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CQC Compliance

CQC Compliance. Presented By: Alex Zarneh (Dr.) Head of Medical Physics & Radiation Protection Services Medical Physics Department Mid Yorkshire Hospitals NHS Trust Incorporating Dewsbury & District, Pinderfields and Pontefract Hospitals alex.zarneh@midyorks.nhs.uk

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CQC Compliance

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  1. CQC Compliance Presented By: Alex Zarneh (Dr.) Head of Medical Physics & Radiation Protection Services Medical Physics Department Mid Yorkshire Hospitals NHS Trust Incorporating Dewsbury & District, Pinderfields and Pontefract Hospitals alex.zarneh@midyorks.nhs.uk • MID YORKSHIRE HOSPITALS NHS TRUSTDEWSBURY AND DISTRICT HOSPITALMEDICAL PHYSICS DEPARTMENTHALIFAX ROADDEWSBURYWEST YORKSHIREWF13 4HS Outcome 11 Safety, Availability and Suitability of Equipment

  2. Take Your Seats, Sit Back, Relax And Enjoy

  3. This presentation gives an overview from the following points of view:- Head of Medical Physics with operational and professional responsibility- Acting as out of hours on-site duty manager- being accountable for patients not having basic kit such as Static Mattresses or Pillows Neglect or Ignorance?

  4. The Trust was inspected by Care Quality Commission Assessors60 assessors arrived and spent one week across 3 hospitals and care closer to home premisesThey also came back at weekends and did unannounced inspection What Happened?

  5. A lot of Evidence was presented prior to their visit but was not Enough to satisfy the requirements of outcome 11! What Happened?

  6. The registered person, the Trust must make suitable arrangements to protect service users and others who may be at risk of using unsafe equipment Outcome 11 – Safety, Availability and Suitability of Equipment

  7. To ensure that any devices is:Properly maintained and suitable for its purpose Used correctly Is available in sufficient quantitiesRole of Medical Devices Library Availability Of Devices

  8. The Device is: Suitable for its purposeIs properly maintainedIs used correctly and safelyPromotes independenceIN-HOUSE MANAGEMENT OF MEDICAL DEVICES POLICY! Fit For Purpose

  9. Do You Know Who is responsible In Your Trust for:- Static / Foam Mattresses or Pillows- Wheel Chairs? How many are lying around broken?- Commodes? / Bariatric Equipment_ Pressure Relief Mattresses?- Decontamination / Cleaning of Medical Devices? Responsibilities?

  10. - Who is responsible for Clinical Training?- Who is responsible for managing external medical devices contracts?-Who verifies the contractors service reports? Ward clerk?- Who accepts the device back into service? Ward Clerk / Domestics? Responsibilities?

  11. - Who decides on the level of contract needed? -Is there a centralised database with full visibility?- Is there a replacement programme for all the devices?- What is your standardisation Policy?- Who stands up to users and clinical colleagues who are putting pressure on to purchase the “Deal of the Day”? Responsibilities?

  12. - Assessors spent time on the wards- Command centres were set up at each hospital site- Head of Medical Physics - Director- Matrons- Chief Nurse Deputy CQC Assessment

  13. - Inventory ?- Training Records? How many were in date?Some wards also created their own folders: Labeled – CQC Evidence? – Not acceptable! Yellow Folders!

  14. We met with each other every two hours - Kept in touch via text and mobile – signal issues- Walked round the wards and corridors- Engaged with porters to move items from corridors- Lots of biscuits / Fruit and Chocolates- Created good relationship between different colleagues CQC Assessment

  15. - Some staff not familiar with the sites- Working for the same organisation?- Making assumptions- What happened to day to day tasks?- Tired - Having spent 4 weeks collecting evidence! Operational Issues

  16. - Each day requests came from CQC for information- Can you do it for now?- Remember - All Information must be credible- We had a lot of explaining to do! CQC / Trust Expectations

  17. What were the issues for Medical Physics?- Labeling of service dates on devices- I sent a global Email to other Trusts for comments- Received some good and some rude and ignorant Emails- Spot checking of service dates via telephone call from the assessor CQC / Trust Expectations

  18. - CQC asked for a list of outstanding jobs- List of outstanding PVIs- High Risk, Medium Risk and Low Risk- What is the problem? CQC / Trust Expectations

  19. - The information was presented to CQC- Decision made to withdraw the “Yellow Folders” What happened Next?

  20. - No Formal feedback - Various informal questions re Inventory for various areas- !Number of NIBPs in a certain area! Feedback?

  21. - Continue with achieving compliance (91%)- Debate re stickers and service lables? What Have We Done?

  22. Thank you for your attention 14

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