CQC activity in Coventry
Coventry Cares Learning Network
1 March 2013
Coventry and Solihull team
Compliance Manager: Lesley Ward
Compliance Inspectors:
Brenda Smart
Martin Brown
Michelle McCarthy
Erica Davies
Fiona Stephenson
Rachael Ratcliffe
Sara Gibson
Sandra Wade
Keith Briant
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Regulated Locations in Coventry
•Social Care Organisations 162
•Independent Health Care 7
•Dentists 45
•GP’s (so far) 65
•NHS 2 University Hospital Coventry and Warwickshire and St Cross
(Coventry and Warwickshire Partnership Trust is covered by the
Warwickshire team).
We also cover 221 locations in Solihull and 2 large NHS trusts:
Birmingham and Solihull Mental Health Foundation Trust and Heart
of England Foundation Trust.
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What have we been doing?
• Planned inspections of all social care organisations and
independent health care organisations (registered on 1 April 2012).
•Responsive inspections in response to concerns.
•Inspections of all acute NHS hospitals.
•50% of dentists this year.
•Following up on compliance actions.
•Working with partner agencies – safeguarding and information
sharing.
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Compliance
•Most locations are compliant. Well done to everyone who has had a
fully compliant inspection.
•Based in inspections to 15/2/13 in Coventry:
• Social care organisations:
•111 locations inspected. 25 had one or more compliance actions.
77% fully compliant. 23% work to do.
•Independent healthcare:
•5 locations inspected. 1 location had compliance actions. 80% fully
compliant. 20% work to do.
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Compliance
•Dentists:
•13 locations inspected. One location with compliance actions. 92%
fully compliant. 8% work to do.
•NHS:
2 locations inspected. UHCW and St Cross. Both compliant in the
areas we inspected.
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What is not compliant?
Social care organisations:
•Personal Care (DCA’s): Compliance actions made:
•Outcome 4: Care and welfare (3)
•Outcome 9: Management of medicines (1)
•Outcome 13: Staffing (2)
•Outcome 14: Supporting workers (2)
•Outcome 16: Assessing and monitoring quality (2)
•Outcome 20: Notification of other incidents (1)
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What is not compliant
Care and nursing homes:
•Outcome 1: Respecting and involving (5)
•Outcome 2: Consent (1)
•Outcome 4: Care and welfare (9)
•Outcome 5: Meeting nutritional needs (1)
•Outcome 7: Safeguarding (3)
•Outcome 8: Cleanliness and infection control (3)
•Outcome 9 Management of medicines (3)
•Outcome 10: Safety and suitability of premises 91)
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What is not compliant
•Outcome 12: Requirements relating to workers (3)
•Outcome 13: Staffing (3)
•Outcome 14: Supporting workers (4)
•Outcome 16: Assessing and monitoring quality (4)
•Outcome 17: Complaints (1)
•Outcome 21: Records (6)
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Key to compliance?
From our experience the key to compliance is:
• Leadership, good managers and well supported, trained and
committed staff (outcomes 12, 13 and 14).
•Providers who really know what is going on in their service and act
on what they know (outcome 16)
•Focusing on people’s individual care and welfare needs (outcome
4).
•If these are right, in most instances so will everything else be.
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Assessing compliance?
We base this on:
•Regulations / outcomes.
•What you say you are doing (statement of purpose).
•What we see on the day – care plans, interactions, environment etc.
•What people tell us – people using services, relatives, staff, external
sources.
•What we know about your service: notifications, safeguarding,
intelligence via website, comparison with similar services nationally.
•Corroboration: Evidence from more than one source.
•So what? What does it mean for people using the service.
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Example: Outcome 4: Care and
welfare
Care and treatment was planned and delivered in a way that
was intended to ensure people’s safety and welfare.
(Evidence) - The records included an assessment of the risks of
people getting sore skin and how staff should support them to
minimise this risk. (Corroboration) - We saw that all of the people
living there had special mattresses on their bed that helped to
reduce the risks of this and they had pressure relieving cushions on
their wheelchairs. Staff we spoke told us how they supported each
person to reduce the risk of getting sore skin. (So what) This meant
that people were supported appropriately to minimise the risk of
them getting sore skin.
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Example: Outcome 14: Supporting
workers
(Evidence) The service had an up to date training plan that include an
analysis of training completed and needed. We saw training records,
supervision and appraisals records on staff files. (Corroboration) Staff told
us that they received regular training that helped them to do their jobs better.
One member of staff told us that recent training on safeguarding vulnerable
adults had helped her to identify a concern, which she had then reported to
her manager. Staff told us that they had regular supervision with their
manager and an annual appraisal. Staff told us that these sessions had
helped them to think about the care they were giving and to identify training
needs. They told us that the manager always had an open door and was
readily available if they had any questions and concerns. People using the
service told us that staff always explained what they were doing and helped
them in ways that met their individual needs. We saw staff putting their
training into practice during our visit. Examples included helping people with
their mobility and reassuring a person who was confused. (So what?)
People were having their health and welfare needs met by competent staff.
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Summary - what we look for
•Intelligence helps us to prioritise, guide and focus inspections.
•Records provide direction and a framework, information and an
audit trail. They are important but they are not the main focus of our
inspection.
•What we see, what you / staff tell us and what people who use tell
us are crucial.
•How well (or not) these elements corroborate each other forms the
basis for a compliant / not compliant judgement.
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What will we be doing in 2013/14?
•Inspecting all social care organisations and most independent
health care organisations.
•Dentists who have not already been inspected.
•Pilot inspections of GP practices have started and these will be
rolled out once the methodology has been confirmed.
•Developing our work with the NHS further.
•Working with partner agencies.
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Questions?
Email: [email protected]
Phone :03000 616161
On line feedback : www.cqc.org.uk
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