1. QUALITY INSPECTIONS Inspection team briefing

2. THE PURPOSE OF QUALITY INSPECTIONS: To provide a rolling programme of assurance throughout the year To ensure readiness for re-inspection by the CQC – announced and unannounced To identify any areas requiring further support in terms of ensuring compliance with standards To help staff understand a formal inspection process in order to be fully prepared should their ward be inspected The inspection aims to replicate a CQC inspection looking at certain standards with bespoke audit tools

3. QUALITY INSPECTION METHODOLOGY During a Quality Inspection, the team are required to: Speak with patients (and relatives) about their experiences of receiving care Talk to staff (multidisciplinary teams) Observe patient care to check that the right systems and processes are in place, and that patients are treated with kindness, dignity and respect Look for evidence that care is meeting national standards Look at documentation – i.e. have observations been done, medication given, risk assessments completed, plans of care documented Observe staff interaction – look for evidence that teams are supportive and respectful of each other Look at environment – is it clean, uncluttered, calm, ordered? Look at patient information available – are notice boards up to date, relevant, tidy?

4. MOCK INSPECTION METHODOLOGY It is important that wards/areas are not forewarned that you are visiting them – this is to ensure a true picture on the day of inspection, as would be the case with a CQC inspection. Inspections will continue to be carried out in teams of three: A clinical team leader (Matron, Head of Nursing) A senior member of the Trust Management team (inc Execs & Non- Execs) A patient representative – a volunteer/lay representative or another member of non-clinical staff Each team member will have a certain aspect of patient care to look at and will use a bespoke inspection tool…

5. Role of the Clinical lead: Will lead the inspection Will identify the nurse in charge and introduce the inspection team, explaining the purpose of the visit Will ask the nurse in charge to identify any patients with whom it would not be appropriate to speak Will primarily review health records using the inspection tool The clinical lead may give guidance to the rest of the team around any clinical issues which arise and take the lead in ‘verifying ‘ any findings Should ensure all team members’ feedback is collated and that the whole inspection team are present to feedback to Nurse in charge Should lead on any action arising required – i.e. urgent clinical issue on the day INSPECTION METHODOLOGY

6. Patient Representative Should aim to speak with at least three patients on the ward/area Should introduce themselves to the patient and ask if it is alright to spend some time speaking with them Will be required to ask the questions defined in the inspection tool Should be mindful not to interrupt or obstruct patient care Senior Manager Will speak with at least three staff members Will observe what is happening on the ward Will check equipment (with guidance of a member of nursing staff) and when doing so should wear gloves and apron Will specifically speak with the nurse in charge to carry out part of the inspection

7. The team should take care to ensure: They are bare below the elbows They wear soft soled shoes They have a name badge clearly displayed What to do if a patient raises a concern, or if you see something of serious concern E.g. Urgent safety/safeguarding issue of concern - Discuss with the Clinical lead who will discuss with Nurse in Charge E.g. Patient requesting attention – Alert a member of the frontline team, tell patient what you have done BEFORE & DURING THE INSPECTION

8. Use your senses – listen carefully to what staff, patients and relatives are saying to you How does it make you feel? Gut feelings are important but try to unpick why you have had this feeling – this is important for constructive feedback Appear relaxed and allow patients time to get all their feelings and thoughts over to you Probe the answers if necessary Record any additional observational comments – both positive and negative, on the tools provided BEFORE & DURING THE INSPECTION

9. INSPECTION PLAN: Before The Risk team will contact you with your area and team members contact details Please make contact with other team members prior to the day of inspection to arrange a venue to meet 10 minutes ahead of the inspection During The team should aim to complete the inspection in around 1 hr and 30 minutes Please write legibly on the forms as these will be transcribed and used to inform the overall analysis of compliance across all wards by the Risk team. After The team should have a de-brief for 10 minutes and then spend 5 minutes providing a hot debrief to the nurse in charge. The team may make a recommendation around a potential rating: Results are transcribed within 2-3 days and are fed back to inspection teams for apprval. Inspection teams approve/amend within a further 3 days. This enables prompt feedback to division and wards. All inspection audit forms must be collated by one of the team and deposited in the box-file outside the Chief Nurse Office, 1 st Floor Grosvenor Wing – alternately collection can be arranged with the Risk team Ext1175

10. INSPECTION PREPARATION CHECKLIST: Receive email advising inspection area: 2 – 3 days in advance Contact other team members if necessary to arrange meet up Ensure you are bare below elbows and in soft soled shoes Collect inspection tools from area indicated in email Undertake inspection and record findings on audit tools Ensure team provide immediate feedback to ward manager Return completed audit tools to filing box as indicated Review and approve transcription of inspection report once received ( within 3 working days) Remember to raise any immediate concerns with clinical inspection lead/ward or dept manager.

11. PROVISIONAL CQC RATINGS