CQC Inspection Ian Tombleson Director of Corporate Governance
CQC Inspection Ian Tombleson, Director of Corporate Governance Tracy Luckett, Director of Nursing Declan Flanagan, Medical Director Kaajal Chotai, Head of Compliance 9 -13 May 2016 Trust Board 31 st March 2016
The CQC Inspection Presentation overview CQC inspection overview Inspection preparedness activities Project governance Priority themes 5 weeks (and 2 days!) countdown www. moorfields. nhs. uk compliance@moorfields. nhs. uk
Who are the CQC and What do they do? The CQC is the independent regulator for health and social care. The CQC monitors, inspects and regulates health care services to ensure that they are providing people with safe, caring and effective high-quality care, which is well-led. www. moorfields. nhs. uk compliance@moorfields. nhs. uk
What the CQC wants to know is… Are we safe, effective, caring, responsive, and well-led? (KLo. E) www. moorfields. nhs. uk compliance@moorfields. nhs. uk
CQC inspection The Inspection is but one step on the Quality journey March 2014 July 2014 Compliance Assessment Framework Compliance • • Trust-wide focus on compliance the development of an assurance model of quality and safety • • www. moorfields. nhs. uk May 2015 Ward-to-board view of organisation Discussions with widerange of staff ‘worry-list’ used to identify areas of concern for further action (such as deep-dive reviews) Triangulation with other data Self-Assessment & Improvement Action Planning • • Self-assessment mapped to CQC domains and KLo. E Self-assessment process June – December 2015 Results in dashboard Improvement action planning October onwards compliance@moorfields. nhs. uk
CQC inspection The Inspection is but one step on the Quality journey December 2015 May 2016 The Inspection is Announced • • • Moorfields’ Eye for Quality’ initiative launched November 2015 Inspection announced December 2015 PIR 1 and PIR 2 delivered on time Project management structure On-going communication www. moorfields. nhs. uk June 2016 onwards The Inspection • • • Improvement activity in leadup to inspection But, improvements are not just for the inspection Re-enforcement of existing good practice whilst addressing weaker areas Beyond the Inspection • • Acting on the inspection outcomes Maintaining the momentum of ‘inspection-improvement’ Enhancing the CAF The commitment to quality compliance@moorfields. nhs. uk
Inspection sites The CQC needs to inspect at least 65% of our activity to be able to rate us Around 50 inspectors will visit 9 sites over 5 days May make data requests whilst on site www. moorfields. nhs. uk 1. City Road 2. St Georges 3. Queen Mary Roehampton 4. Croydon 5. Purley 6. Bedford 7. Barking 8. Mile End 9. Ealing 10. Any other sites compliance@moorfields. nhs. uk Our data return and onsite inspection are weighted 47% 53% respectively Unannounced inspection(s) within 10 working days Can speak to any staff, any where, any time
Preparation for inspection (commenced Q 2 2015) Identifying strengths and weaknesses via self-assessment, to drive learning and improvement Listening to staff and patients to ensure we understand their needs and respond to them Informing Moorfields – innovations in communication and engagement – e. g. policy infographics The inspection experience – gathering information from other Trusts to prepare for ours Planning and governance – the CQC inspection project board and sub groups www. moorfields. nhs. uk compliance@moorfields. nhs. uk
Priority Themes from the Self-assessment process The self-assessment process has identified general themes considered a priority to improve. These are: • Leadership and visibility (at all levels) • Behaviours (includes staff welfare and raising concerns) • Patient experience (includes service flow) • Communication www. moorfields. nhs. uk compliance@moorfields. nhs. uk
Project Board – governance structure CQC Project Board (CEO weekly briefing) CQC Operational Improvement Group CQC Engagement and Communications Group www. moorfields. nhs. uk CQC Data and Information Group compliance@moorfields. nhs. uk CQC Onsite Inspection Readiness Group Policies and Governance work stream
Sub-groups update Operational Readiness Engagement & Communication Data and Information Onsite Inspection • Commenced 23. 02. 16 • PIR 2 received 11. 02. 16 • Commenced 19. 02. 16 • Assurance for operational improvement actions and escalations • Focus on messaging, audiences, materials and key milestones • Deadline 10. 03. 16 (+/- a few days) successfully met; issues flagged • Additional support recruited to brief senior staff www. moorfields. nhs. uk compliance@moorfields. nhs. uk
Seven week project deliverables Now week 6 (28. 03. 16 – 03. 04. 16) Engagement and Communications • • Staff pocket book to printers Manager’s inspection toolkits disseminated (released in sections for speed) Onsite Inspection Readiness • • • www. moorfields. nhs. uk Complete room bookings and technological requirements for 9 sites Staffing rotas for inspection period drafted MEH hub processes agreed compliance@moorfields. nhs. uk Data and Information • • • Undertake a review of PIR 2 submission to understand gaps Communication to staff about PIP Ensure outstanding PIR 2 requests completed
The walkabout process has identified some general themes: • Lack of identification of senior managers • Inability to describe corporate priorities • Poor knowledge of the names of the safe guarding leads • Poor compliance with bare below the elbows policy • But overall has been quite positive www. moorfields. nhs. uk compliance@moorfields. nhs. uk
Improvements and innovations from CQC inspection preparation • • Improved staff engagement, for example face to face team brief New quality and safety boards to put up around network Improved diligence around policies plus introduction of info graphics leading to better staff familiarity Better assurance about mandatory training levels New ways of data handling. Model developed to link HR and finance data highly commended by CQC Introduction of ‘SURE’ assurance process Local teams being more proactive in taking action www. moorfields. nhs. uk compliance@moorfields. nhs. uk
Overall outcomes of CQC self-assessment process indicated that the Trust continues to aim for a ‘good’ rating and this was submitted to the CQC www. moorfields. nhs. uk compliance@moorfields. nhs. uk
www. moorfields. nhs. uk compliance@moorfields. nhs. uk
Lots to do in: 27 days 5 weeks and 2 days 9 13 May 2016 Any questions? www. moorfields. nhs. uk compliance@moorfields. nhs. uk
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