At Care Group Level CQC Compliance Monitoring Framework 1. Utilising cascade training, Clinical Managers to ensure the staff within their Care Group are aware of the regulations, how to ensure compliance, the implications of failing to comply and how to raise a concern. All staff should know about the CQC staff leaflet available on the intranet; http://nww.bridgewater.nhs.uk/subpage.aspx?ipageid=14011 2. On an on-going basis all Clinical Managers to assess and monitor compliance with all CQC outcomes utilising the evidence guide across their care group. This should be documented on the form at appendix A 3. All care group level meeting agendas must include discussion re CQC e.g. i. Any current or potential compliance issues ii. Risks to compliance iii. Incidents that suggest a risk to compliance iv. Clinical audit that suggest a risk to compliance 4. On an on-going basis all staff are responsible for raising concerns re the quality of care provided directly with their line manager (or in exceptional circumstances utilising the whistleblowing policy). 5. On a monthly basis Clinical Managers to complete dashboard and submit to Service Manager (appendix B). 6. Any amber/red declarations must be accompanied by an action plan (appendix E) that articulates the exact nature of the compliance shortfall, which service or services it affects and the applicable Borough, the actions required to achieve compliance and associated deadlines. The action plan must be signed off by the General Manager. 7. Service Managers are responsible for; i. Working with their Clinical Managers and Clinical Leads to embed understanding of compliance and to ensure any shortfalls are identified and addressed. ii. Aggregating their care group declarations into a service declaration quarterly (appendix C) iii. Are accountable for the accuracy of the declaration 8. Care Group level compliance to be validated through Service Reviews. At Directorate Level 1. Service level declarations to be utilised to inform production of quarterly directorate declaration (appendix D). 2. Directorate compliance to be reported within Directorate assurance / governance structure quarterly.
3. Quarterly directorate declarations submitted to inform production of quarterly CQC Compliance report to Quality and Safety Committee. NB General Managers are accountable for the accuracy of the Directorate declarations and are responsible for signing off the reports before they are submitted up to the corporate body (appendix D). 4. Any non-compliance identified within a directorate should be raised with the Exec Nurse/Director of Governance and/or Chief Operating Officer by the General Manager. The impact on the Bridgewater registration should be agreed and where appropriate CQC should be contacted). 5. Any changes to services that may impact on the Bridgewater registration must be brought to the attention of the Exec Nurse/Director of Governance at the earliest opportunity by the General Manager so that any CQC change forms can be completed and submitted to CQC in a timely manner (appendix F). At Corporate Level 1. Staff bulletin articles/leaflets to be produced to raise staff awareness regarding compliance with CQC registration requirements and also the implications of non-compliance. 2. Quarterly submission of CQC Compliance report to Quality and safety Committee.
Assessment of Compliance with CQC Registration Requirements Flowchart Production and submission of quarterly CQC Compliance report to Quality and Safety Committee by Head of Governance Quarterly signed Directorate declarations submitted to Head of Governance Monthly submission of Service compliance dashboards to Directorate Governance Meeting Service level compliance validated by Service Reviews On an on-going basis all staff are responsible for raising concerns re the quality of care provided directly with their line manager (or in exceptional circumstances via the whistleblowing policy Monthly submission of care group compliance dashboards to Service Managers who then aggregate to produce a Service compliance dashboard Bridgewater Evidence Guide to help services selfassess and monitor on-going compliance. Clinical Managers to complete dashboard monthly.
Appendix A [Name of directorate] Directorate [Service Name and Care Group] Care Quality Commission Essential Standards Compliance Report Outcome 1 Respecting and involving people 2 Consent to care and treatment 4 Care and welfare of people who use services 5 Meeting nutritional needs 6 Cooperating with other providers 7 Safeguarding people who use services 8 Cleanliness and infection control 9. Management of medicines 10 Safety and suitability of premises 11 Safety, availability and suitability of equipment 12 Requirements relating to workers 13 staffing 14 Supporting workers 16 Assessing and monitoring quality of service provision 17 Complaints 21 Records Compliance level Narrative Summary Key pieces of evidence relied upon
Section 5 Quality and management Section 4 Suitability of staffing Section 3 Section 2 Section 1 Safeguarding and safety Personalised care, treatment & support Involvement and Information Appendix B Care Group Declaration Name of Care Group 2013/14 Outcome Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 1 Respecting and involving people who use services 2 Consent to care and treatment 4 Care and welfare of people who use services 5 Meeting nutritional needs 6 Co-operating with other providers 7 Safeguarding people who use services from abuse 8 Cleanliness and infection control 9 Management of medicines 10 Safety and suitability of premises 11 Safety, availability and suitability of equipment 12 Requirements relating to workers 13 Staffing 14 Supporting Staff 16 Assessing and monitoring the quality of service provision 17 Complaints 21 Records If you are declaring anything other than fully compliant you are required to specify reason for non-compliance and report action plan to the relevant Head of Service Full compliance Insufficient Assurance Not Compliant Outcome Not Relevant to Service
Section 5 Quality and management Section 4 Suitability of staffing Section 3 Section 2 Section 1 Safeguarding and safety Personalised care, treatment & support Involvement and Information Appendix C Service quarterly declaration (to be signed and dated by Service Manager) Name of Service 2013/14 Outcome Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 1 Respecting and involving people who use services 2 Consent to care and treatment 4 Care and welfare of people who use services 5 Meeting nutritional needs 6 Co-operating with other providers 7 Safeguarding people who use services from abuse 8 Cleanliness and infection control 9 Management of medicines 10 Safety and suitability of premises 11 Safety, availability and suitability of equipment 12 Requirements relating to workers 13 Staffing 14 Supporting Staff 16 Assessing and monitoring the quality of service provision 17 Complaints 21 Records If you are declaring anything other than fully compliant you are required to specify reason for non-compliance and report action plan to the relevant Head of Service Full compliance Insufficient Assurance Not Compliant Outcome Not Relevant to Service
Section 5 Quality and management Section 4 Suitability of staffing Section 3 Section 2 Section 1 Safeguarding and safety Personalised care, treatment & support Involvement and Information Appendix D - Directorate quarterly declaration (to be signed and dated by General Manager) Name of Directorate 2013/14 Outcome Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 1 Respecting and involving people who use services 2 Consent to care and treatment 4 Care and welfare of people who use services 5 Meeting nutritional needs 6 Co-operating with other providers 7 Safeguarding people who use services from abuse 8 Cleanliness and infection control 9 Management of medicines 10 Safety and suitability of premises 11 Safety, availability and suitability of equipment 12 Requirements relating to workers 13 Staffing 14 Supporting Staff 16 Assessing and monitoring the quality of service provision 17 Complaints 21 Records
Appendix E Reporting Non-compliance Care Quality Commission Essential Standards Action Plan Directorate: Location/Service: Borough: Action Plan relating to: Care Quality Commission Outcome Or Heath and Social Care Act 2008 Criterion Action required to Enhance Compliance Not Compliant Identify the details of the area that needs to be improved i.e. what is the shortfall in compliance and what is the impact on patients. Use data where available to illustrate the shortfall. What action needs to be taken? Say explicitly what is to be achieved: By when and by whom: How are you going to ensure that improvements have been made? What measures are going to put in place and who will do it? Describe the resources needed to implement the changes and whether or not they are in place: Describe the impact the improvements will have on people who use the service: How we will monitor to check that the action plan is working? Action Plan to be Signed and Dated by General Manager:
Appendix F Registration with Care Quality Commission Change to Services/Location Notification Form It is essential that any changes to services are highlighted as soon as possible in order to ensure that the necessary forms can be submitted to CQC with sufficient time for the certificate of registration to be amended. Please be aware that it can take up to 8 weeks for CQC to update the certificate of registration. NB CQC state that; you cannot start to provide a regulated activity from a new location until your application has been approved, and you have received a Notice of Decision to confirm this it is illegal to carry on a regulated activity before you are registered, and you must not backdate the application form. You are only registered when we issue you with a Notice of Decision. Directorate: Potential New Contract. Please provide brief outline below regarding potential new services e.g. service type, regulated activity, location, intended start date etc. No longer providing a service. Please provide brief outline below regarding service that will no longer be provided e.g. service type, regulated activity, location, date service due to cease etc. Services transferring to different location. Please provide details of original and new location including intended date of transfer. Closure of location. Please provide details of services provided from the closing location, the impact on service provision and intended date of closure. Form to be signed and dated by General Manager: