PAPER FOR NHS LUTON COMMUNITY SERVICES BOARD MEETING HELD ON 21 ST APRIL 2010

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1 PAPER FOR NHS LUTON COMMUNITY SERVICES BOARD MEETING HELD ON 21 ST APRIL 2010 TITLE AUTHOR(S) PRESENTED BY DIRECTOR S SIGNATURE PURPOSE/ SUMMARY DECISION REQUIRED Standards fr Better Health & CQC Registratin Reprt Andy Nuckcheddee, Assciate Directr f Gvernance & Crprate Affairs and Acting Directr f Operatins, Lutn Cmmunity Services. Andy Nuckcheddee, Assciate Directr f Gvernance & Crprate Affairs and Acting Directr f Operatins, Lutn Cmmunity Services. Chris White, Interim Chief Operating Officer, Lutn Cmmunity Services The purpse f this paper is t infrm the Shadw Bard f changes in relatin t the Care Quality Cmmissin s new Registratin & Assessment Prcess and als t prvide an update f the cmpliance against cre Standards The Shadw Bard Members are asked t nte: (1) The new Registratin prcess and the requirements fr NHS prviders as f 1 st April (2) LCS cmpliance against the Cre Standards and the end f financial year declaratin. DATE 21 st April 2010 SPECIFIC LINKS TO RISK REGISTER LINKS TO STANDARDS FOR BETTER HEALTH FINANCIAL IMPLICATIONS DIVERSITY IMPACT CLINICAL IMPLICATIONS PATIENT SAFETY IMPLICATIONS PRE MEETING ENQUIRIES TO There are specific links t the Risk Register in relatin t Crprate Gvernance and adherence t legislative requirements. C2, C5d, C7e, C18 and C23 The new system f registratin fr prviders f healthcare services carries a registratin charge in the regin f 30k. It is nt yet knwn whether there will be a similar charge levied n cmmissiners. It is intended that the new system f registratin will ensure that a basic minimum f quality services will be met by prviders ensuring that high quality services are available t all members f the ppulatin. The cnsultatin that is currently underway cncerning cmmissiners fcuses heavily n jint wrking acrss bth health and scial care t bring abut effective partnership wrking that addresses health inequalities. The Care Quality Cmmissin aim t raise the standard f healthcare services t ensure that high quality services are available t all members f the ppulatin. The Care Quality Cmmissin aim t raise the standard f healthcare services t ensure that high quality services are available t all members f the ppulatin. Andy Nuckcheddee, Assciate Directr f Gvernance Ext 3881 ( anand.nuckcheddee@lutn-pct.nhs.uk) 1

2 1. Executive Summary The purpse f this paper is t: (1) Highlight the changes already implemented by the Care Quality Cmmissin (CQC) in terms f the registratin f prviders f healthcare services. (2) Give a current psitin statement n the Standards fr Better Health Declaratin n the Cre Standards as f 31 st March (3) T prvide LCS Bard Members with key infrmatin n the Registered Activities and Lcatins fr LCS (4) T prvide infrmatin n hw the new assessment prcess will be cnducted by the CQC in relatin t the Regulated Activities and Lcatins. 2. New Registratin system fr prviders f healthcare services April 2010 a) Registered r Regulated Activities Under the new registratin prcess there are a ttal f 15 Regulated Activities. Fllwing lengthy discussins with the CQC Lead Assessr, it was agreed that LCS services shuld fall under the fllwing Regulated Activities: ; Accmmdatin fr persns wh require treatment fr substance misuse; Treatment f Disease, Disrder and Injury; Diagnstic Screening; Family Planning. It was agreed by the CQC Assessr that Health Visiting falls under the regulated activity f Nursing Care and that persnal care prvided by healthcare assistants emplyed by LCS wuld als fall under. It is imprtant t nte that LCS had initially prudently registered minr surgical interventins carried ut at the Ldge under the Gynaeclgy services as a Regulated Activity but fllwing a review by the CQC assessrs LCS was advised that surgical vasectmy carried ut under lcal anaesthetic within cmmunity setting did nt fall within the definitin f Regulated Activities fr Surgical Prcedures. Evidence f discussins such as s crrespndence and minutes f meetings with the CQC Assessrs are available fr future reference. b) Registered Lcatins Under the new registratin prcess all prviders are required by law t register the Lcatins where the abve mentined Regulated Activities are prvided n a day t day basis. It was agreed by the CQC Assessrs that it wuld be impracticable t register all lcatins r bases frm where Lutn Cmmunity Services prvide healthcare services. Therefre, bases such as the Atrium, Regents Curt, Wigmre Lane Health Centre, Liverpl Rad Health Centre and any ther such Health Centres where the Heads f Services and the Clinical Gvernance activities are managed r crdinated shuld be registered under the Headquarters, that is, the Learning & Develpment Centre. Fllwing further discussins with the CQC Assessrs, the numbers f Registered Lcatins were reduced t the fllwing: The Ldge (Registered Manager, Head f Service) Treatment f disease, disrder and injury Diagnstic Screening and Screening Prcedures Family Planning 2

3 Respite Huse (Registered Manager, Shared Drug Services Mdern Matrn) Accmmdatin fr persns wh require treatment fr substance misuse The Lutn Treatment Centre (Registered Manager) Treatment f disease, disrder and injury Diagnstic Screening and Screening Prcedures Walk-in-Centre (Registered Manager, Directr f Service Imprvement) Diagnstic Screening and Screening Prcedures Treatment f Disease and Disrder Edwin Lb Centre (Registered Manager, Head f Children Services) Treatment f Disease and Disrder Diagnstic Screening and Screening Prcedures Learning & Develpment Centre (Registered Managers, Heads f Service) Treatment f Disease and Disrder Diagnstic Screening and Screening Prcedures 3. Regulatins f NHS prviders As f April 2010 the Annual Health Check Declaratin fr Standards fr Better Health will cease t exist. This has been replaced by new regulatry framewrk under the Health and Scial Care Act Instead f carrying ut assessments under Standards fr Better Health in the middle f a financial year, the CQC will cnduct unannunced inspectin visits t any f the abve Registered Lcatins. The system f registratin is the fundatin f the new regulatry framewrk, whereby prviders will need t meet essential standards f safety and quality set by registratin. The CQC will cnduct nging mnitring f cmpliance and take actin where there are areas f cncern r risk. In additin, the CQC inspectrs will undertake peridic reviews. The purpse f these reviews is t assess cmpliance f Registered Lcatins against the belw listed Regulatins. N. Regulatin 9. Care and welfare f service users 10. Assessing and mnitring the quality f service prvisin 11. Safeguarding service users frm abuse 12. Cleanliness and infectin cntrl 13. Management f medicines 14. Meeting nutritinal needs 15. Safety and suitability f premises 3

4 16. Safety, availability and suitability f equipment 17. Respecting and invlving service users 18. Cnsent t care and treatment 19. Cmplaints 20. Recrds 21. Requirements relating t wrkers 22. Staffing 23. Supprting wrkers 24. C-perating with ther prviders 25. Care and welfare f service users The CQC s strategy fr fcuses n the fllwing five strategic pririties:- 1 Ensuring care is centred n peple s needs and prtects their rights; 2 Champining jined-up care; 3 Acting swiftly t help eliminate pr quality care; 4 Prmting high quality care; 5 Regulating effectively in partnership. 4. NHS Prviders Quality Risk Prfile In rder t assist with the mnitring prcess, all NHS trusts have been prvided with a Quality Risk Prfile (QRP) by the CQC. This gives infrmatin abut NHS prviders quality f care and will assist cmmissiners in ensuring that quality services are being cmmissined and delivered as per the cmmunity services cntract. The QRP is split int five sectins that cver invlvement and infrmatin; persnalised care, treatment and supprt; safeguarding and safety; suitability f staffing and quality and management. Drawing n a range f infrmatin surces, the CQC highlights any areas f cncern within each sectin. Fr example, the sectin n suitability f staffing includes utcmes frm the annual staff survey, s culd include areas f cncern arund persnal develpment r flexible wrking. The QRP als details thse standards that were declared as either insufficient assurance r nncmpliant fllwing the mid year declaratin fr Standards fr Better Health. QRPs fr all prviders will becme available n the CQC website frm the 1 st April 2010 and all NHS rganisatins have been prmpted t ensure that they plan fr any media interest r Freedm f Infrmatin requests that the QRP may generate. It is imprtant t nte that as it currently stands all independent healthcare services will need t be registered with the CQC by the 1 st Octber Other independent cntracts such as Dental Services will have t be registered by April 2011 and GP practices by April All cmmissiners f healthcare services have been asked t cnsider whether apprpriate internal mechanisms are in place thrugh which significant cncerns can be identified and where apprpriate respnded t in relatin t cmmissined services. These systems and prcesses must be in place by the 1 st April NHS Lutn has undertaken a review f its mnitring mechanisms and has in place a system that will ensure that bth the registratin f its prviders and QRP s are scrutinised. NHS Lutn is requesting the QRP frm all prviders. 4

5 5. NHS LCS Mid-year year Declaratin f Cmpliance against Standards fr Better Health Check a) Criteria fr Assessing Cre Standards in 2009/10 The CQC assessment and rating f NHS Lutn in 2009/10 has taken a different frmat frm that f previus years. The new frmat allws the CQC t reprt separately n the perfrmance f services which the PCT prvides (as prviders, Lutn Cmmunity Services) and its rle as a cmmissiner f healthcare services fr its lcal cmmunity. T reflect these changes tw sets f criteria fr assessing PCTs; ne fr their rle as prviders and ne set fr their rle as cmmissiners f services has been prvided as guidance fr PCTs t wrk frm. b) Mid-Year Declaratin 2009/10 With reference t the CQC mid-year Declaratin there are sme terms that are used t decide the statement f cmpliance fr each f the cre standards and they are as fllws: Cmpliant & Reasnable Assurance: A standard can be declared cmplaint if there is sufficient assurance fr the perid 1 April 2009 t 31 Octber Fr the Bard t declare a standard cmpliant, they must be assured that any prcesses, plicies, prcedures etc have been in place fr the date perid year withut any significant lapses; Significant lapses: In making this decisin, Bards will cnsider the extent f risk f harm this lapse psed t patients, staff and the public, r indeed the harm actually dne as a result f the lapse; Insufficient Assurance: If the Standard has nt been in place fr the perid 1 April 2009 t 31 Octber 2009, it is pssible t declare insufficient assurance. This is where the standard wuld have a full actin plan in place that supprts any wrk that is nging t reach cmpliance; Nt met: This means that the Bard was clear that there had been ne r mre significant lapses in relatin t a standard during the assessment year. In December 2009 NHS Lutn Cmmunity Services declared insufficient assurance against the fllwing standards fr the mid-year declaratin: Standard Statement f Cmpliance C2 - Safeguarding Children Insufficient Assurance C5d - Clinical Audit Insufficient Assurance C7e - Equality & Diversity (discriminatin, equality and respect human rights) Insufficient Assurance C18 - Equal Access & Chice t Ppulatin Insufficient Assurance C23 - Disease preventin and health prmtin prgrammes t meet NSFs & natinal plans Insufficient Assurance 5

6 c) 09/10 Declaratin n Annual Health Check The cmpliance against Standards fr Better Health has been mnitred thrugh the mnthly Standards fr Better Health Meetings. LCS Bard als submits mnthly Gvernance self certificatin t the East f England Strategic Health Authrity in which it prvides regular updates n the prgress achieved in ensuring that LCS meets full cmpliance against the abve mentined Standards. By 31 st March 2010 NHS LCS declared full cmpliance against all the cre standards including thse which were declared as having insufficient assurance in the mid year declaratin. The main areas f cncern were risk f achieving full cmpliance against Standard C 23 relating t natinal targets such as Chlamydia, Smking Cessatin and Breast Feeding. These have been discussed with LCS Bard and als with the relevant Standard Lead and actin plans have been develped t ensure that LCS will meet full cmpliance in the year end 10/ Update n CQC Registratin An Actin Plan will be submitted t the next LCS Bard demnstrating hw NHS LCS is mnitring cmpliance with its Quality and Risk Prfile, in particular the areas f cncern raised by CQC in relatin t previus Staff Surveys 07/08 based n the fllwing Regulatins: Regulatin 11 (safeguarding Children); Regulatin 12 (Staff Survey); Regulatin 15 (Cunter Fraud and NHS Security Management Service); Regulatin 21 and 23 (Staff Survey- Equal Opprtunities and Flexible Wrking) and Regulatin 10 ( Clinical Audit). LUTON COMMUNITY SERVICES JUNE