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
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