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CQC inspections – What are we doing to improve

May 30, 2019

Following the visit from the Care Quality Commission (CQC) in September 2018, the regulator published their report in April this year. Overall our Trust retains its rating of “requires improvement” however they rated our services as “outstanding” in the caring domain.
There is more to do, to ensure our acute children’s and adult services can achieve a “good” rating but also much to celebrate with removal of the “inadequate” ratings for safety and “outstanding” ratings for critical care.

In Medicine and Emergency Care, colleagues have begun drawing up plans in earnest, working hard to help the Trust move from ‘requires improvement’ up the ‘good’ rating we aspire to by highlighting key learning points from the inspection.

Emergency Care

  • Staff up to date with all Mandatory Training
  • Sufficient numbers of substantive staff are on each shift
  • Staff receive up to date annual appraisals, supervision meetings, and appraisal of work performance
  • Staffs understanding of mental capacity assessments, and lack of understanding of how to support MH patients.
  • Review how staff competencies are delivered and assessed
  • Four hour target to see, discharge, admit or transfer patients is fit for purpose.
  • FFT lower than national average

Admitted Care

  • Improve time to investigate complaints, to match trust policy
  • Risk registers have all relevant risks, that are complete and reviewed within designated
    time scales
  • Ensure mental capacity assessments, and best interest decisions are recorded in clinical notes. Actions needed to assess if patients had capacity to choose their level of support, or to give consent
  • Policies are kept up to date
  • Appropriate assessments for delirium, lying and standing BP and vision
  • Confidentiality of records, computers left unlocked.
  • Staff had limited understanding of Duty of Candor

David Carruthers, Medical Director added:,

“I think it’s important with any report like this that we do take on board the areas for improvement that have been identified for us to look at but we should also continue to keep working on the aspects of our services we already perform well at, many of which form part of our quality and safety plans.”

Chief Nurse, Paula Gardner, said:

“I was pleased to see the improvements in community inpatient ratings. The team have done some phenomenal work. Well done to everybody. The CQC also called out some outstanding practice that we need to be proud of such as the blue pillow initiative, domestic violence advisors in EDs, dedicated listening time for relatives in our stroke unit and the infant feeding conversation cards. We still have some more work to do, to get us to good and outstanding everywhere and that is making sure we get the basics right.”

We expect the CQC to return within 12 months to see how we have improved since last September.