CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

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1 CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST Agenda Item 9.4 Report of: Professor R C Pearson Medical Director Paper prepared by: Sarah Corcoran Director of Clinical Governance Date of paper: July 2015 Subject: CQC Comprehensive Inspection November 3 rd 6 th 2015 Indicate which by Information to note Purpose of Report: Support Resolution Approval Consideration of Risk against Key Priorities: (Impact of report on key priorities and risks to give assurance to the Board that its decisions are effectively delivering the Trust s strategy in a risk aware manner) Recommendations: 1. Stand down the scheduled Quality Reviews Contact: Name: Sarah Corcoran, Director of Clinical Governance Tel:

2 The CQC has announced its intention to undertake a comprehensive inspection of CMFT over 4 days, 3 rd 6 th November A copy of the notification outlining the pre-inspection process is included at appendix A. Notification of the visit was received on Tuesday 16 th June providing a 20 week notice period. At present both Acute and Community areas are expected to receive a visit. At present no information has been received as to the size or composition of the inspection team. The core services that will be inspected are: Acute Urgent and Emergency Care Medical Care (including older people) Critical Care Surgery Maternity and Gynaecology Children and Young People End of Life Care Outpatient Services and Diagnostic Imaging Community Services Community health services for adults Community health services for children, young people and families Community health inpatient services Community end of life care It is also likely that there will be a focus on certain groups of patients examples are given as: Patients with a learning disability Patients with a mental health condition Patients with diabetes Patients with dementia Patients subject to a Deprivation of Liberty order Patients with protected characteristics Any other area may also be included at the time of the visit. 2

3 Process and Key Dates Notification of Board, OMG, CHDs and key personnel - complete 16 th June Notification of staff Notification of CCG Preparation of information request Information request 2 Inspection planning day Inspection visit - complete Thurs 18 th June - complete 22 nd June - complete due 30 th June submitted - due 11 th August (preparation in progress - will be due for submission 8 th September 2015) - 3 rd November (1/2 hr presentation from CEO) - 4 th, 5 th, 6 th November Figure 1 CQC inspection Process It is proposed that the Quality Review visits are stood down as the dates coincide exactly with those planned for the reviews. The Quality Review packs are now nearing completion so it is proposed that these are circulated and used, as planned, to address any issues evident. An assurance report is being prepared and will be used as the format for progress reporting over the next 20 weeks. 3

4 Proposed Inspection Logistics As yet the Trust has not been informed who will chair the visit or how many inspectors there will be. It is likely this will be 70+ people. The logistics will be coordinated by Sarah Corcoran and her team as soon as these details are known. It is proposed that a small group come together in the coming weeks to oversee the logistics and evidence preparation. All improvement work will continue to be undertaken by the current working groups, the oversight group will coordinate evidence submission from the work in progress. Planned key preparatory tasks for the inspection days and leads are: Sarah Corcoran to meet CQC Team and take them over to Nowgen (booked as a base for the CQC for the week) EDT: Tuesday 3 rd November PM: Attend main lecture theatre for presentations and introductions CEO presentation on: Background to the organisation Its approach to quality What is working well or outstanding Areas of concern or risk Tea and coffee served in Post Grad servery Admin Support Medical Director s PA to set up presentations Visitors passes to be distributed Site maps to be distributed Key personnel contact details and availability to be distributed* CQC onsite team support arrangements: *Corporate - Sarah Corcoran Jill Alexander Cheryl Lenney Dympna Ebah Catering arrangements for the week Sam Rowlands Divisional Directors Clinical Directors Heads of Nursing Clinical Effectiveness Leads. * Free up non-essential meetings and be available for introductions, internal communications, way finding and information gathering and diary clinical commitments to ensure availability known. Clinical commitments are not to be cancelled. 4

5 Key Risks / Concerns Quality assessment to date would suggest that there are a number of continuing risks for the organisation. These are: The quality of the health record Nurse staffing Cleanliness Pain management Management of the Mental Health Act and DoLS related issues End of Life Care Policy / guideline document control and storage / access The environment in MRI ED Food and nutrition These areas will continue to receive attention to try and address the risks and any ongoing risk will be presented as part of the CQC presentation required on 6 th November. Recommendations The Board are asked to support the decision to stand down the scheduled Quality Reviews in October / November and note the arrangements detailed in this paper. 5

6 Appendix A Care Quality Commission Health and Social Care Act 2008 Information about some of the ways CQC will gather people s views during our inspection Trust name: Central Manchester University Hospitals NHS Foundation Trust Provider ID: RW3 Dear Mr Deegan, As you know, we will be inspecting your trust on 3 rd 6 th November When an inspection takes place we gather information from a variety of sources. For example we will: Speak with people who use services. Hold a listening event. Hold small group meetings with leaders of key services. Hold drop in sessions for people who use services and staff. Hold focus groups with people who use services and their carers, and with separate groups of staff. Work with the Patients Association to carry out an analysis of the complaints handling process. Interview individual directors as well as staff of all levels. Check that the right systems and processes are in place. To do this effectively and to reflect the service being provided, we would like the inspection to be accessible to as many people who use the service and staff as possible. We would like your help to do this using the following methods. In advance of our inspection: Provider Information Request Stage 1 A short provider information request Excel workbook is attached to this letter. This asks for some basic information about your organisation structure and about the locations and services provided by the trust. We will use this information to inform the core 6

7 services to be inspected. It also asks for details of your main commissioners so that we can contact them as part of the pre inspection process. A guidance manual has been produced to help you complete the workbook. If you have any questions or queries about the information request then please contact Niomie Warner (Analyst Team Leader, [email protected]). Please submit this information no later than 30 th June To help us gather this information in a secure and efficient manner we would like you to use our dedicated Secure File Transfer Portal (SFTP). The portal works by CQC issuing login details to individual/s from your trust who can then access the site and save the information into their designated folders. The system then generates a notification informing us data has been received which we then retrieve from the system and forward to our analysts. The SFTP has many benefits as it significantly reduces demand on mailboxes and helps maintain the integrity of the data we receive, allowing us to forward to our analytical teams without delay. To enable us to create an account for yourselves could you please provide details of the person/s that require access (Name, Address & Phone Number) to [email protected]. It is recommended you provide these details as soon as possible so that the account/s can be set up well in advance of your submission deadline. Provider Information Request Stage 2 Twelve weeks prior to your inspection you will receive a more comprehensive provider information request which you will have 4 weeks to complete. All staff We have enclosed with this letter an to send to your staff. This outlines our invitation for staff to share their experience of working in your services through contacting our National Customer Service Centre or by speaking directly with our inspectors during the inspection visit. For community health services staff only we have provided a further option. These staff may alternatively wish to share their views and experience by completing our secure online questionnaire; details are included in the all staff . This information will be shared directly with the inspection team and none of the information provided will be used to identify individual responses. We ask that you: a) distribute the to your staff as soon as possible b) copy me in 7

8 Posters We want to receive as much feedback as possible from people who use your services. To give them advance notice of this, we have produced posters advertising the inspection and how to contact our inspectors. We would be grateful if you would display this information in reception areas, meeting rooms and communal areas where you think they would be most visible and have the most impact. We will supply the posters to you two weeks before the inspection and ask that you display them as soon as possible. Comment cards community health services only To enable us to receive additional feedback from people who use your community health services, we have produced comment cards for them to complete before the inspection. We would be grateful if you would arrange for these to be distributed to people who use services. Cards may be taken out by community nurses, for example, as well as being left on display in clinic areas. We will supply the comment cards along with sealed collection boxes to you three weeks before the inspection and ask that you display and distribute them as soon as possible. We ask that you: a) place the boxes where they can be most easily accessed by people who use community health services b) label each box so that we know which service(s) and/or location(s) the comments relate to c) collect the boxes and bring them with you when you come to present on the first day of the inspection We are grateful for your support in gaining the views of people who use services and staff members. During the inspection: Provider presentation The first day of the inspection 3 rd November 2015 will be a planning day. Towards the end of this day, we would like you and members of your senior team to make a thirty minute presentation to the inspection team about what are your organisation s strengths and what you think could be improved and/or are issues that you think pose a risk. 8