs and wishes so that they are ready to leave hospital at the right time?Do I provide patients and their families with the sufficient information to leave hospital with?Do I ensure nutritional and hydration needs are met (red trays, red beakers and water jugs with red lids)?Do I ensure multi-disciplinary team handovers include all parties to ensure consistence of care – including relatives?Do I take account of patients needs at each stage of their treatment?Do I ensure the patient has made adequate arrangements for leaving hospital?Do I encourage patients to complete patient survey's or signpost to make complaints?Do I ensure the welfare needs of patients extends beyond the hospital back in to the community?
27 Are they well-led? CQC Key Lines of Enquiry Domain – Well LedNo.KLOEBy well-led, we mean that the leadership and governance of the organisation is effective in holding itself and others to account for decisions, performance and actions; it welcomes and seeks challenge and feedback and strives for improvement to deliver high quality, patient focused care through a supportive culture of fairness, openness and transparency.W1Is the governance framework coherent, complete, clear well understood and functioning to support delivery of high quality care?W2How are staff concerns dealt with; risks identified, managed and mitigated in a manner that ensures quality care and promotes innovation and learning; and what assurances are sought and provided?W3How does the provider make sure that the leadership within the organisation is effective, maintained and developed?W4Are there high levels of staff engagement; cooperation and integration; responsibility and accountability; and do HR practices reinforce the vision and values of the organisation.
28 What does this mean in your daily practice? PRACTICAL APPLICATIONWho is your matron?Who is your head of Nursing/DDNGTidy wardWhat are patients sayingAssistance at mealtimesWhite boards above bedPOLICIES AND PROCEDURESSupporting StaffTemporary StaffAvailable via the intranet homepage
29 What can you do prior to inspection Consider the following questions:Have I had an appraisal?Am I up to date with my MAST training?How do I keep my knowledge and skills up to date?Do I know what the trust values are?What areas of my work am I proud of?What worries me? How am I addressing my concerns?
30 Quality Inspections: Identified Risks Not all staff have had Individual performance reviews
31 CONCLUSIONWe must meet the essential standards, for the sake of our patientsWe got much of it right in AugustWe need to get it right, everywhere, for all of our patients – consistencyThis is our responsibility to our patientsThis presentation and further resources are available via the intranet homepage