‘Well Led Review’
GETTING PREPARED FOR THE CQC INSPECTION CQC STAFF HANDBOOK
CQC STAFF HANDBOOK
The Care Quality Commission We need to show the CQC (CQC) will be inspecting our what a great job we are services in the very near future. doing and how we continuously strive for improvement. The purpose of their inspection is to make sure we are This booklet has been continuing to deliver high designed as a ‘check list’ to quality care to all our service help all of us prepare for our users and that the Trust is inspection so that we continue well led. to meet expectations and aspire to exceed them.
PERFECT CARE Care has always been at the heart of everything we do and we strive to provide Perfect Care. It shows how we are: • improving the quality of our services • enhancing the skills and productivity of our people • making better use of our resources • preparing for our future now. What we stand for: Mersey Care believes that service users, carers and staff should all be treated with dignity and respect, and be valued as citizens. Our Values • Continuous improvement • Accountability • Respect • Enthusiasm • Support. 2
GETTING PREPARED FOR THE CQC INSPECTION
CQC INSPECTION
What are they looking at?
Inspectors will visit some inpatient services and a selection of clinics and community teams, but we don’t know which ones or when they will be. We have been asked to provide a lot of information before their visit, and will be asked for more during the visits, as they follow key lines of enquiry/questioning and triangulate information. The CQC will visit teams, talk to managers, clinicians, and heads of department. They may talk to administrators, receptionists, facilities management staff, porters and other support staff. They will observe care and any information that links to the service user’s journey. They might ask for feedback and may host listening events with you, patients and carers.
The CQC will ask questions about the quality of services based on what matters most to patients. It is these five questions that we should ask ourselves at all times. 1. Is it safe? Patients are protected from physical, psychological or emotional harm or abuse 2. Is it effective? Patients’ needs are met and care is in line with national guidelines and NICE quality standards, helping patients maintain quality of life
After the CQC have visited clinical areas, they will be undertaking a well led review. This consists of a series of individual interviews with members of the Board of Directors, senior leaders and heads of departments. The CQC will write a report based on their findings and will rate the Trust and its services as ‘Outstanding’, ‘Good’, ‘Requires Improvement’ or ‘Inadequate.’ Action plans and their progress will be tested by later unannounced inspections.
3. Is it caring? Patients are treated with compassion, respect and dignity and care is tailored to their needs 4. Is it responsive? Patients get treatment or care at the right time, without excessive delay and are involved and listened to 5. Is it well-led? There is effective leadership, governance and clinical involvement at all levels, and a fair, open culture exists that learns and improves through listening and experience.
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CQC STAFF HANDBOOK
HOW BEST CAN I PREPARE? There is a lot you can do to ensure you are prepared for the CQC’s visit including:
• Keep informed – attend briefing sessions, talk to your team/manager, read updates via the weekly staff newsletter and other communications such as the Chief Executive’s weekly blog and the special CQC microsite • Review the five questions overleaf – these will give you a good overview of the five key questions and useful prompts for you to consider personally and as a team • Share best practice and learning – with your team and other colleagues • Paperwork – CQC inspectors might ask to see copies of things like staff rotas or training records, so be sure to have these available • Service user records – make sure records are up to date and that there is evidence of service user involvement in developing their care plan
GENERAL HOUSEKEEPING FOR EVERYONE • Wear your ID badge at all times • Check notice boards are up to date, information leaflet stands are current and stocked – the CQC may ask you about information that is displayed (Communications Team will assist you with this)
• Knowledge – consider how you will show evidence that you’re aware of the incidents, complaints, audits, peer reviews and other issues which have happened in your service in the past six months. Do you know what’s on the risk register for your area of work?
• Ensure the Trust CQC rating poster is displayed in patient areas
• Personal development – the Trust invests heavily in its staff, starting with induction and including compulsory and development training, as well as mentoring opportunities. Make sure you are up to date with all your training and supervision
• Ensure all areas, including offices/reception areas are clean and tidy
• Continue to deliver great care – we have a skilled and professional workforce that managers are proud of. Crucially, service users know it delivers for them.
• Remove or report broken furniture or items no longer used
• Ensure alcogel availability and use on entering the premises
• Make sure your email inboxes are clear enough to allow for information flow during the visit
• Ensure your appraisal, supervision and mandatory training are up to date • Know where to find Trust policies and be aware of the content of those relevant to your role. All policies are available on the Trust website here www.merseycare.nhs.uk/ about-us/policies-and-procedures/
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GETTING PREPARED FOR THE CQC INSPECTION
OUR APPROACH We welcome the CQC’s inspection. This is our opportunity to: • Showcase our good work and the improvements we have made • Demonstrate that we know where our improvement areas are and what we are doing about them • Demonstrate how we gain feedback about the care we provide, how we learn and share lessons to make changes for the better for our patients. What’s expected? • Patients’ needs come first at all times – this will be expected and understood by the inspecting team • Be honest, polite and helpful – answer any questions you are asked to the best of your ability • Be proud and positive – you should be proud of the excellent work you do
• Be prompt and responsive – if an issue is raised, rectify it as soon as you can, or where this isn’t possible, log it and report it with your line manager as soon as you can/are able; provide additional information requested as promptly as you can • Report problems to your line manager as soon as you notice them. Leaving things until the inspection could mean patient care is compromised – raise issues with your line manager now. • Act in line with our values of 1. Continuous improvement 2. Accountability 3. Respect 4. Enthusiasm 5. Support.
• Be ready and able – familiarise yourself with your environment and working practices so you are able to provide the inspectors with evidence to demonstrate the good work that you do
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CQC STAFF HANDBOOK
YOUR QUESTIONS ANSWERED What should I do if my service gets a visit? Greet the inspector as you would any other visitor. Tell the most senior staff member that the inspector has arrived. Make sure the operations manager (where appropriate) for your service is aware too. Please email the cqcteam@merseycare.nhs.uk with the information. Be proud of the standard of care you and your team deliver. This is your opportunity to shine! Be ready to show them examples of how you have helped to improve care and include as much supporting evidence as you can.
‘Mersey Care is striving for Perfect Care. A bold ambition in challenging times’. Professor Ed Coffey
Should I let an inspector in if they don’t have an ID badge? No. All CQC inspectors will have an ID badge and a warrant card which you should ask to see. If anyone turns up at your service claiming to be an inspector without ID, politely decline them access and contact: cqcteam@merseycare.nhs.uk or call 0151 472 7423/ 0151 473 2736. What if they want to talk to me? That’s fine. They are there to make sure we are doing a good job. Please answer any questions as best you can and remember you won’t be expected to know the answer to everything. Be open and honest and remember that all you say and do will be written down. If you’re not sure about something, ask your line manager. Be able to tell people and evidence: • Three things your team is good at – think about some examples that show how you care and what difference was made • Three things your team is working on – these might be ward strategies, partnership with carers, links with the community or new care models • Be proud – these things may seem basic and every day to you but will be important to the inspection team. So much of what we do is innovative and amazing – this is our chance to share good practice.
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GETTING PREPARED FOR THE CQC INSPECTION
What will they be focussing on? The entire pathway. This is so they can try to understand the service user’s journey. They will be particularly interested in: • Care planning and crisis planning • Effective use of the Mental Health Act (where appropriate) • Effective use of the Mental Capacity Act, particularly evidencing capacity of the service user where asked to do so • Ensuring our staff are suitably trained to carry out their role • Ensuring our staff get good supervision • Safeguarding • Deprivation of Liberty Safeguards (DoLS)
Do the inspectors have the right to see service users’ records and other confidential material? Yes. CQC inspectors are carrying out a statutory duty. In this context access is lawful, ethical and permissible, without the need to gain consent from individual service users. Where records are stored electronically, our staff will operate our systems on behalf of the inspectors and show them the information they need, printing off hard copies if requested.
Can I talk to the inspectors in private, without anyone else knowing? Yes. It’s your right to meet with CQC in confidence. On the day of the inspection, you’ll be provided with the inspector’s details. That way you can make arrangements to meet them in private if you wish to do so. You can also contact the CQC at cqc.org.uk
• Patient rights • Listening to service users, carers and staff.
What sort of evidence might they ask for? Any of the following: • Past and current staffing rotas • Copies of local policies and procedures • Examples of care plans • Compliments and positive stories • Examples of complaints and how they were resolved • Service improvements • Learning from events put into action • Examples of changes made as a result of feedback • Audits. Please do not let the inspector remove any data from your service, ask them to go through the information request process.
FREEDOM TO SPEAK UP GUARDIANS The Trust has dedicated staff whose role is to solely give all staff support and freedom to speak up for themselves, their patients and all of us. The role of Freedom to Speak up Guardian, as they are known, was recommended by Sir Robert Francis, following his review and subsequent report into the failings in Mid Staffordshire NHS Foundation Trust. Freedom to Speak Up Guardians Pat Prescott Tel: 07881 002 626 (Monday – Thursday) Bernie Rochford Tel: 07867 341 050 (Thursday – Friday) Email: freedomtospeak.guardian@merseycare.nhs.uk
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CQC STAFF HANDBOOK
ZERO SUICIDE As part of our commitment to Perfect Care and the pursuit of excellence, we have made a commitment to eliminate suicide for all those in our care. We know that there are certain times and situations where people are at risk of suicide, especially during the period after discharge from inpatient care. These areas will be our initial focus. Every service user with a history of intent or self-harm will also be given a personalised safety plan while a Safe from Suicide Team will be created as part of the new assessment and immediate care service. The team will continually monitor the highest risk service users who have either been referred to us or are already in our care, and intervene rapidly and effectively to reduce risk. 8
Briefing Packs These will be available on the Mersey Care CQC microsite homepage http://sharepoint.merseycare. nhs.uk/Mersey%20Wiki/CQC.aspx There will be a number of briefings highlighting key areas and practices across the Trust.
GETTING PREPARED FOR THE CQC INSPECTION
OUR BOARD AND NON - EXECUTIVE DIRECTORS JOE RAFFERTY Chief Executive
BEATRICE FRAENKEL Chairman
MATT BIRCH Non-Executive Director Retail
MURRAY FREEMAN Non-Executive Director GP
GAYNOR HALES Non-Executive Director Nurse
GERRY O’KEEFE Non-Executive Director Business Transformation
PAM WILLIAMS Non-Executive Director Finance
NICK WILLIAMS Non-Executive Director Digital
TRISH BENNETT Executive Director of Nursing and Operations
ELAINE DARBYSHIRE Executive Director of Communications, Corporate Governance and Estates
LOUISE EDWARDS Director of Strategy
DAVID FEARNLEY Executive Medical Director
NEIL SMITH Executive Director of Finance (Deputy Chief Executive)
AMANDA OATES Executive Director of Workforce
COUNCIL OF GOVERNORS As an NHS Foundation Trust, we have established a Council of Governors which ensures that the views of our members, as well as those of the wider community, are represented and to help the Trust shape its plans for the future. The Council of Governors is made up of a number of elected and appointed governors and is chaired by the Trust’s Chairman. Information can be found on the Trust website www.merseycare.nhs.uk/council-of-governors/ about-the-council-of-governors/
‘We believe that our Perfect Care ambition is possible. Our service users and carers deserve nothing less. Every member of staff has a role to play.’
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CQC STAFF HANDBOOK
WORKING IN PARTNERSHIP WITH SERVICE USERS AND CARERS
• recruitment and selection of staff
Mersey Care’s policy on involving service users and carers was widely acknowledged as best practice within mental health services when it was introduced in 2004. Since that time the policy and practice has evolved into a dynamic participation programme based upon a commitment to co-production at all levels of our organisation. This programme encompasses wide ranging activities where decisions are made which affect the experience of and outcomes for service users and carers including:
• strategy development groups and associated activities
• audit and evaluation • co-facilitation and co-production activities (including recovery groups) • complaints and incident reviews • equality and human rights analysis • induction and training of staff • inspections (including PLACE and QRVs) • governance groups and leadership teams • objective setting and appraisal of staff
• research and innovation • service development and design
• task and finish groups • Trust Board committees. The participation of a diverse range of service users and carers who reflect the community we serve is essential if the Trust is to be a relevant and responsive organisation. Participation as equals in decision making has good recovery outcomes for service users and carers. It also has good outcomes for the Trust such as improved staff and services. Participation of service users and carers as equal partners in decision making is a means of tackling the power imbalance that often exists between professionals and lay people, and a means of achieving cultural change. The Trust also ensures that service users and carers are properly trained, supported, and recognised for their contribution to the work of the Trust. In April 2014 Mersey Care became the first of the 56 statutory providers to receive the highest Triangle of Care Award by the Carers Trust for its work in engagement.
• policy development and review
The terms service users and patients are interchangeable.
‘The staff here really care. They’ve helped to change my life. I have hope again’ Mersey Care service user
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GETTING PREPARED FOR THE CQC INSPECTION
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WHAT WILL HAPPEN?
For more information contact: CQC Team Mersey Care NHS Trust V7 Building, Kings Business Park Prescot, Merseyside L34 1PJ T: 0151 473 2736 or 0151 472 7423 E: cqcteam@merseycare.nhs.uk 12