CQC INSPECTION. Ann Marr Chief Executive July 2016

Transcription

1 CQC INSPECTION Ann Marr Chief Executive July 2016

2 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

3 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

4 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

5 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

6 The 149 moment

7 A state of mind. 1 x 1 = 1 2 x 2 = 4 3 x 3 = 9 4 x 4 = 15

8 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

9 Clinical and quality performance Quality indicator 2013/ /15 Mortality (HSMR) 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

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12 Consistent messages

13 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

14 What we are most proud of No never events since May % harm-free care in 2014/15 NHS Litigation Authority Level 3 for Maternity Services Reductions in numbers of falls and pressure ulcers

15 Our staff say Staff Survey % Score % above average Care of patients is the organisation s top priority The organisation acts on patients concerns Recommending the organisation as a place to work Happy with the standard of care for a relative

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

17 What our patients say 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

18 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

19 (Our) key ingredients of outstanding

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

21 .ensuring that every decision the Trust takes truly puts patients first Ann Marr Chief Executive

22 Meaningful values and behavioural standards

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24 Genuinely putting patients first (through actions not just words)

25 A happy ending..