CQC INSPECTION

Ann Marr

Chief Executive

July 2016

Introduction to the Trust

• Acute District General Hospital, with obstetrics and paediatrics, major provider of non-elective services, regional burns and plastics centre

• 887 beds, 4200 FTE staff, £309 million turnover • New PFI estate, opened 2010 • Ancient and long-serving CEO with stable,

talented Executive Team • CQC Inspection August 2015

CQC INSPECTION PREPARATION

• Visited other Trusts who had recently been inspected • Staff handbook – hard copies and available on the intranet • Dedicated intranet pages – with the CQC presentations and

handbook • Staff briefings, including sessions with student nurses,

therapy teams, junior doctors induction, Clinical Senate, Clinical Directors Forum, Grand Round, housekeepers, ward administrators and individual directorates based on the data pack issued by the CQC

• Weekly meetings with Matrons and Ward Managers • Team brief – monthly updates

CQC INSPECTION PREPARATION

• Staff magazine • Operational planning group • Regular progress reports to Executive Committee and to

Board • Mock CQC inspections with initial assessment,

development of action plan and reassessment • Internal service level assessments and action plans • Corporate assessment and action plans, e.g. reviewing all

policies, patient information and website • Ward visits by Executive team and Non-Executive Directors

CQC INSPECTION PREPARATION

• Lanyards for all staff with the Trust’s vision • Personalising the Trust vision – “what does it mean to

me?” displayed as boards throughout the Trust and on the intranet

• Board briefings for those being interviewed • Mock interviews for service leads – Directorate Managers

and Matrons, and for Executives, Chairman and Chair of Quality Committee

• Lots of anticipating and preparing for the information requests

• Identified a separate data lead and logistics lead

The ‘149’ moment

A state of mind……….

1 x 1 = 1 2 x 2 = 4 3 x 3 = 9 4 x 4 = 15

About the Trust

• Ever increasing numbers of patients are choosing the Trust for their care

• Provides acute, paediatric and maternity care

• Top class facilities – “one hospital on two sites”

• Optimal configuration of services

• 887 beds

• Out-patients and ambulatory care at St Helens

• £309m turnover

• 4200 FTE staff

Clinical and quality performance

Quality indicator 2013/14 2014/15

Mortality (HSMR) 98.6 98.1

Safety Thermometer (new harm free care) 95.2% 98%

Stroke Achieved Achieved

MRSA 4 2

C-Diff Achieved 33 Avoidable

Targets for Cancer waiting times Achieved Achieved

A&E Access (4 Hours) Achieved 94.2%

Referral to treatment targets Achieved

Achieved

Diagnostic waiting time targets Achieved

Achieved

% of patients treated 28 days following cancellation Achieved Achieved

Consistent messages

What we are most proud of

• Best patient experience in the NHS

• First nationally for PLACE

• 4th in national cancer survey

• First for Advancing Quality in 2014

• Top 20% scores for staff survey

• “Exceptional” medical engagement – top quintile

• Highest for flu vaccination rates

What we are most proud of

• No never events since May 2013

• 98-99% harm-free care in 2014/15

• NHS Litigation Authority Level 3 for Maternity Services

• Reductions in numbers of falls and pressure ulcers

Our staff say…

Staff Survey % Score

% above average

Care of patients is the organisation’s top priority 79 +12

The organisation acts on patients’ concerns 82 +13

Recommending the organisation as a place to work

72 +17

Happy with the standard of care for a relative 78 +16

Current challenges

• Activity pressures

– Discharges

– A&E 4 hour target

– Outliers

– Readmissions

– Length of stay

– Bed occupancy

• C- Difficile

• Incidence of falls

• Recruitment hotspots

• Complaints response times

• Finance

“Massive thank you to

A&E and the Surgical

team. Cannot fault the care

that Joe received from you

all. You are a credit to the

NHS and we as a family

will never forget how lovely

you all were.

C, D and Jx

What our patients say

Tips on managing the inspection itself

• Look after the inspection team • Bright orange lanyards for easy identification • Debrief after every interview, and at the end of

every day • Implement a system for logging and responding to

information requests via a central point • Respond to factual accuracy challenges with

evidence • Act swiftly on any issues raised – shows you are

capable

(Our) key ingredients of

“outstanding”

Clear, consistent vision translated into Trust objectives and different staff roles

“….ensuring that every decision the

Trust takes truly puts patients first”

Ann Marr Chief Executive

Meaningful values and behavioural standards

Genuinely putting patients first

(through actions not just words)

A happy ending…..