New Victoria Hospital - CQC Guide for employees

What to expect from your CQC inspection: Guidance and self-evaluation for clinical employees

Contents Introduction

3

The inspection process What to expect from your inspection

4

Tips for your inspection

5

Self-evaluation Reassuring yourself you have the knowledge

6

Safe Check the care you provide is safe

7

Effective Check the care you provide gives the best outcomes

9

Caring Check that every aspect of the care you provide cares for the person

11

Responsive Check that the care you provide is responsive to people’s needs

13

Well-led Are you well-led and do you lead by example?

15

Key contacts & Helpful resources

17

Our values

18

Notes

19

2 | NEW VICTORIA HOSPITAL

Introduction The aim of this booklet is to make sure you have all the information you need to be able to confidently showcase the outstanding care you provide every day, during a CQC inspection.

The CQC’s job is to check whether hospitals, care homes, GPs, dentists and other healthcare services are meeting national standards. They do this by inspecting facilities according to five domains: • Is this care safe?

• Is this care effective?

• Is the facility caring?

• Is the organisation responsive to people’s needs?

• Is the organisation well-led?

You can use this booklet as a self-evaluation tool, alongside guidance from your manager, to make sure you’re meeting all of the requirements within each domain that the CQC will focus on.

If there’s anything you come across that causes concern, or you need more help with, then note them down in the blank section at the end of the booklet and raise them with your manager or a member of the CQC support team, whose contact details are included at the end of the booklet.

It is important that you understand the Key Lines of Enquiry for the CQC: Safe, Caring, Responsive, Effective and Well-led.

Thank you for being an important part of the CQC inspection.

NEW VICTORIA HOSPITAL | 3

The inspection process To make sure that we’re compliant with the fundamental standards of the CQC and their five domains of focus. The CQC can undertake announced and unannounced inspections of any healthcare provider.

The inspection is most likely to be unannounced; the process can broadly be broken down in to three stages.

1 Pre-inspection 1. Remote information gathering from numerous agencies 2. Recruitment of inspection team 3. Capture patient views 2 Inspection – this lasts one to two days • • Core services • • Five key lines of enquiry • • Visits to clinical areas, focus groups • • Interviews with key stakeholders • • Additional data requests 3 Post-inspection • • The inspection team will request additional information from the Hospital to clarify/support their findings • • Report writing and confirmation of ratings ••D raft report sent to site and factual accuracy checks carried out • • Final report published Each core service will be rated – inadequate, needs improvement, good or outstanding. Once each core service has been rated, the Hospital will be given an overall rating.

4 | NEW VICTORIA HOSPITAL

Confidentiality and consent The CQC always maintains the confidentiality of any information reviewed during an inspection. Inspectors will ensure the prior consent of patients is sought, wherever necessary

Tips for your inspection • Welcome the inspectors politely and professionally as you would any patient or visitor.

• Check their identification and notify Gill Welch, Registered Manager or Designated Deputy of their arrival.

• Remember, the inspectors are not there to trip you up or lead you into saying anything. Feel confident in answering their questions openly and honestly.

• If you don’t know something then don’t worry – just explain who you’d speak to or where you’d go for the information.

• Despite the inspection it’s business as usual at the Hospital – behave as you normally do.

• Put patients first. If you’re dealing with a patient then continue to do so and explain this to the inspectors. They understand that patients come first.

• Respect patient confidentiality and always seek consent with patients if inspectors want to observe your interaction with them.

• Please don’t share your personal login details to electronic records. All of the inspectors will use guest logins that will be arranged in advance of them arriving.

• Patients’ files may be viewed by inspectors, but shouldn’t be removed for any reason.

• If inspectors ask for hard copies of anything discussed during the inspection process, please pass this request along to the CQC support team who will be coordinating additional data requests.

If you want to find out more about the CQC and the inspection process, visit their website where you’ll find more information explaining the CQC process in a simple and engaging way: www.cqc.org.uk/content/what-we-do.

NEW VICTORIA HOSPITAL | 5

Self-evaluation Over the next few pages, you’ll find five checklists that match up with the five domains that the CQC will focus on during an inspection.

Use the lists to check your understanding of process and procedure. For the most part, it’ll be reassuring, showing you just how much you already understand and use every day.

Some of the areas may not be relevant to your role, so just mark these with ‘n/a’. If there are any areas you answer ‘no’ to – or you’re unsure about – then please contact your manager to make sure you’re up to date.

6 | NEW VICTORIA HOSPITAL

Y

Safe

13 Do I ensure that any equipment used with a patient considers their dignity, comfort and safety?

14 Do I understand medicines’ policies and procedures relevant to my role?

People are protected from abuse and avoidable harm Y

N

n/a

15 Do I know how to obtain advice on medicines?

1 Is safety a priority for me in my dayto-day role?

16 Do I know what procedures to follow for controlled drugs?

2 Do I know who to talk to if I have any concerns about safety within my team?

17 Do I know what to do if a patient has an adverse reaction to a medicine?

3 Do I know how to report an incident, near miss or allegation of abuse?

4 Do I know which types of incidents I should report?

5 Am I open and honest if things go wrong?

6 Does my team discuss incidents and complaints and how we can learn from them at team meetings?

18 Do I know how to ensure that patients receive blood products safely?

19 Do I always follow hand hygiene procedures before touching a patient or before entering and leaving a clinical area?

20 Do I ensure equipment is cleaned after use?

21 Do I know who to contact for advice regarding infection control?

7 Am I familiar with the policies and procedures relevant to my role?

22 Do I know how to handle different types of waste?

8 Do I always ensure the working environment is safe before seeing a patient?

23 Do I know how to handle clinical specimens

9 Do I always ensure that medical equipment I use is up to date with its maintenance before use?

10 Do I understand what a single use device is?

24 Do I always record information on patients’ records so that their needs can be met safely?

25 Do I know when I should seek written or verbal consent to share information?

11 Am I trained and competent in all equipment I use?

26 Do I know who I should contact if I have a concern about an adult or child?

12 Do I know where I can access resuscitation equipment?

27 Do I know how to respond to any signs or allegations of abuse?

28 Do I know who to raise day-to-day risks and concerns with?

N

n/a

Y 29 Do I know what to do if a patient’s health deteriorates; am I familiar with NEWS? 30 Would I know what to do in the event of an emergency or major incident?

31 Do I or someone within my team, receive and act on safety alerts (MHRA)?

32 Do I use clear communications when transferring patients?

N

n/a

Are you aware of the following policies and procedures and know where they’re stored?

• Duty of Candour Policy • Safeguarding Children Policy & Procedure •S afeguarding of Vulnerable Adults Policy •A naphylaxis Recognition and Management Policy •C PR Policy •M edicines Management Policy

33 Do I know about storing medical records safely in departments and am I aware of information governance?

•M anagement of Controlled Drugs Policy

34 Do I know who the New Victoria Hospital Caldicott Guardian is?

• Reporting and Management of Incidents and Adverse Outcomes Policy

35 Do I understand the difference between formal and informal consent?

•S afe & Effective Use of Blood and Blood Products Policy

36 Do I know when to obtain written consent?

•H ealth and Safety Policy

37 Do I know when I can take verbal or implied consent?

38 Do I know how to document and keep records of consent?

39 Do I know where to find the Raising Concerns (Whistleblowing) policy and contact details?

40 Am I aware of the Duty of Candour Policy?

41 Is my mandatory training up to date?

•F alls Prevention Policy

• I nformed Consent Policy • I nfection Prevention and Control Manual •W aste Management Policy •D econtamination of Equipment Policy • Management of Infusion Devices & Peripheral Cannulae Policy • I nformation Security Policy •B usiness Plan •B omb Threat Policy •R aising Concerns (Whistleblowing) Policy •T raining and Development Statement •M edical Records Policy

8 | NEW VICTORIA HOSPITAL

Y

N

n/a

Effective People’s care and treatment achieves good outcomes, promotes a good quality of life and is based on the best available evidence Y

N

n/a

1 Do I undertake all necessary risk assessments and care plans when I first see a patient?

2 Do I consider a patient’s holistic needs when I treat them?

3 Do I continue to monitor and review risk assessments and care plans throughout a patient’s treatment?

4 Do I ensure people approaching the end of life are identified and care is delivered according to their care plan?

5 Do I ensure multidisciplinary involvement in a patient’s care, where appropriate?

6 Do I ensure patients’ advocates are involved in discussions and decisions about patient care?

7 Do I participate in handover or multidisciplinary meetings?

8 Do I ensure patients’ nutrition and hydration needs are met?

9 Do I help patients to manage their pain in a timely way?

NEW VICTORIA HOSPITAL | 9

Y 10 Do I understand discrimination, equality and diversity?

11 Have I had an appraisal (IPR) in the past 12 months?

N

n/a

Are you aware of the following policies and procedures and know where they’re stored?

•N ursing Documentation Policy • Do Not Attempt Cardiopulmonary Resuscitation Policy

12 Do I maintain my knowledge by attending training days, educational forums or conferences and reading relevant material?

•N utrition screening of adult hospital patients using ‘Malnutrition Universal Screening Tool’ (MUST)

13 Do I attend regular, documented one-to-ones with my manager?

•P aediatric Pain Management Policy

•O rganisational Audit Programme

14 Do I understand the capability and performance management processes?

•D isciplinary & Dismissal Policy

15 If I am a mentor, have I had an update within the last year?

•P ractising Privileges Policy

16 Have all of my competencies been assessed and signed off?

17 Do I know the results of the Patient Satisfaction Survey?

18 Do I know which action plans are in place to improve patient satisfaction?

19 Do I understand and follow the correct recruitment procedures? (if relevant to role) 20 Do I understand what revalidation for doctors and nurses is and what this process entails?

21 Am I aware of which audits are undertaken in my department? Are audit results discussed?

10 | NEW VICTORIA HOSPITAL

•A cute Pain Management Policy

Y

N

n/a

Caring Employees involve and treat people with compassion, kindness, dignity and respect Y

N

n/a

Y

1 Do I always introduce myself to people?

6 Do I listen to patient feedback?

2 Do I always wear my name badge?

7 Do I know what patients are saying about my department / the Hospital?

3 Do I always give the Hospital’s contact details to patients?

4 Do I give patients written information, when appropriate?

5 Do I always involve patients, their families and carers in decisions about their care?

8 Do I know what improvements are being made within my team following patient feedback?

9 Do I know how to obtain an advocate, if a patient needs one?

N

n/a

Y 10 Do I always consider a patient’s personal, cultural and religious needs?

11 Do I know how to access translation services?

12 Do I feel confident having conversations with patients and families?

13 Do I always respect patient confidentiality, verbally and in written records?

14 Am I always considerate and respectful in my interactions with patients and their families?

15 Do I always respect the privacy and dignity of patients?

16 Do I help patients to manage their pain in a timely way?

17 Do I help patients with their physical needs when required?

18 Do I respond in a timely way to call bells?

19 Am I confident supporting people to cope emotionally with their care and treatment?

20 Do I promote self-care, selfmanagement and independence?

21 Do I know how to access multi-faith support for patients?

22 Do I know what to do when a patient dies?

23 Am I aware of support services available to me if I’m stressed or upset?

12 | NEW VICTORIA HOSPITAL

N

n/a

Y

N

n/a

Y

N

n/a

24 Do I report any episodes of disrespectful, discriminatory or abusive behaviour towards patients or staff?

25 Do I ensure that when patients are transferred or discharged they are given sufficient information?

26 Do I ensure that when patients are transferred or discharged their families and carers are involved?

Are you aware of the following policies and procedures and know where they’re stored?

•P atient Information Policy • Bullying at Work Policy • I nterpreters List • End of Life Care / Management after Death Policy

Responsive Facilities are organised so they meet people’s needs Y

N

n/a

1 Do I know what the protected groups are under the Equality Act 2010?

2 Am I aware that different people have different needs when accessing the Hospital?

3 Do I take action to address barriers to ensure all of these groups are able to access the service?

4 Do I know how to assess the mental capacity of patients?

5 Do I make appropriate adjustments for patients who lack capacity or have a learning disability?

6 If a patient lacks capacity, do I know how to ensure their best interests are assessed and recorded?

7 If I have to cancel an appointment, do I always give an explanation to the patient?

8 If appointments are cancelled, do I rearrange as soon as possible?

9 Do I prioritise patients according to their need?

NEW VICTORIA HOSPITAL | 13

Y

N

n/a

10 When patients are discharged, do I ensure all pertinent information is shared with the relevant agencies?

20 Do I know of any changes that have been made as a result of a complaint?

11 Do I share any compliments I receive with my manager and the rest of my team?

21 Do I know what DNACPR stands for?

12 Do I encourage patients to give feedback about the Hospital using Patient Satisfaction Questionnaires?

13 Do I know what the comments/ feedback given by patients and families are saying about my department?

14 Do I use patient feedback to improve the service I provide?

15 Do I know what the Friends and Family Test score is for the Hospital?

16 Do I know how to resolve a problem or complaint if it is raised with me directly by a patient or a family member?

17 Do I know how to advise a patient or family member of how they can make a complaint should they wish to do so?

18 Do I know how to access the Complaints Policy?

19 Do I discuss complaints and concerns at team meetings in an open and honest way?

14 | NEW VICTORIA HOSPITAL

Y

N

n/a

Y

N

n/a

22 Do I know what the process for making this decision is and where it’s documented?

23 Do I know what an Advanced Directive is?

Are you aware of the following policies and procedures and know where they’re stored?

• Complaints Policy •D o Not Attempt Cardiopulmonary Resuscitation Policy

Well-led The leadership, management and governance of New Victoria Hospital assures the delivery of high quality person-centred care, supports learning and innovation and promotes an open and fair culture Y

N

n/a

1 Do I know what New Victoria Hospital’s value words are?

2 Do I know what my role is in helping to deliver the Hospital’s vision?

3 Did I attend an induction when I started employment?

4 Did I receive a departmental induction when I began?

5 Do I know how temporary employees are inducted into my department?

6 Have I agreed my personal objectives with my manager?

7 Am I familiar with my Job Description 8 Do I know what my responsibilities are?

9 Do I understand why the Hospital has an appraisal process?

10 Do I attend regular team meetings?

NEW VICTORIA HOSPITAL | 15

Y 11 Do I receive and read team meeting minutes?

12 Do I know who to talk to if I have a suggestion for improving our service?

13 Do I know the Hospital’s Integrated Governance and Risk structure?

14 Do I know what the Integrated Governance and Risk team do?

15 Do I know how to raise any issues causing concern? (Whistleblowing) 16 Do I know what the current risks are for my department?

17 Do I understand the process for reporting sickness absence?

18 Am I aware of the occupational health service and how to access it?

19 Do I know who my Executive Management Team are?

20 Do I know what the purpose of a Medical Advisory Committee is?

16 | NEW VICTORIA HOSPITAL

N

n/a

Are you aware of the following policies and procedures and know where they’re stored?

•M anagement of Sickness Policy • Occupational Health Referral Policy • Hospital Strategy • Appraisal Policy • Raising Concerns (Whistleblowing) Policy

Y

N

n/a

Helpful resources Throughout the self-evaluation questions, there are several references to healthcare guidance and other acronyms. To help you to locate the information you need to feel confident in answering all of the questions, we’ve drawn together a list of resources here.

Find out more about the CQC and what they do: www.cqc.org.uk/content/what-we-do Find our policy library here: G Drive: Documents/Policies Familiarise yourself with the policies within: G Drive/Documents/Staff Information/Employee Information Folder Find our latest training details on G Drive: Documents/Staff Information/Mandatory Training

Key contacts If there’s a question you and your manager can’t answer, or you’d like some help or advice on anything to do with your CQC inspection, you can contact the CQC support team using the details below: Gill Welch Director of Clinical Services gwelch@newvictoria.co.uk Ruth Oliver Director of Integrated Governance and Risk roliver@newvictoria.co.uk Dorinda Lester Deputy Integrated Governance and Risk Manager dlester@newvictoria.co.uk Clement Olusoji Integrated Governance and Risk Assistant colusoji@newvictoria.co.uk

NEW VICTORIA HOSPITAL | 17

Our Values Compassionate

Evolving

We are totally driven by the quality of patient care and will always treat our patients and their families with dignity and understanding.

Our environment is one of constant change and our independence enables us to adapt to new opportunities presented, continually improving and extending our services.

We are considerate and kind in how we work with others and understand the benefits of mutual respect and collaboration.

We are ambitious and address new challenges together as a team, helping and inspiring each other through strong leadership, support and personal development.

Exceptional Our aim is for perfection. We strive to do our best and carry out our duties above and beyond expectations.

We recognise that only by being honest with ourselves and constantly learning from our mistakes can we aspire to provide an ever improving service.

Ethical We are committed to ensuring our patients’ safety, be it clinical, physical or emotional.

We are motivated by integrity and trust in each other, encouraging openness and honesty.

We take pride in being a charity, able to provide pro bono work and give medical support.

18 | NEW VICTORIA HOSPITAL

Notes

NEW VICTORIA HOSPITAL | 19

For further information on the extensive range of treatments and services we offer at New Victoria Hospital, please visit our website.

www.newvictoria.co.uk

If you would like further information please contact us on: Telephone: +44 (0) 20 8949 9000 Fax: +44 (0) 20 8949 9098 Email: enquiries@newvictoria.co.uk

New Victoria Hospital 184 Coombe Lane West Kingston upon Thames Surrey KT2 7EG Registered Charity No. 1141784

New Victoria Hospital is accredited for the quality of its service with CHKS Healthcare Accreditation and Quality Unit and is certified ISO 9001:2015.

January 2022