Getting ready for our Care Quality Commission visit guide

Getting ready for our Care Quality Commission (CQC) visit

Welcome Welcome to our Getting ready for our Care Quality Commission (CQC) visit guide, which we have produced to help you access all the information you need on preparing, finding out answers in response to questions, and welcoming the CQC. CQC colleagues will be inspecting the whole organisation against the well-led domain through the second half of August. Under the new CQC inspection format, they will also be undertaking a series of ‘core service’ visits before the end of July. We would expect and should be prepared for ED, theatres, ITU, paediatrics and end of life care to be assessed as a minimum. There could also be core service visits to any part of PAHT. We are here to support you - please refer to this guide and the range of resources we have made available to help you prepare for our CQC visit.

Best wishes Lance McCarthy Chief executive

Reminder: PAHT and our plans for the future PAHT2030

What lies ahead is a journey of transformation and improvement through the PAHT2030 strategy, which will lead us successfully into the future, enabling us to deliver modern, integrated and outstanding care that keeps our growing and ageing population healthier.

Our vision Modern We will always use up to date treatments, technology and facilities.

Integrated We will work as one to provide joined up healthcare that puts our patients first.

Outstanding We will deliver healthcare that our patients deserve and makes us proud.

Preparing

We are on the verge of a defining moment in our history.

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Our priorities 1. Transforming our care 2. Our culture 3. Digital health 4. Corporate transformation 5. Our new hospital

Never before has the reality of a new hospital been so close, having submitted our pre-consultation business case in September 2019, coinciding with the launch of the government’s Health Infrastructure Plan (HIP) Programme. In October 2019, the Department of Health announced that PAHT would be one of six trusts in the first wave of the HIP programme, giving the go ahead for us to develop our outline business case, with a new hospital build on a greenfield site as the preferred way forward. With the development of a national new hospital programme, we are one of the frontrunner eight organisations working closely with the national team to deliver a new hospital for Harlow and surrounding areas.

It will be a world-class hospital for the future, providing first-rate care for our patients and the best place to work for our people.

You can read more on our microsite, www.pah.nhs.uk/newhospital.

Preparing

New hospital

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Objectives Patients We will continue to improve the quality of care and experiences that we provide our patients, integrating care with our partners and improving our CQC rating.

People We will support our people to deliver high quality care within a compassionate and inclusive culture that improves engagement, recruitment and retention and results in further improvements in our staff survey results.

Performance We will meet and achieve our performance targets, covering national and local operational, quality and workforce indicators.

Places We will maintain the safety of and improve the quality and look of our places and we will work with our partners to develop an outline business case for a new hospital, aligned with the further development of our local integrated care partnership.

Pounds We will manage our pounds effectively and modernise our corporate services to achieve our agreed financial control for 2020/2021 and our local system control total.

Values

Respectful Treating others as we would wish to be treated.

Caring Always putting patients first.

Responsible Doing what we say we are going to do.

Committed Striving to be the best.

We will soon be introducing our new values: Patient at heart Always holding the patient and their wellbeing at the centre of our thoughts and efforts.

Everyday excellence Sharing and celebrating our successes, being honest when we get it wrong, giving us the ability to learn from both.

Creative collaboration Knowing strength comes from diversity, we combine our experiences, skills and talents, working together to find new and better ways to care.

Preparing

Our current organisational values are:

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Getting ready Practise safe staffing

y Be able to talk about safe staffing levels, including the skill mix required and also what we are doing to recruit and retain staff. y Be able to risk assess, manage and escalate issues when staffing is stretched or patients become acutely unwell. y Be able to induct temporary staff and document that this has been done.

Manage medicines safely

y Medication rooms, cupboards, trolleys, fridges and IV fluids should be locked away securely. y Medicines stationery, scripts and prescription charts should be stored securely. y Medicine administration issues/prescription errors/omissions (where appropriate) should be reported through Datix. y Ensure that bottles of liquid medications are dated, signed on opening and do not exceed the expiry date.

y High performing organisations have high levels of reporting. Can you demonstrate how to put an incident onto Datix, and explain what happens once an incident has been submitted i.e. can you give an example of an incident that has recently been reported and the feedback you received? y Know how to escalate a concern. y Review your teams regularly. y What has improved in your area as a consequence of learning from an incident? y Ensure you know how to raise a risk. y Ensure you know what happens to risks once they are raised. y Know what the top three risks are in your area and how they are being y managed. y Be familiar with the risk register for your service.

Keep documents up-to-date and secure

y Make sure assessments, observation charts and medical records are completed when required. y Charts must be stored securely. y Computer screens should not be left displaying patient information. y Computer screens should be locked when not in use. y Every clinical department is responsible for regularly reviewing the quality of the recordkeeping against best practice standards and addressing any gaps. This will include the completion of mental capacity assessments, DNACPR forms and Deprivation of Liberty safeguarding applications.

Preparing

Report all incidents properly

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Keep learning, keep growing

y Tell your healthcare group leaders and the executive directors your department’s successes to ensure they are aware and can help to publicise them outside your team. y Understand when things go wrong and use this as a platform to improve. y Be open and transparent, value and empower your teams.

y We provide an opportunity for our people to express concerns or issues within a psychologically safe environment. y Our Freedom to Speak Up Guardian roles have been created to support all of our people in raising concerns in a protected, confidential and safe environment. y Our Freedom to Speak Up Guardians are Lisa Thurley and Lorraine Nixon. We have also recruited five additional Clinical Freedom to Speak up Guardians as a direct result of your feedback on the need to improve the ability to speak up and raise concerns. All five of our new Guardians are practising clinicians in the trust and across a range of professions and grades. They will be joining Lorraine and Lisa as the current Guardians to create a team of seven. Once the new Guardians have been trained and registered with the National Guardians Office they will be able to take up post officially and support you if you have concerns that you feel you cannot raise through your line management or feel that they have not been addressed. The five new Guardians will be (in alphabetical order): y Natalie Gray y Lindsay Hanmore y Miriam Mbayiwa y Jeff Phillips y Jane Snook y You can email them at: freedomtospeakup@nhs.net. y You can always contact the people team for advice and each area has an associate director you can ask too. y Dedicated groups as well as one-one sessions can help. y The raising concerns in the workplace (whistleblowing policy) also sets out how you can raise concerns (available in the policies section of Alex). y Encourage your team to reflect, analyse and develop.

Ensure handover is safe and effective

y Your approach to handover needs to be formalised e.g. A-G, Essential Care, your documentation should follow the same process. y You should use recognised models (e.g. SBAR). y Handover at the bedside, safety huddle, NerveCentre handover tool, and your approach to discussing patient information in a confidential way will be reviewed.

Preparing

Give your team an opportunity to express concerns and develop

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What are we proud of?

y Our amazing people have been recognised with a variety of accolades in the last year – congratulations to all. y Dr Shico Visuvanathan, consultant microbiologist and director of infection prevention and control, was awarded an MBE in the New Year’s Honours list for services to microbiology, infection prevention and control, particularly during the COVID-19 response. y Dedicated volunteer Joanne Busson, who has supported patients to have precious video calls with their loved ones during the COVID-19 pandemic, received a British Empire Medal in the New Year’s Honours list. y Two nurses were recognised for the outstanding patient care they give and the support they provide for colleagues by Ruth May, chief nursing officer for England. Francina Mushaninga, matron, medical healthcare group, and Victoria Andrews, lead nurse for practice development, were each awarded a Chief Nursing Officer’s Silver Award. y We received an international accolade in recognition of our work to improve the outcomes for patients with sepsis with the introduction of the procalcitonin test for the early identification of sepsis in the emergency department (ED), for which we were awarded a Global Achievement Award. The awards are run by a partnership of leading professional organisations. y The United Kingdom Accreditation Service (UKAS) awarded accreditation to the PAHT pathology team across all services.

UKAS assess against internationally agreed standards; accredited organisations are endorsed as being competent and trusted to operate safely and accurately. y The Patient Panel were honoured to receive the Queen’s Award for Voluntary Service in June last year. They were awarded the accolade in recognition of their dedication to representing the voice of patients at PAHT. y Thank you to everyone who supported with the COVID-19 vaccination programme at our hospital vaccination hub in January and February, with second booster vaccinations taking place in March and April. y Last year heralded a big change to the usual format of our annual Event in a tent for all PAHT people. The original event was reworked and delivered as an entirely virtual Events not in tent. A wide mix of webinars, videos and presentations from a range of invited speakers were built into a three day schedule in September. The webinars were all recorded and added to a RELOADED YouTube playlist so that everyone could access at a time to suit them/their shift and viewed on PCs and mobile devices on or offsite. Additionally, externally sourced content was used to create an Events not in a tent YouTube playlist that could be viewed at any time. The programme also included our annual Amazing People Awards and Long Service Awards. y Our Long Service Awards were announced at an event, open to all,

Preparing

We are proud of our amazing #PAHTPeople, who show extraordinary commitment to patient care or supporting the teams who deliver patient care. As a reminder of some of our achievements across the year:

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y

y

y

y

y

y

y

Preparing

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that gave people the opportunity to be recognised and celebrated by the executive team and colleagues. Certificates and badges were delivered to line managers who personally delivered them to the people in their team. In a temporary move away from award categories, our Amazing People Award was awarded to everyone and, as a special recognition of the hard work and commitment of all, a gift of an extra day of leave in 2021 to celebrate each person’s birthday, or other special day, was announced.

In December we hosted Winter webinars and festive fun, a great range of virtual events and health and wellbeing webinars to support our PAHT people ahead of the festive period. The day consisted of sessions hosted by keynote speakers, pantomime teasers and a festive quiz.

A number of colleagues across PAHT have shared their perspectives with our executive directors as part of an innovative reverse mentoring programme. The scheme is an opportunity for those in non-managerial and junior roles to regularly meet with an executive director to discuss their experiences. The aim of reverse mentoring is for a more junior colleague to mentor a senior colleague, with both gaining a different insight and a new perspective on the organisation.

Our dedicated research, development and innovation team secured a place in the top 20 for recruiting patients onto the GenoMICC research study, with almost 190 trusts taking part - a fantastic achievement. The study is an observational study that aims to identify the specific genes that cause some people to be susceptible to specific infections and consequences of severe injury. The study compares DNA and cells from carefully selected patients and healthy people.

The research, development and innovation team have supported 11 research trials and recruited 1171 participants in the fight against COVID-19. The studies were both observational to collect data on COVID-19 positive patients in order to assess any trends, or a complex interventional trial that compared many different treatments.

The gastroenterology team maintained a prestigious professional accreditation for their endoscopy services following a rigorous evaluation. The department was accredited by the Joint Advisory Group in May 2020 for its high quality gastroenterology services, having held the accolade for the last five years.

In response to the COVID-19 pandemic, we started to offer telemedicine appointments for our outpatients. We were able to continue to provide patient appointments virtually, without the need for patients to visit or travel to the hospital. Since April 2020, we have performed approximately 6,348 outpatient consultations, excluding maternity and community services.

The last year has seen our emergency department (ED) team respond to COVID-19 by putting in place many changes in the department and also the many changes needed to the ways that care is now delivered.

This has meant some very busy and tough days for the whole team, which have also been reflected in the high numbers and high demand across the hospital as high numbers of patients were admitted.

This year, the extensive estates capital programme includes almost £25m worth of investment to improve our hospital and the estate to

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y y y y y y y

ensure that we maintain a safe and comfortable environment for our patients and the teams caring for them.

In January 2021, we opened the Adult Assessment Unit (AAU), a new facility to support the health and wellbeing of patients.

One of our goals is to be a modern organisation. We started this transformation by developing a brand new working environment – Kao Park.

The modern new fracture clinic facility has greatly improved the experience for our patients and our people.

We have continued to manage our pounds effectively to achieve our financial targets and control total.

The trauma and orthopaedics department has been recognised for its training excellence by the East of England Trauma and Orthopaedic Training Programme, Health Education England.

PAHT is one of the best performers (as part of the Integrated Care System) in elective recovery in the east of England.

Mr Ashraf Patel, associate specialist in breast surgery, was awarded an MBE for services to funding and research for breast cancer in the Queen’s Birthday Honours List.

Preparing

Please take a moment to think about what you are proud of and would like to share with our CQC colleagues.

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A CQC inspection - what you need to know Who are the CQC and why do they want to inspect us?

The CQC is a government agency whose responsibility it is to regulate all health and social care services in the UK. The CQC checks that any organisation providing health or social care meet the government standards and provides services in a safe, effective, and compassionate way.

As we are an acute healthcare facility, the CQC will inspect us to make sure we are compliant to the fundamental standards of care; the standards below which care must never fall.

What will happen once the CQC are on site?

The purpose of the CQC inspection is to make sure that as a hospital we comply with the fundamental standards of care. To do this, the CQC will observe what we do, how we do it, and interview our people and patients.

They may also spend time observing and recording how we communicate with patients and each other.

During the visit the inspectors will sit and watch various elements of practice and processes. They will talk to our people in groups and individually. They will speak to consultants, patients and their relatives.

They will look at a wide range of hospital documents and patient records, including staff personal files. They will review policies, audits, patient information leaflets, individual training records and enabling excellence paperwork.

At the end of the inspection visit, the executive directors will receive some verbal feedback. We will not know the final outcome of the inspection until we receive the formal report. The content of this may be different to the verbal feedback we receive, as the CQC have to cross reference the information we will have sent to them with what they observed during their inspection. We can review the report for factual accuracy and comment on it with corrections before publication. The final report will be published by the CQC about three months after their visit.

What does a CQC rating mean?

y CQC ratings give patients and their relatives confidence in the care and treatment they will receive in our hospitals. CQC ratings raise patients’ expectations, and ours, of the care we give and how we treat each other. y Positive CQC ratings support our recruitment and retention and help us ensure that our values remain at the centre of everything we do. y Positive CQC ratings reward us as individuals and teams for our daily hard work and commitment to provide safe and high quality care.

Preparing

The result of the inspection

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Our Care Quality Commission (CQC) inspection - the details CQC inspection key questions

When our CQC colleagues inspect us, there are five questions they will ask: y y y y y

Is it safe?

Is it effective?

Is it caring?

Is it responsive to people’s needs?

Is it well-led?

The CQC state that patients have the right to expect these fundamental standards in hospital.

Please note that the key questions are also referred to as key lines of enquiry (KLOEs).

Are services safe?

Are services effective?

Are services caring?

Are services responsive to people’s needs?

Are services well-led?

People are protected from abuse and avoidable harm. People are protected from physical, sexual, mental, or psychological, financial, institutional or discriminatory abuse and neglect.

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

Staff involve and treat people with compassion, kindness, dignity and respect.

People get the treatment and care they need at the right time, without excessive delay and services are organised so that they meet people’s needs.

Leadership, management and governance of the organisation assure the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture.

Preparing

The key questions (domains) explained

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Finding out If you are not sure of the answer to any question a CQC colleague asks you, please do not be concerned. Explain who you would normally contact or go to for the information.

You can signpost our CQC colleagues to your line manager or other member of the leadership team as appropriate, and can show the CQC where you would find the information on Alex.

First impressions count Recognising a CQC colleague

Most CQC colleagues will wear a photographic ID badge. Once we know they are here for the planned visit, we will give them a red lanyard – stating ‘visitor’. They also need to be carrying a warrant letter that gives them the authority to enter areas and inspect. If you are in any doubt about a visitor’s identity, please ask politely to see their letter of authority and their ID badge.

What to do when the CQC arrive

If the CQC colleagues arrive unannounced out-of-hours, the ward manager or senior nurse of the area should contact the clinical site manager. This should happen in and out of hours.

Create the right first impression

y Be welcoming, professional, confident and polite. If you see a CQC colleague (who will be wearing a red lanyard), go up to them confidently and take control of the conversation – this way you can tell them all the good things about your unit. They need to adhere to infection control policies. y Let any CQC colleague know who is in charge of the area, and introduce them to each other. y Help them with access to all staff, patients and volunteers they might want to speak to. y Answer any questions you are asked honestly and openly. y Treat patients with dignity and respect. y Remember we are a functioning hospital and it is ‘business as usual’ even though the CQC are on site. y If you are caring for a patient when the CQC inspector arrives, continue to care for your patient and politely explain to the inspector that you will

Finding out

When the CQC inspectors arrive at reception, the first thing to do is to welcome the inspectors – be as friendly, polite, and professional as you would normally be. Whilst one receptionist is attending to the CQC inspectors, another must follow the CQC flow chart and start the communication chain immediately.

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be with them as soon as you have finished caring for them – they understand that patients always come first. y Patient dignity, respect and confidentiality is our priority, and you should check with your patient that they are comfortable and happy for the CQC inspector to speak to them before allowing them in to see a patient. y Keep a clean, clutter-free and calm environment. y Ensure all the notices and posters in the clinical area are laminated and are attached straight. Remove any out of date information.

Maintain a clean hospital

The standard you walk past is the standard you accept. y All surfaces are to be kept clear and clean. y Patient areas must be cleaned and dust-free to the highest standard, including high level dusting (tops of curtain rails, cupboards etc.). y Remove all clutter and unnecessary items from corridors and patient areas.

Know the story of your ward/department – why have you made the improvements you have made? y What improvements are you most proud of? y Have you made changes because of complaints or incidents? y Have you made changes because of knowledge of good practice elsewhere? y Have you made changes as a result of audits undertaken and what are they? y What are you and your team most proud of? Remember this is your time to shine. y When being interviewed by a CQC inspector, try to use as many examples of outstanding care that you or your team have provided as often as you can; especially if these include actions taken to improve practice or service delivery as a result of a patient complaint or adverse event.

Respect confidentiality at all times

y Always check with patients or service users if inspectors want to observe you at work. y Challenge an inspector if you see that they are not wearing identification or are not complying with infection control procedures. y Inspectors need to wash their hands before and after every patient contact and if they enter a patient’s bed space they need to wash or gel their hands before and after. y Inspectors in clinical areas should be bare below the elbows. y CQC inspectors will always maintain the confidentiality of any information provided to them or reviewed, and will always ensure prior consent of patients is obtained before speaking to them where necessary. y CQC inspectors will be provided with a guest log-in if it is required, as in some instances they will want to review electronic information – if a CQC inspector asks for your log-in details or asks you to log them

Welcoming

Speak confidently about your work

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in to the hospital system, politely decline – this would be a breach of data security. y If an inspector asks to review a patient record, they can be given the patient notes, but they must not be allowed to remove them from the department for any reason – to do so would be a breach of patient confidentiality and a security breach.

Providing information

y If during your interview the CQC inspector asks for copies of information, please let your head of department know as any information requests will be provided from a nominated person. y If during the inspection, or as part of your group/individual interview with the CQC inspectors you are concerned that you may have provided the inspector with the wrong information or wish to clarify any information given, please speak to your head of department or a member of the hospital senior management team who can arrange for your clarification to be made.

If the CQC identify a concern

During the inspection of your area, if the CQC point out something that is not to the required standard, it is important that you discuss this with your line manager as soon as possible. Your line manager or you should also call the contact centre. This will ensure we take urgent and appropriate action to address the issue. This will show the inspectors that we are responsive.

The CQC colleagues have the right of access to any area within the trust and can observe the delivery of care in any setting. You will need to ask your patients for their permission if they consent to having a CQC colleague observing elements of their care. In a theatre setting, they will need to change into full scrubs and follow infection control precautions.

At all times the care, confidentiality and safety of the patient is paramount.

Length of each visit

Each visit could be between 30 minutes and two to three hours. It will depend on the purpose of the visit, where they visit, and how many people they wish to speak to.

Being observed while you are with a patient

CQC colleagues are trained to introduce themselves and should ask if it is ok to observe a patient. If they do not ask, you should explain to your patient who they are and then ask permission from your patient.

Welcoming

Access to theatres

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Inspection during busy periods

The CQC colleagues will try and keep disruption to a minimum, and aim to not impact the delivery of patient care. You will be asked to speak to them, but it will be possible to seeI whether this can be scheduled around your availability. You will need to make yourself available, within reason.

Public listening event during the inspection

The CQC will arrange to hear the views of our people and our patients.

We are yet to be advised how this will be undertaken. Previously the CQC have organised listening events or stayed in public areas of the hospital. The aim of this is for our patients and staff to talk about their experiences. Patients’ feedback will help the CQC colleagues determine which areas to look at during the inspection.

How we will support you after our CQC visit We are committed to supporting you at every stage of our CQC inspection. This will include through our CQC inspection control centre, which will be responsible for sharing any information requested by the CQC during their visit and to provide support and the opportunity for a debrief immediately after an inspection.

For advice, please contact:

Lisa Flack, compliance and clinical effectiveness manager on x 8381 or lisa.flack1@nhs.net.

Please also speak to your line manager if you require further support.

Remember y y y y y y y y

Be proud of your work and department.

Be as friendly and polite as always.

Behave as you usually do.

Patients come first.

Check CQC colleagues’ IDs. Answer all questions openly and honestly.

Say what you are proud of or have done well.

If CQC colleagues raise an issue, take full details, check and escalate quickly, as appropriate.

Welcoming

Sheila O’Sullivan, associate director for quality governance on x 8963 or sheila.osullivan@nhs.net.

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Our trust board Our executive team

Lance McCarthy Chief executive

Sharon McNally Deputy chief executive and director of nursing, midwifery and allied health professionals

Stephanie Lawton Chief operating officer

Dr Fay Gilder Medical director

Saba Sadiq Finance director

Michael Meredith Director of strategy and estates

Jim Mcleish Director of quality improvement

Ogechi Emeadi Director of people, organisational development and communications

Phil Holland Chief information officer

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Our trust board Our non-executive directors

Helen Glenister Acting chair (nonexecutive director)

John Hogan Non-executive director

Pam Court Non-executive director

George Wood Non-executive director

Anne Wafula-Strike MBE Associate nonexecutive director

Helen Howe Non-executive director

John Keddie Associate nonexecutive director

Darshana Bawa NExT non-executive director

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The Princess Alexandra Hospital NHS Trust, Hamstel Road, Harlow, Essex, CM20 1QX 01279 44 44 55

NHSHarlow @NHSHarlow @PrincessAlexandraNHS The Princess Alexandra Hospital NHS Trust 18