Comprehensive Overview of Preparations for Upcoming CQC Inspection
The content outlines the preparation for an upcoming Care Quality Commission (CQC) inspection, including details on what to expect during the inspection, the Trust's self-assessment, and evaluations across different service areas such as mental health, community care, and more. It emphasizes the focus on ensuring safety, effectiveness, care, responsiveness, and well-led practices within the organization.
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IC5 Preparation for the Upcoming CQC Preparation for the Upcoming CQC Inspection Inspection Team Brief for All Teams in the Trust Team Brief for All Teams in the Trust Caring, safe and excellent
What to expect from the CQC inspection What to expect from the CQC inspection Minimum of 1 core service will be inspected, along with the Well-Led Review. The number of core services that CQC inspect will vary for each organisation. All core service inspections will be unannounced. With some notification for the Well-led review. Oxford Health FT issued provider information request (PIR) in December,2017 and this was submitted to CQC in the same month. Inspections will happen within six months of issuing the Provider Information Request (data return). For OHFT we are expecting the core service visit, around January/February 2018, followed by the Well-Led review in February/March 2018. CQC will inspect us on the five key questions: Safe, Effective, Caring, Responsive & well-led. Please see last slide for the updated Key Lines of Enquiries (KLOES) for each of these domains. The size and make-up of the inspection team will be tailored to the service and the areas they inspect- again can vary for each core service. Caring, safe and excellent
The Trusts self assessment The Trust s self assessment Safe Effective Caring Responsive Well-led Comments Trust-wide we feel progress has been made on the RI requirements within the Safe Domain however due to the challenges with staffing we have still self-rated as RI. Planned staffing levels are generally met by additional use of temporary staff. Requires Improvement Provider wide Good Good Good Good Community Safe Effective Caring Responsive Well-led Comments Requires Improvement Community inpatients Good Good Good Good Requires Improvement Adults community Good Good Good Good CYP Community services delivered by OHFT (Oxford only). Includes 0-19 Universal services/ Community Nursing/ Integrated therapy service/ Phoenix team (including LAC/ YOS/ CSE) Children, young people and families Good Outstanding Outstanding Good Good Clinical audit data did not provide sufficient assurance but new care plan is being piloted and plan to re-audit Requires Improvement End of life care Good Good Good Good Requires Improvement Requires Improvement Urgent care Good Good Good Action plan in place Caring, safe and excellent
Mental Health Safe Effective Caring Responsive Well-led Acute Wards for adults of working age and psychiatric intensive care units Requires Improvement Good Good Good Good Long stay/rehabilitation mental health wards for working age adults Good Good Good Good Good Forensic inpatient Requires Improvement Good Good Outstanding Good Child and adolescent mental health wards Requires Improvement Good Good Good Good Wards for older people with mental health problems Requires Improvement Good Good Good Good Wards for people with learning disabilities or autism (Evenlode forensic LD) Good Good Good Good Good Community-based mental health services for adults of working age Good Good Good Good Good Mental health crisis services and health-based places of safety Good Good Good Good Good Specialist community mental health services for children and young people. Good Good Outstanding Requires Improvement Good Community-based mental health services for older people Good Good Good Good Good Community mental health services for people with learning disabilities or autism Good Requires Improvement Good Requires Improvement Good Other Specialist eg EDS, psychiatric liaison services, complex needs service Requires Improvement Good Good Requires Improvement Good PMS (likely to be combined into one core service) Safe Effective Caring Responsive Well-led Good Requires Improvement Good Requires Improvement Good GP OOH Luther Street Good Good Outstanding Outstanding Good Salaried dental Good Good Outstanding Good Good Adult Social Care Safe Effective Caring Responsive Well-led Good Requires Improvement Good Good Good Other - ASC service Caring, safe and excellent
What to expect from the CQC inspection What to expect from the CQC inspection Methods CQC will use to collate evidence, including: Speak to patients and staff Observe patient care being delivered Look at individual care pathways Review patient records. Review documents and policies. CQC will rate each key question and award a new overall rating after each core service inspection and overall Trust rating following the well-led review. Please use this opportunity to highlight examples of any good and outstanding practice and any areas you are really proud of. CQC will highlight these in the report, which will be published. Caring, safe and excellent
Key areas to focus on for the next 4/6 weeks Key areas to focus on for the next 4/6 weeks Staffing - vacancies, turnover, agency use Evidence of NICE implementation and impact of actions after clinical audits Evidence of tangible clinical outcomes for patients Mandatory training levels (overall for clinical teams 85%) Appraisal levels (overall for clinical teams 70%) Assurance around clinical supervision Bed occupancy with leave high in mental health Caseload sizes and oversight Waiting times and oversight Oversight of safeguarding referrals particularly adults in Oxon and Bucks DOLs; the high number of applications not approved is due to delays in authorisations by the County Council. Caring, safe and excellent
Key Improvement Priorities Key Improvement Priorities- - Adult Directorate Adult Directorate High re-admissions Staffing levels, vacancies and agency use Increase in use of restraint/seclusion High bed occupancy with leave Oversight of DNACPR Review of Out of Area Placements- 18 people in last 12 months placed over 50 miles away. Low Appraisal rate (less than 50%) High ward-to-ward moves Capacity of seclusion areas, sometimes individual wards use each other s seclusion areas High dose monitoring 3 monthly still needs improvement action plan from recent audit Access to emergency resus equipment and drugs access on mental health wards, immediate available drugs will be with resus bags still being worked through for some wards Fridge temperature monitoring - all wards have data loggers on fridges and ambient temperature monitors in clinic room but not working perfectly due to poor battery life Some pharmacy policies are in the process of being revised, RT e-learning package not yet rolled out Compliance of Wenric seclusion room regarding intercom system How embedded LD services are into directorate governance structure LD vision outreach team - care planning still being worked on End of life care revised care plan template not yet evaluated - can demonstrate actions from Sept 2015 but outcomes from new care plan not evaluated or known yet Caring, safe and excellent
Key Improvement Priorities Key Improvement Priorities- - Older People Directorate Delayed Transfers of Care Staffing levels, vacancies and agency use Appraisal rate (less than 50%) Vacancies (above 25%) GP OOH- training levels for GP s still poor Witney MIU child friendly area of waiting room funding now not available till 2018/19 (highlighted as recommendation by CQC during last inspection) Community Hospitals- gap in patient notes being held in one place. Roll out of electronic notes recently, CQC likely to see new processes being embedded. Management of paper records in community hospitals (build-up of more records from earlier action taken in Jan 2017) project manager identified in Oct 2017 although little action has happened so far. Work on medical gas storage and access to supply out of hours - recent audit identified issues Currently not meeting CCG targets for DN s: performance on named nurse seen patient F2F in last 3 months, YTD 48% against a CCG stepped target of 60-75% Waits: PDPS (YTD 44% offered assessment date within 12 weeks of referral), Falls service (YTD 70% routine referrals offered appointment within 8 weeks), Oxon CHC (YTD 59% eligibility decisions within 28 days) Oversight of DNACPR audit planned Access to emergency resus equipment and drugs access on some wards, immediate available drugs will be with resus bags still being worked through for some wards Fridge temperature monitoring - all wards have data loggers on fridges and ambient temperature monitors in clinic room but not working perfectly due to poor battery life Some pharmacy policies are in the process of being revised, RT e-learning package not yet rolled out End of life care revised care plan template not yet evaluated - can demonstrate actions from Sept 2015 but outcomes from new care plan not evaluated or known yet Older People Directorate Caring, safe and excellent
Key Improvement Priorities Key Improvement Priorities- - Children and Young People Directorate Children and Young People Directorate High use of medic agency in CAMHS Oxon and Melksham. Vacancies (above 25%): CCNs, children s integrated therapies South, HV service across Oxon, school nurses Staffing levels, vacancies and high agency use, Highfield, Marlborough House Swindon Use of restraints increased in last 12 months including prone and high use of RT; Highfield (mostly due to patient on HDU). Appraisal rate (less than 50%): Highfield Last inspection, found there were variable quality of risk assessments- need to ensure all risks to young people are properly recorded and managed Quality of risk assessments, actions completed but more work to be done to make an impact Review of caseloads in CAMHS teams and impact on safe patient care Ensure all clinic equipment checked regularly and up to date portable appliance testing is in place Knowledge of MCA- last inspection report stated knowledge was poor To ensure the use of seclusion and long-term segregation at the Highfield Unit is in accordance with Mental Health Act Code of Practice definitions To ensure patients have activities to take part in at weekends Ensure checks of resuscitation equipment are carried out regularly in line with trust policy, recorded on the appropriate forms and that records are kept Access to Emergency resus equipment and drugs access on some wards, immediate available drugs will be with resus bags still being worked through for some wards Last inspection- no infection control audits undertaken in children and young people s services To ensure all patients have same level of proactive support and assistance from advocacy service Caring, safe and excellent
Useful links Useful links Updated Key Line of Enquiries (KLOES), includes rating characteristics: http://www.cqc.org.uk/sites/default/files/20170609_Healthcare- services-KLOEs-prompts-and-characteristics-showing-changes- FINAL.pdf Guidance on how providers meet regulations: http://www.cqc.org.uk/sites/default/files/20150324_guidance_providers _meeting_regulations_01.pdf How CQC monitors, inspects and regulates NHS Trusts (from September 2017 onwards): http://www.cqc.org.uk/sites/default/files/20170612-how-cqc-regulates- nhs-trusts-v1-2.pdf Caring, safe and excellent
