TB 110/15
Meeting title
Trust Board meeting
Report title
Care Quality Commission (CQC) Inspection: 10th – 13th November 2015 –
Progress Update
Meeting date
9th October 2015
Lead director
Ruth Charlton, Joint Medical Director
[email protected] / 701 5122
Charlotte Hall, Chief Nurse
[email protected] / 721 2628
Laura Rowe, Compliance Manager
[email protected] / 701 5064
Disclosable
Report author
FOI status
Purpose
This paper summarises the preparation actions/timetable to-date leading
up to our CQC inspection in November 2015.
To update the Board on progress.
Recommendation
The Board is asked to note the progress made.
Corporate objective
links
Delivering safe and effective care, creating a positive patient experience,
providing responsive care, working in partnerships
CQC standard
Safe, effective, caring, responsive, well-led
Identified risks and
risk management
actions
Areas of risk identified during the preparation for inspection should have
plans in place for resolution and/or should be placed on the trust Risk
Register.
Resource
implications
The costs associated with the preparation for the inspection are
monitored weekly by the CQC Core Steering Group.
Legal implications
None noted.
Equality impact
assessment
None noted.
Report history
Not relevant.
Considered by other
committees
No.
Appendices
None.
Report summary
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TB 110/15
EPSOM AND ST HELIER UNIVERSITY HOSPITALS NHS TRUST
CARE QUALITY COMMISSION (CQC) INSPECTION: 10TH – 13TH NOVEMBER 2015
– PROGRESS UPDATE
TRUST BOARD: 9TH OCTOBER 2015
INTRODUCTION
th
1. On the 24 June 2015, the CQC wrote to the trust to confirm that they would be
undertaking an announced inspection or our services between the 10 th and 13th of
November 2015.
2. During and around the time of inspection the CQC will also gather information from a
number of sources, and will use this information, and the findings of the inspection, to
award a rating to the trust of either ‘Outstanding’, ‘Good’, ‘Needs Improvement’ or
‘Inadequate’. They will speak with people who use our services and our external
stakeholders and will also interview staff individually and within focus groups. In addition,
they will take into account information gathered in the pre-inspection period both from the
trust and from the CQC Intelligent Monitoring indicators.
3. The purpose of this report is to provide a summary of the key milestones to-date.
PROVIDER INFORMATION REQUEST (PIR) 1 AND 2
4. PIR 1 was received by the trust on 24th June 2015. The CQC requested detailed information
concerning our locations, in-patient ward areas, services, bed numbers, staff numbers and
Clinical Commissioning Groups. The CQC also requested a 250 word description of each of
our core services. PIR 1 was uploaded to the CQC by the deadline date of 8th July 2015.
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5. PIR 2 was received by the trust on 17 August 2015. As part of PIR 2 the CQC requested
nearly 400 separate pieces of information. We were required to complete a total of 94 Excel
work books and submit up to 5 pieces of information per data request. Information
requested included (but was not limited to) organisation/directorate structure charts,
performance scorecards, audits, complaint information, reported incidents, risk registers,
trust and directorate meeting minutes, mandatory training records and staffing details
(including bank/agency/locum usage, sickness absence details and planned versus actual
staffing). We were also required to provide narrative information about each of our core
services. PIR 2 was uploaded to the CQC by the deadline date of 11 th September 2015 and
included over 650 supporting documents.
6. CQC analysts will use the information provided in the PIRs to compile a pack about our
organisation for use by the inspectors. We will be given the opportunity to comment on the
factual accuracy of the pack before this is finalised.
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7. Following on from the PIR 2 submission, and based upon the information submitted, each
core service (including SWLEOC and Renal Services) gave a presentation to the Trust
Executive Committee on 23rd September 2015 detailing strengths and weaknesses.
CQC PEER REVIEW
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8. On the 24 September 2015 and 2
nd
October 2015 the trust undertook a ‘mock’ CQC
inspection (CQC Peer Review) at St Helier and Epsom Hospitals respectively. The ‘inspectors’
included volunteers from amongst trust staff and external stakeholders, including
representatives from our Clinical Commissioning Groups and the NHS Trust Development
Authority. Findings from the review were fed back verbally during the events and have also
been documented for sharing with the relevant clinical areas to allow resolution and/or
further action planning, as appropriate.
CQC CORE STEERING GROUP AND CQC ACTION GROUP
9. The CQC Action Group (which met weekly with directorates) has now been subsumed into
the Core Steering Group, which continues to meet weekly to monitor the overarching action
plan leading up to inspection. The Joint Medical Director and Chief Nurse are also meeting
weekly with individual directorates who will feedback their progress reports and any issues.
STAFF BRIEFINGS
10.Two staff information booklets have been produced and distributed to all staff entitled ‘Care
Quality Commission visit: Our Chance to Shine’ and ‘Preparing for our Care Quality
Commission inspection – a guide to self-assessment’. In addition, a number of all staff
briefings are being staged on both sites. There are a total of 16 planned briefings; these
started in September 2015 and will run through to November 2015. Briefings for discreet
groups of staff (e.g. junior doctors and porters, etc.) are also being undertaken.
FOCUS GROUPS
11.In addition to the main inspection, the CQC will also be on site on the 27 th October 2015,
30th October 2015, 2nd November 2015 and the 3rd November 2015. They are planning to
hold ‘focus group’ discussions and will be inviting staff from the designated groups to
attend. The designated groups are:
Allied Health Professionals
Student nurses and HCAs
Administrative/other staff
Band 7/8 Nurses and Midwives
Band 5/6 Nurses
Band 5/6 Midwives
Junior Doctors
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Consultants
Drop in sessions
RECOMMENDATION
12.The Board is asked to note the report.
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