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Registration timeline

Health and Social Care Act 2008 Registration Outcomes Hertfordshire Fiona Wray Compliance Manager Hertfordshire March 2011. Registration timeline. NHS Trusts. April 2010. Adult social care and independent healthcare providers (CSA). Oct 2010. Primary dental care (dental practices)

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Registration timeline

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  1. Health and Social Care Act 2008 Registration Outcomes Hertfordshire Fiona Wray Compliance Manager Hertfordshire March 2011

  2. Registration timeline NHS Trusts April 2010 Adult social care and independent healthcare providers (CSA) Oct 2010 Primary dental care (dental practices) and independent ambulance services April 2011 Primary medical services (GP practices and out of hours) April 2012

  3. Transitional Registration • Services previously registered under Care Standards Act • Some new to scope services included as part of registration • 27,000 transitional registration by 01 April 2010 • Providers offered ‘batch windows’ in which to apply • Self declaration of compliance against 16 essential standards at each location • Cross referenced with other information held by CQC • Some site visits were conducted • Looking for evidence of non compliance • Utilised CQC Judgement Framework and Setting the Bar guidance

  4. Registration under Health and Social Care Act 2008 • Widen scope of registration • Registration relates to the provision of ‘Regulated Activities’ • Registered at provider level rather than location • Location is a condition of registration • Registration no longer includes ‘categories’ of care or need • It is against the law to carry out a regulated activity without registration

  5. Registration Cycle 5 7 Registration application Information capture Judgement on risk 1 Application made Information analysis 2 4 Application assessed Judgement published 6 3 9 8 Judgement made Regulatory judgement Regulatory response Ongoing monitoring of compliance

  6. Registration Cycle • Registered • Registered with conditions • Registration refused in part • Registration refused Registration application 1 Application made 2 4 Application assessed Judgement published 3 Judgement made

  7. Levels of Compliance • Four levels of compliance • Level 1 Two or more compliance conditions applied • Level 2 One compliance condition applied One or more moderate concerns • Level 3 One or more minor concerns • Level 4 No concerns identified

  8. Transitional Registration OutcomesLevels of Compliance Level 1-1:0% Level 2: 23% Level 3: 5% Level 4: 72%

  9. Transitional Registration OutcomesLevels of Concern Compliant – 87% Minor – 9% Moderate – 2% Major – 1% Tbc – 1%

  10. Transitional Registration Conditions • Restrictive Conditions • Registered manager • Bed numbers (where appropriate) • Prohibit the provision of nursing care • Compliance Conditions • Registered manager • Significant none compliance • Overall major concerns • Provider or location level • It is an offence to fail to comply with conditions of registration and may lead to prosecution

  11. Compliance Conditions Registered Manager 77 locations No Registered Manager in post at all services where CQC has a Major Concern

  12. What Next Listen to the people who use services – they know what is really happening 12

  13. Compliance Monitoring 5 7 Information capture Judgement on risk • Continuous process • Response on information, analysis and risk • Quality Risk Profile • Minimum frequency of planned review • 3 – 24 months • Based on ‘level of compliance’ Information analysis 6 9 8 Regulatory judgement Regulatory response Ongoing monitoring of compliance

  14. Reviews of compliance Responsive Planned • A planned review of compliance: • is a scheduled check that looks across all regulated activities (at a location) to assess compliance with all 16 core quality and safety outcomes • Will take place at intervals of three months to no less frequent than two years • Will be proportionate, with additional activities focused on gaps on information • May include a site visit • All findings will be published • A responsive review of compliance: • is triggered when specific information, or a gap in information raises concern about compliance • is not a full check of all 16 core quality and safety outcomes • is targeted to the area(s) of concern • May include a site visit • All findings will be published

  15. How we capture information We will hold a Quality and Risk Profile on each provider summarising all relevant information. The Quality and Risk Profile will enable us to assess where risks lie and prompt front line regulatory activity, such as inspection.  As new information arrives, it will be added to the profile and assessors and inspectors will be alerted and will take action proportionate to the risk. DRAFT 15

  16. Information capture New information can come from a variety of sources: DRAFT People who use services, families and carers Providers Other regulatory bodies and Information Centre Staff and other professionals Other bodies eg. Ombudsman, commissioners CQC Assessors and Inspectors

  17. Evidence to make a judgement • To determine whether the evidence is adequate and robust, consider the • following points: • ● Is it current? (within 12 months or longer if a long-term focus) • ● Is it reliable? (is the source credible, is the evidence consistent, can it • be validated or triangulated with another source) • ● Is it relevant? (is it related to the regulations, the regulated activities • and CQC’s remit) • ● Is it sufficient? (is there an adequate amount of evidence with • enough detail to make an assessment) • ● Does it demonstrate the quality of outcomes and/or experiences of • people who use services? • ● Does it demonstrate what controls (processes) the provider has in • place?

  18. Judgement on risk 5 7 Information capture Judgement on risk • Information held by CQC • Utilise information from others • Commissioners • LINks • Survey’s • Request from provider • Provider Compliance Assessment Information analysis 6 9 8 Regulatory judgement Regulatory response Ongoing monitoring of compliance

  19. Regulatory Response Improvement Action • Actions to maintain compliance with essential standards • Report re how they will maintain compliance and the action needed to do so • Inform us when they have taken the action detailed • Actions to achieve compliance with essential standards • People not at immediate risk of serious harm • Report re how they will achieve compliance and the action needed to do so • Tell us when the action has been taken Compliance Action • People at immediate risk of serious harm enforcement will be taken • Moderate or Major concerns identified • Conduct management review • Range of options – civil and criminal Enforcement Action

  20. Reporting Urgent Compliance Action • Utilised where issue is too serious to wait for report to be produced • Send provider ‘compliance action letter • Highlighting area of concern and asking them what they are going to do • Public facing document - Published on CQC website • Produced after each responsive or planned review of compliance • Include standards assessed only Compliance Report

  21. Civil enforcement action Warning Notice Conditions Variation / Removal / Imposition Urgent variation / removal / imposition Suspension Extend period of suspension Urgent suspension Cancellation Cancel registration Urgent cancellation Criminal law and options Warning Notice Fixed Penalty Notice Simple Caution Prosecution Formal Regulatory Action Improvement Action Compliance Action

  22. Offences : Fixed Penalties

  23. Offences and fines: Prosecution

  24. Notifications • Mandatory statutory notifications are a new requirement for the NHS. • No longer optional to report to the NPSA or SHA • NHS providers submit some notifications to the NPSA. These include; • • Deaths of people using the service • • Injuries • • Abuse and allegations of abuse • • Events that stop or may stop the service from running safely and properly.

  25. Notifications directly to CQC • Not all the notifications exist in the SUI system and some have to be • made directly to CQC. • These include: • • Changes to the statement of purpose • • Absences of registered managers • • Changes such as a new provider taking over the service, changes of address, changes to services provided • • Deaths and unauthorised absences of people detained under the Mental Health Act 1983 • • Applications to deprive a person of their liberty under the Mental Capacity Act 2005

  26. Submission of notifications • There is separate notifications guidance on CQC’s website for: • • NHS providers • • Adult social care and independent healthcare providers. • The guidance explains: • • How to download or get copies of notification templates • • The timescales for submitting different notifications • • How to submit notifications • • Which NHS notifications are submitted to CQC and which to the NPSA.

  27. More information Go to our website at www.cqc.org.uk Send information to us about what people think about local services to www.cqc.org.uk/localvoices Sign up for our newsletter at www.cqc.org.uk/newsandevents Talk to your local CQC compliance manager Ring or send enquiries to our National Contact Centre at 03000 616161 or enquiries@cqc.org.uk For copies of our reports, you can go to www.cqc.org.uk/publications

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