CQC follow-up inspection

10-12 May 2016

Members Meeting 12 April 2016

Professor Suzanne Hinchliffe, Chief Nurse/Deputy Chief Executive

Craig Brigg, Director of Quality

Part 1

The local and national context for

inspection

NHS Context

- Huge constraints on public

finances

- Increasing demand (ageing

population)

- Complexity of patients

- Secretary of State

championing safety and

transparency

Deliver purpose with fewer

resources

Co-regulation, risk based

registration

Responsive and tailored

Inspections

Assessing how providers use

Resources

... and what is new at the CQC?The next phase in the regulatory approach, Published in October 2015

150 hospitals inspected up to 31

May 2015

1% Outstanding (2)

34% Good (51)

57% Requires Improvement (85)

8% Inadequate (12)

Lower proportion of good and

outstanding ratings compared to adult

social care and primary care

All hospitals to be inspected by end of

March 2016

CQC State of Care report 2014/15Annual report on inspections and ratings

Part 2

CQC comprehensive inspectionMarch 2014

9

Framework for inspection

Surveillance

CQC inspectors talked to patients and their families and carers…

and observed the care provided

and they talked to staff …

and they reviewed a range of

information about our Trust …

Outpatients & DiagnosticServices

Critical Care Medical Care Surgical Care

Children’s & Young People

Urgent Care Maternity & Gynaecology

End of Life Care

8 clinical pathways (core services)

The CQC visit other areas as well based on their information

and what they hear from patients, carers, families and staff

What the CQC told us

Key question Rating

Safe Requires Improvement

Effective Good

Caring Good

Responsive Requires Improvement

Well led Requires Improvement

Overall rating Requires Improvement

Core services

Core Service Rating

Medical Care Requires Improvement

Urgent Care Good

Maternity Good

Children Requires Improvement

Surgery Requires Improvement

End of Life Care Good

Critical Care Requires Improvement

Outpatients Good

Hospital Location

Location Rating

LGI Requires Improvement

Chapel Allerton Good

Wharfedale Good

St James’s Requires Improvement

Seacroft & LDI Not inspected

Safe Effective Caring Responsive Well Led Overall

Urgent Care

Medical Care

Surgery

Critical Care

Maternity

Children

End of Life Care

Outpatients & Diagnostics

St James’s hospital

Safe Effective Caring Responsive Well Led Overall

Urgent Care

Medical Care

Surgery

Critical Care

Maternity

Children

End of Life Care

Outpatients & Diagnostics

Leeds General Infirmary

Safe Effective Caring Responsive Well Led Overall

Urgent Care

Medical Care

Surgery

Critical Care

Maternity

Children

End of Life Care

Outpatients & Diagnostics

Chapel Allerton

Safe Effective Caring Responsive Well Led Overall

Urgent Care

Medical Care

Surgery

Critical Care

Maternity

Children

End of Life Care

Outpatients & Diagnostics

Wharfedale

Some examples of actions we were required to take

• Nurse staffing

• Mandatory training attendance and appraisal completion

• Support for trainee doctors

• Medical cover out of hours/weekends

• Handover

• Follow procedures for Safeguarding, Mental Capacity Act and DoLs

• Risk assessments (tissue viability and hydration)

• Share learning from incidents

• Participation in national clinical audits

• Equipment replacement

Part 3

Preparing for May follow-up

inspection

Two new regulations came into force on 27 November

2014

• a fit and proper person requirement for directors - all

Directors to make a declaration

• Duty of Candour for NHS organisations

There is also a requirement to display ratings at our

hospital entrances

New Regulations

CQC inspection w/c 9 May 2016 (that’s 4 weeks today)

• Recommendations from last inspection reviewed; these

will be a trigger for the inspection

• CQC are mostly interested in what happens in clinical

practice (patients, staff and visitors) “we were told ... “

• CQC will focus on areas that were judged to require

improvement and may also review other areas

Inspection is not an exact science

These will be a key feature of the inspection process to engage

with the public and service users to help the CQC understand

more about the services provided and the experience of care in

our hospitals.

The CQC will advertise the public listening events and they will

be held locally inside our hospitals.

These will be held on Monday 18 April and Friday 22 April.

Staff focus groups will be arranged during the inspection week

Public Listening Events

Staff focus groups will be arranged during the inspection week

• Nursing staff and Midwives

• Consultants

• Allied Health Professionals

• Student Nurses and Clinical Support Workers

• Doctors in training

• Admin and clerical staff

• Members of the Board

Staff Focus Groups

Actions we are taking

• Submitted information about our services to the CQC to

help with their preparations

• Undertaken a self-assessment and identified our strengths

and weaknesses

• Communications plan – safety messages and trust wide

briefings

• Identified good practice and innovation

• Engaging with staff groups

• Visits to core services

• Task & Finish Group – framework for preparation

• Meeting with CQC inspectors

• Developed our culture and values – the Leeds Way

• Governance and Committee arrangements reviewed

• QI programme/Leeds Improvement Method

• Sign up to Safety pledges (Safety Improvement Plan)

• Risk and Complaints improvement plans

• Learning lessons and sharing learning

• Increased our capacity to support quality and safety –

Patient Safety & Quality Managers (4), Clinical Fellows (6)

Some of the things we have done since

March 2014... that will be subject to inspection to check our progress

Building on #TheLeedsWay

Changing our culture

TeamBrief

Clinical Director

General Manager

Head of Nursing

£Sustainability

The Leeds Improvement Method – partnership with

Virginia Mason

Integrated

the Leeds

Improvement

Method into

our strategy

Our Quality Improvement Programme

The Ward Teams

The Faculty

LEEDS Deteriorating

Patient

Intervention Bundle Developed and tested by our Collaborative Ward Teams

LEEDS

Falls

Intervention Bundle Developed and tested by our Collaborative Ward Teams

• Reduction in 2222 calls - 30%

in pilot wards

• L37 achieved over 1 year between calls (average 29 days)

• L35 went 166 days between calls (average 52 days)

• L19 went over 65 days (average 17 days)

• J96 went over 70 days (average 22 days)

• J89 went over 200 days without a call.

• Reduction in falls- 25%

in pilot wards

• J49 have gone 67 days without a fall

• J15, L12 & L50 all achieved over 45 days without a fall

• J07, J08, J16, J14, J19, L17, L18, L21 all achieved over 25 days without a fall

• All wards in the collaborative have gone at least 18 days without a fall

Safety Improvement Plan

The Trust signed up to the national

safety campaign in August 2014

Pledges – put safety first, reduce

avoidable harm, continually, learn,

be honest and transparent, share

learning and support staff

Safety Improvement Plan (January

2015)

Maternity improvement plan -

£750K funding from NHSLA

Safety huddles

Bringing fun and improvement to the

frontline1 ward one day... 4 wards in 2013... 8 wards in 2014... currently 50 wards

AND

Whole organisation Oct 2016

Complaints Improvements

In 2014/15 we received 857 complaints

In 2015/16 (up to end of February) we have received 663complaints

This is a reduction of 23% (to date) – increase in PALS enquiries and support from PALS

QA process introduced to improve responses

Recorded meetings with complainants (36 to date)

0

50

100

150

200

250

300

350

400

Ma

r-1

4

Apr-

14

Ma

y-1

4

Jun-1

4

Jul-1

4

Aug-1

4

Sep-1

4

Oct-

14

No

v-1

4

De

c-1

4

Jan-1

5

Feb

-15

Ma

r-1

5

Apr-

15

Ma

y-1

5

Jun-1

5

Jul-1

5

Aug-1

5

Sep-1

5

Oct-

15

No

v-1

5

De

c-1

5

Jan-1

6

Feb

-16

Open, closed, reopened and new complaints

Total open on 1st day of month

Total closed in month

Total reopened in month

Total received in month

Friends & Family Test (FFT)

Response Rate

In the year to January 2015 the average response rate was

23.4%

In the year to January 2016 this had risen to 30.4% - 33%

increase

Percentage Recommended

In the 4 months to January 2015 the average percentage of

patients who recommended the service was 91.1%*

In the year to January 2016 the average percentage was

92%.

Pressure Ulcers

In 2014/15 we reported 796 pressure ulcers

57 of these were Category 3 pressure ulcers

5 were Category 4 pressure ulcers

In 2015/16 (up to end of February) we have reported 713pressure ulcers – 10.4% annual reduction (to date)

51 of these were Category 3 pressure ulcers

0 were Category 4 pressure ulcers

Appraisal

•Appraisal season introduced 1 April – 30 June

• > 95% 2015/16

Mandatory training

• Induction programme refreshed to cover mandatory

training requirements

• Mandatory training compliance 89.9% - March 2016

• Delayed transfers of care

• Surgical never events

• Infection rates

• Nurse and medical staffing in specific areas

• Care of patients with behavioural problems

Our priorities for improvement- 2016/17

So how do we move from a judgement of

requires improvement to good?

A culture of collective responsibility

What will we do next?

We will continue to engage with our clinical teams,

partner organisations and the CQC as we prepare

for the visit in May

We welcome your feedback and contribution to the

inspection

Questions and discussion

Information about the approach to inspection is on the CQC

website http://www.cqc.org.uk/ and in their handbook

If you require advice, please contact

Professor Suzanne Hinchliffe CBE Chief Nurse/Deputy

Chief Executive

Craig Brigg, Director of Quality

Further Information