Compliance with Care Quality Commission Essential Standards of Quality and Safety

1. Compliance with Care Quality Commission Essential Standards of Quality and Safety

2. Essential Standards of Quality and Safety There are 16 essential standards of quality and safety that are mandatory to all Trusts. They are divided into 5 distinct sections Each section has outcomes that are related to a specific regulation in the legislationThere are 16 essential standards of quality and safety that are mandatory to all Trusts. They are divided into 5 distinct sections Each section has outcomes that are related to a specific regulation in the legislation

3. Care Quality Commission Expectations Initial Greater initial emphasis on evidence from policies, procedures and systems – always in relation to the impact they have on people who use the service As system is embedded Evidence should directly demonstrate outcomes or comes directly from people who use the service Providers should Think about how to collect this evidence and monitor their own compliance with the outcomes routinely Initial expectations – Greater initial emphasis on evidence from policies, procedures and systems – always in relation to the impact they have on people who use the service As system is embedded – evidence should directly demonstrate outcomes or comes directly from people who use the service Providers should – think about how to collect this evidence and monitor their own compliance with the outcomes routinely Initial expectations – Greater initial emphasis on evidence from policies, procedures and systems – always in relation to the impact they have on people who use the service As system is embedded – evidence should directly demonstrate outcomes or comes directly from people who use the service Providers should – think about how to collect this evidence and monitor their own compliance with the outcomes routinely

4. CQC: Monitoring Compliance Information capture The Quality and Risk Profile is used to assess risk and act as a prompt for regulatory action Supports CQC judgement (registration) Examples Information from service users, Local involvement networks, Overview and Scrutiny Committees Information from Health and Safety Executive, NHS Litigation Authority, National Institute for Health and Clinical Excellence, Monitor, Mental Health Minimum Data Set, Royal College Data, Parliamentary and Health Service Ombudsman (not exhaustive) Information Capture Quality and Risk Profile (QRP) – used to assess risk and act as a prompt for regulatory action. Supports CQC judgement. Information from service users, LINks, overview and scrutiny committees Information from Health and Safety Executive, NHS Litigation Authority, National Institute for Health and Clinical Excellence, Monitor, Mental Health Minimum Data Set, Royal College data, Parliamentary and Health Service Ombudsman (not an exhaustive list) Information Capture Quality and Risk Profile (QRP) – used to assess risk and act as a prompt for regulatory action. Supports CQC judgement. Information from service users, LINks, overview and scrutiny committees Information from Health and Safety Executive, NHS Litigation Authority, National Institute for Health and Clinical Excellence, Monitor, Mental Health Minimum Data Set, Royal College data, Parliamentary and Health Service Ombudsman (not an exhaustive list)

5. Quality and Risk Profile: Summary This is a quality and risk profile summary and the sections relate to the section headings outlined in slide 2This is a quality and risk profile summary and the sections relate to the section headings outlined in slide 2

6. This slide outlines the overall contextual risk estimate for the Trust This slide outlines the overall contextual risk estimate for the Trust

7. Judgement on risk Use of the CQC judgement framework Based on impact on people using the services and likelihood the impact will happen – minor, moderate or major concerns Judgement on risk Use of the judgement framework Based on impact on people using the services and likelihood the impact will happen – minor, moderate or major concerns Judgement on risk Use of the judgement framework Based on impact on people using the services and likelihood the impact will happen – minor, moderate or major concerns

8. CQC: Monitoring Compliance Statutory Notifications Changes to Statement of Purpose Certain changes to and other events concerning the service Certain deaths of people who use the service (through NPSA) Deaths and unauthorised absences of people detained or liable to be detained under the Mental Health Act 1983 Certain serious injuries (through National Patient Safety Authority) Applications to deprive a person of their liberty under the Mental Capacity Act 2005 Allegations of abuse (through NPSA) Events that prevent or threaten to prevent the registered person from carrying on the service to the essential standards of quality and safety (through NPSA) Absence of registered managers Changes such as a new provider taking over the service, changes of address, changes to services provided Statutory Notifications Changes to Statement of Purpose Certain changes to and other events concerning the service Certain deaths of people who use the service* Deaths and unauthorised absences of people detained or liable to be detained under the Mental Health Act 1983 Certain serious injuries* Applications to deprive a person of their liberty under the Mental Capacity Act 2005 Allegations of abuse* Events that prevent or threaten to prevent the registered person from carrying on the service to the essential standards of quality and safety* Absences of registered managers Changes such as a new provider taking over the service, changes of address, changes to services provided *through NPSAStatutory Notifications Changes to Statement of Purpose Certain changes to and other events concerning the service Certain deaths of people who use the service* Deaths and unauthorised absences of people detained or liable to be detained under the Mental Health Act 1983 Certain serious injuries* Applications to deprive a person of their liberty under the Mental Capacity Act 2005 Allegations of abuse* Events that prevent or threaten to prevent the registered person from carrying on the service to the essential standards of quality and safety* Absences of registered managers Changes such as a new provider taking over the service, changes of address, changes to services provided *through NPSA

9. CQC: Monitoring Compliance Information analysis Reviews of compliance e.g. planned (between 3 months and 2 years of registration); high risk (more frequent); responsive (gaps in information or concerns about compliance) Outcome evidence – detailed in essential standards of quality and safety For people who use services providers should consider how evidence relates to or has an impact on a range of outcomes; Quantitative and qualitative measures e.g. clinical data Policies, Procedures and Systems Implementation and monitoring of policies; Specifically relating to staffing, learning and development; Systems for reporting and learning from incidents; Safeguarding procedures Outcomes direct from people (as system for monitoring compliance is embedded) Demonstrates outcomes for people directly or indirectly Information Analysis Reviews of compliance Planned – a rolling programme between 3 months and 2 years of registration High risk will generate more frequent reviews Responsive – gaps in information or concerns about compliance Contact people who use services Contact LINks and HOSC Submission request to providers Requesting information/telephone call to providers Site visit Focus on outcomes Observation of delivery of care Review of records Expert by experience Unannounced Outcome evidence – detailed in Essential Standards of Quality and Safety For people who use services providers should consider how evidence relates to or has an impact on these outcomes: Health and clinical outcomes and how these are maintained and improved following interventions or non-interventions Whether individual needs are met What kind of experience people have when they use a service Whether people are treated with dignity and respect Whether individual’s human rights are protected Whether people feel involved in their care Whether people are enabled to make informed choices Whether people receive care that is safe Whether people’s independence is promoted Whether people are safeguarded against abuse In addition quantitative and qualitative measures such as Clinical data Absolute performance or trends over time Feedback from patients and people acting on their behalf Feedback from staff members Evaluation of skills and competence Monitoring use of good practice Measuring satisfaction Monitoring risks Implementing learning or monitoring action plans Policies, Procedures and Systems Implementation and monitoring of policies demonstrating: The impact they have on outcomes and experiences of people using the service How they help to meet people’s needs How they help identify and manage risks to the health, welfare or safety of people That they are effective and implemented where necessary That all relevant staff understand them How people who use the service were consulted and involved in development That implementation and the impact on people are monitored How they are reviewed and updated to ensure the provider continues to be compliant How feedback about the impact of policies and procedures is gathered from people who use services Specifically policies, procedures and systems that relate to: Procedures to identify, plan, monitor and review staffing mix and numbers or staff learning and development, taking account of diversity and assessed needs of people using the service Systems for reporting and learning from incidents – demonstrate clear action planning and implementation has led to change, reduced risk and improved outcomes Safeguarding procedures – demonstrating procedures are reviewed to ensure they are effective in protecting people from abuse Outcomes direct from people (as system for monitoring compliance is embedded) Survey results Complaints and comments Patient reported outcome measures (PROMs) Feedback from specific groups of people Feedback from the public Focus groups and other involvement activities Local involvement networks (LINks) Patient Advice and Liaison Service (PALS) Demonstrates outcomes for people directly or indirectly from: Actions and improvements resulting from people’s feedback Staff survey results and feedback and outcomes reported by staff Internal and external reviews of services Audits, including clinical audits Effective risk assessment and management Individual care records Individualised needs assessments Staff skills and competence Incident reports, learning and improvement actions National and local data sets and comparative information Equalities data and evaluations Assessments from other regulatory bodies, inspections or accreditation schemes Information Analysis Reviews of compliance Planned – a rolling programme between 3 months and 2 years of registration High risk will generate more frequent reviews Responsive – gaps in information or concerns about compliance Contact people who use services Contact LINks and HOSC Submission request to providers Requesting information/telephone call to providers Site visit Focus on outcomes Observation of delivery of care Review of records Expert by experience Unannounced Outcome evidence – detailed in Essential Standards of Quality and Safety For people who use services providers should consider how evidence relates to or has an impact on these outcomes: Health and clinical outcomes and how these are maintained and improved following interventions or non-interventions Whether individual needs are met What kind of experience people have when they use a service Whether people are treated with dignity and respect Whether individual’s human rights are protected Whether people feel involved in their care Whether people are enabled to make informed choices Whether people receive care that is safe Whether people’s independence is promoted Whether people are safeguarded against abuse In addition quantitative and qualitative measures such as Clinical data Absolute performance or trends over time Feedback from patients and people acting on their behalf Feedback from staff members Evaluation of skills and competence Monitoring use of good practice Measuring satisfaction Monitoring risks Implementing learning or monitoring action plans Policies, Procedures and Systems Implementation and monitoring of policies demonstrating: The impact they have on outcomes and experiences of people using the service How they help to meet people’s needs How they help identify and manage risks to the health, welfare or safety of people That they are effective and implemented where necessary That all relevant staff understand them How people who use the service were consulted and involved in development That implementation and the impact on people are monitored How they are reviewed and updated to ensure the provider continues to be compliant How feedback about the impact of policies and procedures is gathered from people who use services Specifically policies, procedures and systems that relate to: Procedures to identify, plan, monitor and review staffing mix and numbers or staff learning and development, taking account of diversity and assessed needs of people using the service Systems for reporting and learning from incidents – demonstrate clear action planning and implementation has led to change, reduced risk and improved outcomes Safeguarding procedures – demonstrating procedures are reviewed to ensure they are effective in protecting people from abuse Outcomes direct from people (as system for monitoring compliance is embedded) Survey results Complaints and comments Patient reported outcome measures (PROMs) Feedback from specific groups of people Feedback from the public Focus groups and other involvement activities Local involvement networks (LINks) Patient Advice and Liaison Service (PALS) Demonstrates outcomes for people directly or indirectly from: Actions and improvements resulting from people’s feedback Staff survey results and feedback and outcomes reported by staff Internal and external reviews of services Audits, including clinical audits Effective risk assessment and management Individual care records Individualised needs assessments Staff skills and competence Incident reports, learning and improvement actions National and local data sets and comparative information Equalities data and evaluations Assessments from other regulatory bodies, inspections or accreditation schemes

10. Regulatory response Compliance with essential standards – no action Less than full compliance – use of a ‘setting the bar’ framework High confidence in capability minor – informal regulatory action moderate – formal regulatory action major – compliance / enforcement action (warning/conditions etc) Low confidence in capability minor – formal regulatory action moderate – formal regulatory action below the bar – compliance / enforcement action (warning/conditions) major – compliance / enforcement action (penalty/suspend/prosecute) Regulatory response Compliance with essential standards – no action Less than full compliance – use of a ‘setting the bar’ framework (CQC reserves the right to exercise discretion when using the bar framework) High confidence in capability Minor – informal regulatory action or formal regulatory action (most appropriate lever for improvement Moderate – Formal regulatory action Major – Compliance action and enforcement action (warning notice/conditions/penalty notice/suspend/cancel/prosecute) Low confidence in capability Minor – formal regulatory action Moderate – formal regulatory action Below the bar – compliance action and enforcement action (warning notice/conditions) Major – compliance action and enforcement action (penalty/notice/suspend/cancel/prosecute) Regulatory response Compliance with essential standards – no action Less than full compliance – use of a ‘setting the bar’ framework (CQC reserves the right to exercise discretion when using the bar framework) High confidence in capability Minor – informal regulatory action or formal regulatory action (most appropriate lever for improvement Moderate – Formal regulatory action Major – Compliance action and enforcement action (warning notice/conditions/penalty notice/suspend/cancel/prosecute) Low confidence in capability Minor – formal regulatory action Moderate – formal regulatory action Below the bar – compliance action and enforcement action (warning notice/conditions) Major – compliance action and enforcement action (penalty/notice/suspend/cancel/prosecute)