continuous quality compliance's podcast

Today I am talking about Evidence

In order for the CQC to ascertain that you are following your Statement of Purpose and that you are meeting the standards you need to provide evidence. Many providers get confused about he level of evidence or how much is required.

Evidence should be provided during the carrying out of the services so the forms you use should be created in a way that it provides the relevant information. What you want to do is be effective in gathering evidence.

For instance, for Social Care providers they usually have to provide information the local authority. Well make sure the forms cover the local authority criteria and that CQC standards that way you do not need to double up. If you’re a nurse ensure that the NMC requirements are covered.

When you do audits check that the forms are indeed providing you with the evidence you need. Have a look at staff files do they show a robust recruitment process? One organisation I went to there was no notes for interviews their was no consistency in the way recruitment was undertaken. It was so haphazard that if they were taken to tribunal, they would have no evidence to provide.

Evidence should not be burdensome. When I worked in a acute hospital I design ed the evidence to provide me the information required by different regulatory bodies. The consultant solved this approach as it made their life easier.

Remember in providing evidence you need to show good record keeping is followed. I say if you are not happy for it to be read in a court of law then do not write it. Think about language and clarity of meaning.

Do not make evidence gathering complex that way staff will not comply. Also explain the reason for the forms because staff are more likely to support if they know why they are being asked to do something.

If you do not write something that you have undertaken in clients notes it has not happened. SO, ensure staff know that all information pertinent to the client needs to be recorded.

The Key Lines of Enquiry are the 5 areas which a provider gets inspected on. These come out of the regulations. Being the KLOE they can be added to taken always moved around unlike the regulations. But it sis important to look at how your processes align with he Key Lines of Enquiry. There are 2 frameworks one for healthcare and one for social care.

Develop you processes and see how they align with the regulations and Key Lines of Enquiry.

The five areas which are looked at are Safe, Caring, Effective, Responsive and Well Led. The way I remember them is using the pneumonic SCREW

SAFE

Here you need to show you have robust systems in place. These should include for safeguarding and recruitment. Safe a key are looked at here is Safeguarding. Safeguarding is seen as everyone’s responsibility. The Registered manager should be trained to level 3 other staff dependent on their roles can be at level 1 or 2 most staff should be level 2.

Recruitment and induction is key to have safe staff who are fit persons. Values based recruitment is important and a robust Induction as well as a robust training regimen. I always say asking staff to read key policies is not enough you have to check competency too, ask at 3 key questions on the policy to ascertain understanding.

You need to show that you have good risk management processes in place which are appropriate for the activity being undertaken.

If you are responsible for medicines management you need to show how that is being done, and that staff are trained adequately and their competency checked.

CQC know that even with the best processes in place things can go they want to know how you deal with the situation. Are lessons learnt and how do you prevent the issue arising again. Do you talk about lessons learnt at meetings?

How do you manage Infection control this needs to be appropriate to the service you provide. For instance infection control in a care home is different to a person home. Clinics will need different levels of infection control protocols dependent on the level of treatments provided

EFFECTIVE

CQC want to know if you are an effective organisation . Do you have a good induction process in place.

They want to know how you assess care and treatment. Is it evidence based following current practice and legislation.

How will you monitor outcomes of your clients, have you discussed their outcomes with them?

ARE you checking that your staff have the right level f knowledge and skills to undertake the treatment procedure or activity.

They also want to know that your staff work well in teams whether that is internal or external. To me external is those other health professionals you work with like GP, OT to deliver effective care

Where the service is responsible howe will you help people to lead healthier lives?

Is consent taken consistently inline with legislation and guidance

If staff handover is required for your activity how is this managed. I have seen some very poor practice in this area.

Is supervision undertaken? How often is it in an effective way?

If you are responsible for peoples Nutrition and Hydration is this done well is it in a person centred way.

CARING

How will the service ensure that people are treated with kindness, respect and compassion, and that they are given emotional support when needed? I always say how would you like your loved ones to be treated.

Do you support clients to express their views? And actively encourage them in the decision making process

Is people's privacy and dignity be respected and promoted?

RESPONSIVE

How will people receive personalised care that is responsive to their needs? Do you take account of the...

It is important to have a business continuity plan because you do not want to think about the steps when you are in the middle of a major incident you want to have steps already set out.

Overall episode topic or theme

CIRCUMSTANCES

A Business Continuity Plan will be activated in response to an incident causing significant disruption to normal service delivery/business, particularly the delivery of key/critical activities. Examples of circumstances triggering activation of a Plan include:

• Loss of key staff or skills e.g. above normal levels of absenteeism due to illness

• Loss of critical systems e.g. ICT failure

• Denial of access, or damage to, facilities e.g. loss of a building through fire

• Loss of a key resource e.g. a major supplier vital to the delivery of a key service

*The ‘Incident Management’ phase of your response to a business disruption is often the most crucial; actions taken during this phase of your response can impact on your ability to recover efficiently and with minimum disruption.

procedures need to be accurate and fit-for-purpose*

PURPOSE OF THE INCIDENT MANAGEMENT PHASE

• Protect the safety of staff, visitors and the wider community

• Protect vital assets e.g. equipment, data, reputation etc

• Ensure necessary communication takes place

• Support the Business Continuity phase

• Support the Recovery and Resumption phase

the plan should cover who will need to communicate and to whom who will have overall responsibility for the plan when it is instigated. There should be phone numbers for instance for major utilities suppliers in an emergency.

Insurance companies

The ‘Business Continuity

phase of your response is concerned with maintaining a level of continuity with your most critical activities.

It is not necessarily about getting all activities back up and running, only those activities that have been identified as a priority.

Implementing contingency arrangements such as moving to a relocation site or identifying alternative working practises i.e. suspending non critical activities is a key feature of this phase of the response. It is important that this is aligned to your business needs.

The ‘Recovery and Resumption’ Stage

This stage is concerned with recovering ‘business as usual’. During the previous business continuity phase, only critical activities are maintained, therefore it is likely you will experience a ‘back log’ of work to catch up with. Now it is about a phased approach building gradually to all activities being recovered with the resumption of ‘normal’ working practises i.e. reoccupation of the usual building, all staff returning to work, or going back to their ‘normal’ roles.

Testing of plans

All plans should be tested or exercised to ensure they are valid and that incident responses are rehearsed in a ‘safe’ environment, without the pressure of a ‘real life’ incident.

This ensures that plans will actually work in an incident, but staff will also feel more prepared and comfortable in their business continuity roles.

Following an exercise it is useful to write a report: contents may include- information about the test i.e. the scenario used, participant information i.e. who was in attendance, general...

Welcome to episode 24 of Continuous Quality Compliance

Today I am talking about you Business Plan.

For a New registration you require a business plan with a 3 year cashflow forecast. It is required for all Providers now before it was just in the Social care sector . Now a business plan is asked for in both Healthcare and Social care. Why because CQC wan t to know you are serious about your business that you have thought it through.

Personally I do prefer using Strategy on a Page approach but the CQC are still old fashioned and require a classic business plan. With a cash flow forecast over 3 years. It does not need to be a thick document.

A business plan should be your guiding tool to help you make decision about the business. It should also be done in advance, so you know if the business you wan to do is feasible. Nothing worse then starting a business on a hope and a whim. A business plan gets you to look at different aspects to check feasibility and financial viability.

Financial viability is actually checked by the CQC they have a form you need to ask your accountant to complete to show that you are financially viable.

Now some of my clients are already running a business and still need to provide a business plan. For these clients I recommend that they look at the past 3 years or 2 years depending on how long they have been going and use that information for the Business plan. You of course need to account for the regulated activity you will be adding and how that affects the other areas. Do you need more staff or do the current staff need further training. They would of course require training in the CQC standards and how that aligns with your business goals.

The purpose of a business plan is to help articulate a strategy for starting your business. It also provides insight on steps to be taken, resources required for achieving your business goals and a timeline of anticipated results. a business plan can be important in providing structure and management objectives to a small business.

For existing small businesses, a business plan should be updated annually as a way to guide growth and navigate the expansion into new markets. For that I like to use Strategy on a Page as everything is on one page and you can clearly see what you need to do.

The cashflow forecast is a forecast so they do not expect you to know all the numbers, but they do expect you to have an idea of expenses and income. Keep the forecast simple you do not need anything too complicated. You do need it for 3 years showing growth of some sort.

Welcome to episode 23 of Continuous Quality Compliance

Today I am talking about Notifications

There are certain events for which you have to notify CQC. If you do not notify CQC than it can be classed as breach. The Portal can be used for notifications. I recommend you have a deputy who also knows how to do notifications when the Registered Manager is away.

You must notify CQC if the registered manager is going be away more than 28 days. Equally when they return you have to notify CQC too. So put it in a calendar/diary so you don’t forget.

Safeguarding allegations needs to be notified to CQC . You should have forms internally to gather the information . Incident reporting forms can be used. AS long as all the relevant information is gathered.

Changes to registered details there are different forms for different kinds of changes so ensure you use the right one.

Death of a person using the service is notifiable.

Serious injury is also notifiable.

The regulations say that the ‘registered person’ must submit notifications. This will often be the registered manager, but you can delegate this task to appropriate members of staff. You need to ensure that your delegation arrangements clearly show which members of staff are responsible for submitting notifications. These, together with your policies and procedures and staff training arrangements, must ensure that CQC is told about notifiable events properly and within the required timescales. In all cases, we need to know the name of the person who submits a notification and who we should contact for more information. There is space in the forms for this. It is the registered person’s responsibility to ensure that notifications are made, and they will be committing an offence if they fail to do so. Any arrangements for delegation of this task must therefore be very clear.

For Social care CQC have to be notified of DOLS.

It is important to know what is a notifiable incident so you do not inadvertently have a breach if in doubt ring them up.

Welcome to episode 22 of Continuous Quality Compliance

Today I am talking about The Statement of Purpose.

Every provider has to complete a Statement of Purpose as part of their CQC application .

Care Quality Commission (Registration) Regulations 2009

CQC can prosecute for a breach of this regulation or a breach of part of the regulation. This means that CQC can move directly to prosecution without first serving a warning notice. Additionally, CQC may also take any other https://www.cqc.org.uk/guidance-providers/regulations-enforcement/glossary-terms-used-guidance-providers-managers#regulatory-action (regulatory action).

The CQC provide a template but I do not like it so I have created my own which covers all part of schedule 3 and its nicer so you can print or email to your new staff during induction.

1. The registered person must give the Commission a statement of purpose containing the information listed in Schedule 3.

2. The registered person must keep under review and, where appropriate, revise the statement of purpose.

3. The registered person must provide written details of any revision to the statement of purpose to the Commission within 28 days of any such revision.

Schedule 3 says:

1 The aims and objectives of the service provider in carrying on the regulated activity.

2. The kinds of services provided for the purposes of the carrying on of the regulated activity and the range of service users’ needs which those services are intended to meet.

3. The full name of the service provider and of any registered manager, together with their business address, telephone number and, where available, electronic mail addresses.

4. The legal status of the service provider.

5. Details of the locations at which the services provided for the purposes of the regulated activity are carried on.

Point 3

· If a provider changes their statement of purpose, it must tell CQC what these changes are within 28 days of making the changes.

· If a provider is applying to vary a condition of its registration, it should send CQC a copy of its proposed statement of purpose with its application.

Welcome to episode 21 of Continuous Quality Compliance

Today I am talking about… Regulation 20 Duty of Candour

The intention of this regulation is to ensure that providers are open and transparent with people who use services and other 'relevant persons' (people acting lawfully on their behalf) in general in relation to care and treatment. It also sets out some specific requirements that providers must follow when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, providing truthful information and an apology when things go wrong.

The regulation applies to registered persons when they are carrying on a regulated activity.

CQC can prosecute for a breach of parts 20(2)(a) and 20(3) of this regulation and can move directly to prosecution without first serving a Warning Notice. Additionally, CQC may also take other https://www.cqc.org.uk/guidance-providers/regulations-enforcement/glossary-terms-used-guidance-providers-managers#regulatory-action (regulatory action). Which you can find in the offences section.

It also sets out some specific requirements that providers must follow when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, providing truthful information and an apology.

Providers must promote a culture that encourages candour, openness and honesty at all levels.

CQC This should be an integral part of a culture of safety that supports organisational and personal learning. There should also be a commitment to being open and transparent at board level.

Definitions :

Openness – enabling concerns and complaints to be raised freely without fear and questions asked to be answered.

• Transparency – allowing information about the truth about performance and outcomes to be shared with staff, patients, the public and regulators.

• Candour – any patient harmed by the provision of a healthcare service is informed of the fact and an appropriate remedy offered, regardless of whether a complaint has been made or a question asked about it.

To meet the requirements of Regulation 20, a registered provider has to:

Make sure it acts in an open and transparent way with relevant persons in relation to care and treatment provided to people who use services in carrying on a regulated activity.

Tell the relevant person, in person, as soon as reasonably practicable after becoming aware that a notifiable safety incident has occurred, and provide support to them in relation to the incident, including when giving the notification.

• Provide an account of the incident which, to the best of the provider’s knowledge, is true of all the facts the body knows about the incident as at the date of the notification.

• Advise the relevant person what further enquiries the provider believes are appropriate.

• Offer an apology.

• Follow up the apology by giving the same information in writing, and providing an update on the enquiries.

• Keep a written record of all communication with the relevant person.

We will consider the size and type of services and the relevance of the regulation to the provided

regulated activity.

The registration inspector will check that the provider has robust systems in place to meet the duty of candour regulation. This would include, but is not limited to, training for all staff on communicating with people who use services about notifiable safety incidents; incident reporting forms which support the recording of a duty of candour notification; support for staff when they notify people who use services when something has gone wrong; oversight and assurance.

When they are inspecting the following KLOE’s will be looked at for compliance with Duty of Candour.

S2: Are lessons learned and improvements made when things go wrong?

Prompt...

Welcome to episode 20 of Continuous Quality Compliance

Today I am talking about… Regulation 19 Fit and proper Person Employed.

The intention of this regulation is to make sure that providers only employ 'fit and proper' staff who are able to provide care and treatment appropriate to their role and to enable them to provide the regulated activity.

To meet this regulation, providers must operate robust recruitment procedures, including undertaking any relevant checks. They must have a procedure for ongoing monitoring of staff to make sure they remain able to meet the requirements, and they must have appropriate arrangements in place to deal with staff who are no longer fit to carry out the duties required of them.

Employing unfit people, or continuing to allow unfit people to stay in a role, may lead CQC to question the fitness of a provider.

“Person employed” will include any member of staff who currently works in the service including agency, bank staff and volunteers (based on the broad meaning of “employment” set out in Regulation 2, which extends the scope to those engaged otherwise than under a contract).

Point 1

Schedule 3 sets out eight categories of information required to be kept by providers about all persons employed in the provision of services. They wont want to see all but some of them to be utilised as part of checking that’s staff remain suitable.

1 Proof of identity including a recent photograph.

2CQC expects each provider to undertake the level of DBS check for which a particular staff member is eligible

3 Closely looked at when exemptions apply related to the DBS

4 Satisfactory evidence of conduct in previous employment concerned with the provision of services relating to— (a) health or social care, or (b) children or vulnerable adults. Obviously it does not apply if they have not previously worked in the sector.

5. Where a person has been previously employed in a position whose duties involved work with children or vulnerable adults, satisfactory verification, so far as reasonably practicable, of the reason why the person’s employment in that position ended.

6 Far as is it is reasonably practicable to obtain, satisfactory documentary evidence of any qualification relevant to the duties for which the person is employed or appointed to perform.

7 A “full employment history” means a career history from the age of first employment. This information may be in the form of a Curriculum Vitae but need not be.

8 Satisfactory information about any physical or mental health conditions which are relevant to the person's capability, after reasonable adjustments are made, to properly perform tasks which are intrinsic to their employment or appointment for the purposes of the regulated activity.

CQC expects providers to be aware of a range of guidelines relevant to their business sector, and to be able to demonstrate that the recruitment and selection procedures are consistent with responsible employment practice.

Point 2

The provider is required to undertake sufficient checks so they can evidence the applicant:

· Is of good character

· Has the necessary qualifications, competence, skills and experience necessary for the work to be performed

· Is able to properly perform the tasks (after any reasonable adjustment)

Point 3

However, most companies/organisations will only provide a statement confirming dates of employment. When this occurs, providers should assess any potential risk and make sure the person has appropriate supervision until they can demonstrate competence.

Point 4

If providers have any current concerns about the performance, abilities, physical or mental health of any of their staff, the Inspector will want to see what steps they have taken to...

Welcome to episode 19 of Continuous Quality Compliance

Today I am talking about Regulation 18: Staffing

CQC cannot prosecute for this but they can take regulatory ac tion.

To meet the regulation, providers must provide sufficient numbers of suitably qualified, competent, skilled and experienced staff to meet the needs of the people using the service at all times .

.Staff must receive the support, training, professional development, supervision and appraisals that are necessary for them to carry out their role and responsibilities.

They should be supported to obtain further qualifications and provide evidence, where required, to the appropriate regulator to show that they meet the professional standards needed to continue to practise.

The regulators can be the GMC, NMC, GDC , they can be associations like the HCPC, BABICOM whose standards you should be meeting if you are a member.

Point 1

Providers must have sufficient numbers of suitably qualified, competent, skilled and experienced staff to make sure that they can meet people's care and treatment needs.

Point 2

CQC are looking for a systematic approach to determine the number of staff and range of skills required in order to meet the needs of people using the service and keep them safe at all times.

The approach they use must reflect current legislation and guidance where it is available.

In determining the number of staff and range of skills required to meet people's needs, they should consider the different levels of skills and competence required to meet those needs, the registered professional and support workers needed, supervision needs and leadership requirements.

Point 3

Staffing levels and skill mix must be reviewed regularly and adapted to respond to the changing needs and circumstances of people using the service. Or in terms of providers undertaking diagnostics and screening they type of reporting you are doing.

Point 4

A robust induction is really important it should prepare the person for their role. You should also ask for feedback on the induction so you can make improvements on it. I have never had a great induction. The worst was turning up and being told the person who was assigned to me was on holiday for the rest of the week. I was just left to fend for myself. It was awful and it was a corporate which made the experience worse. In my other roles I turned up and there was no-one there even to greet me. How do you thing that made me feel. I understand that they were on the wards but a little thought on their part . It could have been a little welcome box or even a simple note would have been better. Luckily It was a new speciality in a hospital I worked so I knew my way around the IT system. But it made me feel unwanted and unwelcome.

Point 5

Staff should be supported to have training. CQC will look for how you are monitoring training and will ask for a training matrix at the least. You should be looking at any additional training which may be required. A good example is when a client of mine was bring in tablets to be sued by staff for their IT platform they were using. A Good move to go paperless. But they had not done pre-requisite work on the competency of their staff and ability of them to use tablets. Some staff did but others were floundering and instead of saying I don’t know how to use this technology they blamed the platform. I wrote an IT competency checklist for my client and is was told to staff that by completing the form it would help the company to know the level

Welcome to episode 18 of Continuous Quality Compliance. Today I am talking about Regulation 17 Governance

CQC’s intention of this regulation is to make sure that providers have systems and processes that ensure that they are able to meet other requirements in this part of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Regulations 4 to 20A). To meet this regulation; providers must have effective governance, including assurance and auditing systems or processes. These must assess, monitor, and drive improvement in the quality and safety of the services provided, including the quality of the experience for people using the service.

The systems and processes must also assess, monitor and mitigate any risks relating the health, safety and welfare of people using services and others.

Providers must continually evaluate and seek to improve their governance and auditing practice.

They are also looking for providers to securely maintain accurate, complete and detailed records in respect of each person using the service and records relating to the employment of staff and the overall management of the regulated activity.

Governance is your overall strategy for the business which encompasses the Quality Assurance element.

Your Quality Assurance system will be part of this , the audits you do to look at the evidence you gather and ensure that they are meeting your standards and CQC standards. Remember the CQC standards are the minimum you have to meet.

Providers must seek and act on feedback from people using the service, those acting on their behalf, staff and other stakeholders, so that they can continually evaluate the service and drive improvement. If you don’t see patients if you are a provider that only does diagnostics reporting, you must still ask for feedback from those that you are providing your service to and those who you employ or those who you contract to do the work for you.

CQC are looking for providers should actively seek the views of a wide range of stakeholders, including people who use the service, staff, visiting professionals, professional bodies, commissioners, local groups, members of the public and other bodies, about their experience of, and the quality of care and treatment delivered by the service. Providers must be able to show how they have:

· analysed and responded to the information gathered, including taking action to address issues where they are raised, and

· used the information to make improvements and demonstrate that they have been made

CQC can prosecute for a breach of part of this regulation (17(3)) if a provider fails to submit such a report when requested. CQC may consider that this failure could prevent the provider from taking appropriate, timely action. CQC could therefore move directly to prosecution for a breach of this part of the regulation without first serving a Warning Notice.

Continuous improvement is important, learning form audits and the analysis lessons learnt are important. Looking at how you can disseminate the findings to others within the organisation. CQC are also looking for how you are going to improve processes for your clients, they want to know what plans you have in place.

Providers must monitor progress against plans to improve the quality and safety of services, and take appropriate action without delay where progress is not achieved as expected.

Where providers have to meet relevant nationally recognised guidance these should be looked at on a regular basis for updates. Providers should be aware that quality and safety...