Ward accreditation programme South Tees Accreditation of Quality

Ward accreditation programme “South Tees Accreditation of Quality Care… STAQC” Paul Rafferty - Clinical Matron Surgical Services Centre

What is ward based accreditation? CQC Essential standards Staff feedback Patient experience CQUi. N measures Trust policy and NICE compliance

What does this mean? “The STAQC process is designed to support nurses in practice to understand how they deliver care, identify what works well and where further improvements are needed, following the Trust approach to service and quality improvement. ”

Data sources

Our journey

THE ASSESSMENT PROCESS

Stage 1 – pre-assessment

Stage 2 – the unannounced inspection

What is being assessed? • • • 20 standards Using a “key lines of enquiry” approach Staff discussions Formal meeting with Senior Sister/ Senior Charge Nurse Observation of care – Patient experience

1. 2. 3. PRESSURE ULCERS FALLS HOSPITAL ACQUIRED INFECTIONS 4. END OF LIFE CARE 5. VTE 6. WEIGHT LOSS AND DEHYDRATION 7. MEDICATION ERRORS 8. EWS 9. RECORDKEEPING 10. PRIVACY & DIGNITY 11. SAFE TRANSFER 12. ENVIRONMENT 13. STAFF SKILL AND KNOWLEDGE 14. SAFEGUARDING 15. COMMUNICATION 16. MANAGEMENT 17. DISCHARGE 18. DEMENTIA CARE 19. PAIN MANAGEMENT 20. PATIENT EXPERIENCE

What do the standards look like?

How often are wards assessed?

The plan • • • All wards must achieve STAQC status by 2017. This will be universal standard of quality care at South Tees Hospitals NHS Foundation Trust. STAQC data is presented at Clinical Standards monthly to Head of Nursing and Clinical Matron’s from the Corporate Nursing team.

How is STAQC status achieved? • • • Wards must achieve and maintain three level 2 (Green) STACQ for 18 months Additional competencies must be met Application for STAQC to panel is made

What next once achieved? • • • Exemplar ward Yearly assessment Yearly review panel

EXPERIENCE OF STAQC & VISIT TO SALFORD TO LEARN

Background • • Nursing Assessment & Accreditation System (NAAS) introduced in 2008 to Salford 13 key standards of assessment Takes up to 2 years to achieve “SCAPE status” Once SCAPE is achieved Ward Manager becomes Ward Matron.

What we liked • • • Mandatory training approach & establishment headroom Near real-time patient feedback, i. e. F&FT Approach to Infection Prevention & Control

What is STAQC like at South Tees? • • • Assessed by Judith Connor & Eileen Aylott Immediate feedback on day of assessment RAG rated - supportive

How does it feel to have a STAQC assessment?

Ward 35’s story & advice

Future plans • • • A task & finish group to develop a standardised approach to link nursing Volunteers needed for this to contact Keir to review bed configurations to have a nursing desk in each bay… how would this work?

Some of the group who attended Salford…

Developing action plans • In small groups please review a STAQC assessment and develop an action plan to ensure that the STAQC outcomes are maintained but importantly non-compliance become compliant.

Summary • • • STAQC is about support Focuses on putting the patient at the heart of everything we do Provides leadership & boosts staff morale