Our Mission Statement and Values
St Luke’s Hospice is committed to improving the quality of life for those with advanced progressive illnesses no longer responsive to cure, who either have such complex needs that they require a specialist palliative care service, or have an expected prognosis of less than one year. It provides support to patients, and extends support to those people important to them whilst maintaining their dignity and respect. In addition, the hospice provides expertise, education and support to the professional health and social care community.
Our mission:
• Reach more people
• Constantly improve what we do
• Extend our impact through collaboration, innovation and education
• Be an accountable and sustainable organisation
Our values:
• Caring – Care for all those who deliver and need our services
• Respect – Demonstrate respect and be open minded, inclusive and approachable
• Excellence – Create an environment of continually achieving our goals
• Inclusivity – Strive to reach all sections of our community in all areas of our work
• Empowerment – Empower our community to live a better life
Preparing for the CQC
This handbook will:
Help you to understand the CQC’s new approach to assessment
Explain the five key questions areas and what are the CQCs Quality Statements
Suggest how best to prepare
Provide you with contacts for further support and where to get additional information
What will happen during and inspection?
The inspection-our approach
The CQC wants to see how our services run on a day to day basis. We welcome the CQC’s inspection as it is an opportunity for all of us across the hospice to:
• Showcase our work and the improvements we have made
• Demonstrate that we know where our improvement areas are, what we are doing about them, and how we have reduced any risks
• Show how we gain feedback about the care we provide from patients, carers, families and staff and how we learn and share lessons to make changes to improve patient care.
How you can help
• Be proud – of the excellent work you do. Think about the positive work you are doing and be prepared to give the inspectors examples or evidence to demonstrate this and how it is making a difference
• Be prompt and responsive – if an issue is raised, correct it as soon as you can, or where this isn’t possible, log it and report it your line manager. Try to provide any additional information requested as quickly as you can
• Make sure your voice is heard – identify any issues that you think may affect patient care and share them with your line manager or team.
Guidance for staff
CQCs approach to assessments
Since our last inspection, we have made significant progress to drive forward improvements. We are in regular contact with the CQC inspectors who are informed of the progress we are making. Regular updates and reports around the quality of our services are also considered at board level.
While inspections will remain a vital part of CQC assessments, the new regulatory model indicates that the CQC will conduct an ongoing assessment of quality and risk rather than one point in time. This means that inspections will not be the sole method of assessing our services. The CQC will collect evidence from six categories, including people’s experiences with health and care services, feedback from staff and leaders, input from partners, observations, processes, and outcomes, to make informed decisions about your service.
The inspection may be announced or unannounced and so they can come at any time. The inspectors will arrive in a small team or it maybe just one inspector. They will visit all areas, but we don’t know in advance the order of preference.
They will review core services in relation to the Five Key Questions.
As they inspect services they will consider:
• Is it safe?
• Is it effective?
• Is it responsive?
• Is it caring?
• Is it well-led?
Underneath each question area is a set of quality statements that providers, commissioners and system leaders should live up to. Expressed as ‘we statements’, they show what is needed to deliver high-quality, person-centred care.
The quality statements show how services and providers need to work together to plan and deliver high quality care and replace the previous system of Key Lines of Enquiry (KLOEs).
When the CQC visits
They will want to talk to patients, carers and staff at all levels about their experiences of care provided, observe everyday activities and the environment. They may also want to review some patient notes to ensure they are accurate and up to date, check systems and processes operate as per policy and follow the patient pathway through services.
What to do when the CQC arrives in your area:
• Welcome the inspectors, introduce yourself and ask to see their identification badges. The CQC inspectors are aware they may be required to show their visitors badges. Do not allow anyone access without the proper authorisation/identification (If in doubt, contact the CQC on 03000 616161)
• Sign them in and ensure the most senior member of your team is called to meet and accompany the inspecting team, to introduce them to the service area and facilitate their visit Our Mission Statement and Values
• Inform your manager
• Ensure your team members are aware that the inspecting team is visiting your area
Things to remember when meeting the inspecting team
Make sure your patients and their carers/families come first – this will be expected by the CQC team.
• Be friendly, polite and helpful
• Be honest and explain how you feel about the care you deliver to your patients and the organisation. This is an opportunity for you to demonstrate how you and your team meet patients’ individual care needs in partnership with them and their families/carers
• Take the opportunity to talk about all the positive work you are proud of
• If the inspector asks for additional information, speak to your manager if any local information is requested, so they can keep a log of all items provided to the CQC
• Contact the Quality Team if an inspector wishes to remove any files or documents, so they can coordinate what they are given
• Be mindful to keep conversations away from public areas to avoid disruption or breaching confidentiality. Encourage your patients and their carers to take part in the conversation where appropriate/possible and check with them first if the inspector wants to observe interactions
• Don’t worry if you don’t understand a question or don’t know the answer, ask for clarification or explain who you would ask for the information
• Don’t share login details with an inspector or log them into systems, and make sure you lock your screen if you get called away
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How can I prepare?
We would like you to focus on three areas moving forwards in your preparations
Your environment
Make sure that patient areas are clean and safe, including infection control, any checklists are completed, no faulty equipment, cupboards are locked, out of date medicine thrown away, no patient identifiable information left out, patients own drugs (PODS) stored safely and issues are escalated where needed.
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What you’re proud of
What are you most proud of/ what would you most like to see in a report about your area or service? That will only be written about if you tell somebody.
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Quality improvement
How can you demonstrate we are always improving, evaluating and learning to make things better? How are we seeking and acting on user feedback?
Another key aspect of a CQC inspection is demonstrating we have high standards – that means making sure you take ownership for our standards of care. What are you walking past? What are you accepting? It is also about having clinical supervision; research shows that people receiving regular supervision feel more attached to an organisation and understand what they’re role is. Make sure you are having it and that you record it, so that inspectors see your commitment to providing high quality care.
Finally, CQC inspections or inspectors aren’t something to fear. In fact, they are good for us because they tell us what we’re good at, what could be developed and what we could do better. See it as an opportunity, like a complaint, because it is a snapshot of how patients experience us. Let’s make sure we use this as our time to shine and be proud of all the great work we are doing.
What is the CQCs focus?
The Care Quality Commission (CQC)’s focus is good patient care. So we must ask – ‘is my service Safe, Effective, Caring, Responsive and Well-led?’. The guidance that follows will provide you with practical prompts to consider within each of these key areas:
This checklist is a helpful reminder of our ‘best practice’ guidelines to help us deliver outstanding care and services
General
Is my name badge and photo ID badge up to date and does it have my correct job role?
Are noticeboards up to date and information leaflet stands stocked in our area?
Is confidential information stored safely and securely within my team?
Is my working area tidy and organised and is there any broken furniture or equipment that needs to be disposed of?
Is my appraisal, personal development plan, statutory and mandatory training all up-to-date?
Am I clear where to find hospice policies, and have I read those that are relevant to my role?
Do I know how to raise a safeguarding alert or concern and who is the safeguarding lead is?
Do I know how lessons are shared and learnt within my team following patient feedback or incidents?
Do I know where to go if I have an idea to improve services within my team or across the hospice
Can I give examples of the improvements made in my department and the difference they have made?
Do I know where to find the department’s business continuity/ major incident plans?
Do I know where to find the fire safety and evacuation plans within my work area?
Do I know how to report an incident?
Do I know what the risk areas are for my area?
Do I know how to access the Freedom to Speak Up Guardian (FTSU)?
Do I know who the infection control lead is?
Do I know who the Information Governance Lead is?
What will they ask? Five key questions
Safe
• Is patient safety my main concern?
• Can I demonstrate some learning and improvement from an incident?
• Do I know what my teams’ risks are?
• Are the patients kept safe in my team/on my ward because we maintain the correct staffing levels, do not rely heavily on bank staff and have effective handovers?
• Do I use SBAR as part of handover of care?
• Where bank staff are used, are they properly inducted and trained?
• Have I been trained in safeguarding specific to the area I work in? Do I know how to report an incident, near miss or allegation of abuse/ safeguarding issue? Do I act promptly and are concerns addressed in a timely way?
• Are medical devices I use well maintained before use? Are they decontaminated before and after use? Am I trained and competent to use them?
• Do I know how to obtain advice on medicines?
• Do I know the procedures for controlled drugs? And safe handling/ securing of drugs?
• Do I always check a patient’s allergy status and note this?
• Do I know what do if a patient has an adverse reaction or if their health deteriorates? Do I know what to do in an emergency?
• Do I know who to contact for advice on infection control?
• Do I know how to raise a concern in the organisation?
• Am I aware of hand hygiene audit results for my area and any learning?
• Where bank and agency staff are used, are they properly Inducted?
• Can I demonstrate any quality improvements that improve patient safety? Effective
• Am I aware of NICE guidance relevant to my work; do I follow it?
• Do I get involved in clinical audits or quality improvement projects and can I show resulting improvements?
• Do I assess the patient holistically and consider all their care needs? Are these reflected in care/ treatment plans and regularly reviewed?
• Do I under take the necessary risk assessments, keep them current and reflect them in care/ treatment plans?
• Do I involve the patient/family to design their own care/treatment plan and offer them a copy?
• Do I ensure multidisciplinary involvement in care and participate in handover and multidisciplinary meetings?
• Do I involve and support carers to be able to care for their loved one?
• Do I ensure people who are approaching end of life are identified and care delivered according to their care plan?
• Do I ensure my patients nutrition and hydration are met?
• Do I suppor t pain management in a timely way? What pain assessments do I use?
• Do I maintain my personal knowledge by attending training/ conferences or reading guidance and journals?
• Do I attend regular meaningful clinical supervision (group or individual) and feel supported in personal development?
• Have all my competencies been assessed and signed-off this year?
• Do I understand and follow the correct recruitment procedure?
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Caring
• Do I always introduce myself and wear my ID badge at all times?
• Do I always give my service contact details to families, and where to get support out-of- hours?
• Do I give patients/carers information about the services available to them, about their treatment or medication, and where to gain further support?
• Are noticeboards and information leaflets up-to-date and stocked?
• Do I always involve patients/ carers in decisions about their care or treatment and take a personalized, co- productive approach?
• Do I promote self-management and independence?
• Do I always consider the patients personal, cultural, religious needs?
• Do I understand discrimination and equality and diversity?
• Do I always treat the patients/ families with dignity, respect and kindness, provide privacy and confidentiality at all times?
• Do I repor t any disrespectful, discriminatory or abusive behaviour towards patients?
• Do families know how to make a complaint/compliment?
• Is the environment clean and comfortable?
• Do I work within the 6Cs of compassion in healthcare?
• Do I always take a personalised approach to care?
• Do I prioritise patients according to their need?
• Do I make appropriate arrangements to support special needs like a learning disability?
• Do I know how to contact an advocate or interpreter for the family/patient?
• Do I gain the appropriate consent before proceeding?
• Do I provide the information (benefits/risks) to gain valid consent? Do I know how to document consent?
• Am I able to test for capacity (under the Mental Capacity Act) and do I understand DoLS (Deprivation of Liberty Safeguards)?
• If a patient lacks capacity, do I know how to ensure their best interests are assessed and recorded?
• If I cancel an appointment, do I give an explanation and provide a follow-up?
• Are patients preferred choices outlined and worked towards?
• Are call bells answered promptly?
• Are patients able to go outside and not prevented for long periods from doing so?
• Do I encourage families to give feedback on their experiences of the service and provide means to do this? Like the friends and family test. Can I recall some learning and improvements made from patient feedback?
• Are families informed about how to make a complaint/ compliment? Are complaints dealt with within timescale?
• Does the team share lessons and learn from clinical audits, incidents or complaints/ compliments? Can I think of some examples?
• Am I aware of any previous CQC inspections to my service? Do I know the issues raised and what actions are in place and progress? And how the team manages its compliance against CQC quality statements? Well-led
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• Did I have a corporate and local induction when I started work here?
• Do I know the hospice values?
• Have I had my appraisal and on-going supervision with my manager?
• Is my mandatory and statutory training up-to-date?
• Do I attend team meetings, staff listening events?
• Do I know how to complain, whistle blow or raise a safeguarding alert?
• Do I know how to find support from Human Resources, Employee Assistance Programme/ Occupational Health or a Union?
• Do I know what the current risks are for my team or service? Are lessons shared and learned from incidents/complaints/audit/ family feedback? Do I know what actions are in place?
You may be asked the following questions by
• Who is the Chair of Trustees?
• Who is the SIRO (Senior Information Risk Officer)?
• Who is the Caldicott Guardian?
• Who is the Registered Manager?
• Who is the Safeguarding Lead?
• Who is the Information Governance Lead?
• Who is the Infection Control Lead?
• Who is the Health & Safety Lead?
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