CQC develops new criteria for quality and safety of care Professor Alan Glasper discusses the Care Quality Commission’s (CQC) new strategy to monitor care delivery in English hospitals—and what it means for the nursing profession patients are always the recipients of optimal care delivery. The CQC has reflected on some of the failings in the health services, but especially on those that affected elderly care at Mid Staffordshire and the care of people with learning disabilities at Winterbourne View, a private hospital in South Gloucestershire (Department of Health (DH), 2012). The CQC has developed the five key questions with reference to the areas that Lord Darzi defined as central to quality in healthcare (CQC, 2013), that is, safety, clinical effectiveness and the experience of people who use services. However, because the CQC regulates social care as well as health services, their approach to assessing effectiveness will be broader than clinical effectiveness. For that reason, the current 28 GAC regulations and the associated 16 outcomes will gradually be replaced by these five key questions during an inspection of any service. The five key questions are: ■■ Is it safe? ■■ Is it effective? ■■ Is it caring? ■■ Is it responsive to people’s needs? ■■ Is it well-led?
Background
In addition to the five key questions that will be asked of any health and social care organisation, over the coming months the CQC will develop new standards of care. These will include the ‘fundamentals of care’ recommended by Robert Francis, which no provider (such as a hospital) will be able to fail without facing serious consequences. Additionally, the CQC will work with the National Institute for Health and Care Excellence (NICE) to ensure these fundamentals of care align with their quality standards and so provide a comprehensive spectrum of standards. The CQC envisages three levels of standards against which providers will be assessed: ■■ Fundamental standards. A legal requirement for any provider to operate a service
Change to the current system is necessary because, since its inception, the CQC itself has come under scrutiny for the way it conducts its operations—exemplified perhaps by the events at the Mid Staffordshire NHS Foundation Trust, which precipitated a crisis in care delivery in the NHS, requiring a re-examination of what the NHS currently does and what it might do to improve. These changes are designed to avoid a repetition of the events at Mid Staffordshire. It is acknowledged that, despite a previous CQC inspection, the harms perpetrated on patients at that trust were not uncovered and it is against this backdrop that the CQC is introducing new strategies to ensure that
110
Standards against which all providers will be assessed
■■ Expected
standards. Standards of care that users should expect as a matter of course ■■ High-quality care. Standards set by bodies such as NICE with the purpose of driving improvements in provider organisations. To help develop the standards of what the fundamentals of care should be, the CQC has started a debate on their formulation, which will focus on the very basics of care that matter to people and will be easily understood by all. The CQC has gone out to public consultation to help in the development of these future standards, but has suggested a number of examples of what might become fundamental standards. For example: ■■ I will be cared for in a clean environment ■■ I will be protected from abuse and discrimination ■■ I will be protected from harm during my care and treatment ■■ I will be given pain relief or other prescribed medication when I need it ■■ When I am discharged, my ongoing care will have been organised properly first ■■ I will be helped to use the toilet and to wash when I need to ■■ I will be given enough food and drink, and help to eat and drink if I need it ■■ If I complain about my care, I will be listened to and not victimised as a result ■■ I will not be held against my will, coerced, or denied care and treatment without my consent or the proper legal authority. The CQC appointed Professor Sir Mike Richards as the new Chief Inspector of Hospitals. Starting in the final months of 2013 and extending into this year, he is leading significantly bigger hospital inspection teams that consist of prominent clinical and other experts, and include trained members of the public. These inspection teams are spending longer periods of time—measured in days— inspecting hospitals, and cover every site that delivers acute services and eight key service areas: ■■ Emergency departments ■■ Maternity
© 2014 MA Healthcare Ltd
T
he Health and Social Care Act 2008 established The Care Quality Commission (CQC) as the principal regulator for health and adult social care in England, with stringent powers to ensure that safe and high-quality services were provided to patients. Its primary mission is to facilitate improvements, champion the rights of the people who use services, acting promptly to address any poor or underperforming areas of practice and gather and share knowledge and expertise.The CQC assessed the compliance of hospitals and other care environments to specified regulations, 28 in total, called ‘essential standards of quality and safety’, known colloquially as ‘GAC’ or ‘guidance about compliance’ (CQC, 2010). These regulations are widely available and have been used by CQC inspectors since 2010 to judge how compliant organisations are in applying the standards. However, in June 2013, the CQC announced that the old system of inspections was to be phased out. It would be gradually replaced by a new system that posed more highly focused questions about the quality and safety of care during inspections in hospitals, care homes and other health and social care institutions (CQC, 2013).
British Journal of Nursing, 2014, Vol 23, No 2
British Journal of Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 27, 2015. For personal use only. No other uses without permission. . All rights reserved.
HEALTHCARE POLICY ■■ Paediatrics ■■ Acute
medical pathways ■■ Acute surgical pathways ■■ Care for the frail elderly ■■ End-of-life care ■■ Outpatients. With regard to end-of-life care, it is important to stress that despite much negative media attention and terminology, such as the ‘road to death’ (BBC News, 2013), the Neuberger Review, led by Baroness Neuberger, has recognised the positive contribution that the Liverpool Care Pathway and similar approaches to end-of-life care have made to clinical decision-making (DH, 2013). These new-style inspections are designed to facilitate the acquisition of a much more detailed picture of care in hospitals than was possible in the past. To this end, inspections will be supported by a better method for identifying risks and with much more information directly from patients, their families and hospital staff. These new-wave hospital inspections are configured as a mixture of unannounced and announced visits. They also include inspections in the evenings and weekends, when care delivery practices are believed to be often less than optimal.
© 2014 MA Healthcare Ltd
What should nursing staff do if they encounter a CQC inspector or specialist advisor in practice settings? Crucially, nurses have nothing to be apprehensive about in the event of a CQC inspection visit to a clinical area. Their focus is always on the impact of care on patients and it is their role to ensure that all patients receive safe and high-quality care wherever and whenever it is provided. CQC personnel are always courteous and will introduce themselves by name to all staff and patients. On arrival to a patient area, they will normally seek out the nurse in charge of that shift and explain their mission. All official CQC personnel carry a CQC warrant, which a nurse on duty should ask to see. CQC inspectors also wear a purple lanyard (neck cord) with photographic identification. This warrant gives CQC personnel a legal right to be there; to request to speak to patients and staff; and to inspect all relevant hospital notes and other documentation. The CQC visitor will explain which of the standards they will be inspecting against, but they may decide to check on additional standards during the inspection. Throughout their time spent in a clinical area, the inspector will crosscheck what they see and hear against other
British Journal of Nursing, 2014, Vol 23, No 2
evidence, such as records or other information, to judge whether or not the regulations are being met. But it is important to stress that, where they see, hear or find evidence to show that the care being provided is what should be expected for people in hospital, or where they see excellent or innovative practice, CQC inspectors will reflect this in their reports. In other words, their job is also to praise examples of good practice, not merely to identify examples of the bad. Many of the specialist CQC advisors will be nurses themselves and will adhere to hospital/ ward protocols concerning safety, infection control, privacy and dignity, among others. For example, all CQC personnel will: ■■ Observe ‘bare below the elbow’ guidance in all patient areas; leave unnecessary clothes/ coats and bags in a secure area before they enter a patient area; wear minimal jewellery; and be mindful of nail decorations, long hair, ties and badges ■■ Use the hand-washing facilities and alcohol dispensers frequently during the carrying out of their duties ■■ Be instructed not to visit the patient areas during protected times (such as meals), unless they are specifically reviewing the management of mealtimes (for example, in elderly-care environments) ■■ Keep notes of their meetings, in accordance with enforcement guidance. A major aspect of a CQC inspection is talking to patients. Inspectors/advisors will endeavour to ask a nurse if an individual patient is well enough to be interviewed, and to accompany them and introduce them to a named patient. It is not the intention of the CQC team to interfere with the smooth running of a ward or department, and CQC personnel will always excuse themselves if a patient needs to be seen by a doctor/nurse or needs a clinical
intervention. Should a patient need nursing or medical attention during an interview, CQC personnel will seek help for them immediately.
CQC inspection timetable The new-style inspections started in October 2013 but will be rolled out nationally throughout 2014 and, over the next three years, the CQC will develop a rating system based on the judgements made by their hospital inspectors. These ratings will also reflect other sources of data, such as findings from clinical audits and from inspections carried out by other professional bodies, such as royal colleges. It is the CQC’s intention (they started in December 2013) to rate providers of acute services with the objective of rating all hospitals by the end of 2015. This new rating system will be a single authoritative assessment of the quality and safety of care of the services regulated under the mandate of the CQC.
Conclusion The CQC wants to make changes to NHS culture that will stop another care catastrophe like that at the Mid Staffordshire NHS Foundation Trust from happening again, and to save other people and other places from similar harm. Nurses already play a major role in all aspects of quality care management, and will welcome this new set of measurable standards BJN and outcomes from the CQC. BBC News (2013) Liverpool Care Pathway: ‘They told my family I was dying’. 15 August 2013. http://www.bbc. co.uk/news/health-23698071 (accessed 8 January 2014) Care Quality Commission (2010) Essential Standards of Quality and Safety. CQC, London Care Quality Commission(2013) A New Start. Consultation on Changes to the Way CQC Regulates, Inspects and Monitors Care. CQC, London Department of Health (2012) Transforming Care: A National Response to Winterbourne View Hospital. DH, London Department of Health (2013) More Care, Less Pathway. A Review of the Liverpool Care Pathway. DH, London
KEY POINTS n The old system of CQC inspections is being phased out and replaced by a new system based on highly-focused questions about the quality and safety of care in hospitals n Changes to CQC hospital inspections are needed to avoid a repetition of the events uncovered at the Mid Staffordshire NHS Foundation Trust n As well as the introduction of five key questions that will be asked of any health and social care organisation, the CQC will develop new standards of care n New-style inspections of hospitals are designed to create a much more detailed picture of care than was previously possible n Nurses should not feel apprehensive about CQC inspection visits, since the CQC’s focus is always on the impact of care on patients
111
British Journal of Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 27, 2015. For personal use only. No other uses without permission. . All rights reserved.
Background
In addition to the five key questions that will be asked of any health and social care organisation, over the coming months the CQC will develop new standards of care. These will include the ‘fundamentals of care’ recommended by Robert Francis, which no provider (such as a hospital) will be able to fail without facing serious consequences. Additionally, the CQC will work with the National Institute for Health and Care Excellence (NICE) to ensure these fundamentals of care align with their quality standards and so provide a comprehensive spectrum of standards. The CQC envisages three levels of standards against which providers will be assessed: ■■ Fundamental standards. A legal requirement for any provider to operate a service
Change to the current system is necessary because, since its inception, the CQC itself has come under scrutiny for the way it conducts its operations—exemplified perhaps by the events at the Mid Staffordshire NHS Foundation Trust, which precipitated a crisis in care delivery in the NHS, requiring a re-examination of what the NHS currently does and what it might do to improve. These changes are designed to avoid a repetition of the events at Mid Staffordshire. It is acknowledged that, despite a previous CQC inspection, the harms perpetrated on patients at that trust were not uncovered and it is against this backdrop that the CQC is introducing new strategies to ensure that
110
Standards against which all providers will be assessed
■■ Expected
standards. Standards of care that users should expect as a matter of course ■■ High-quality care. Standards set by bodies such as NICE with the purpose of driving improvements in provider organisations. To help develop the standards of what the fundamentals of care should be, the CQC has started a debate on their formulation, which will focus on the very basics of care that matter to people and will be easily understood by all. The CQC has gone out to public consultation to help in the development of these future standards, but has suggested a number of examples of what might become fundamental standards. For example: ■■ I will be cared for in a clean environment ■■ I will be protected from abuse and discrimination ■■ I will be protected from harm during my care and treatment ■■ I will be given pain relief or other prescribed medication when I need it ■■ When I am discharged, my ongoing care will have been organised properly first ■■ I will be helped to use the toilet and to wash when I need to ■■ I will be given enough food and drink, and help to eat and drink if I need it ■■ If I complain about my care, I will be listened to and not victimised as a result ■■ I will not be held against my will, coerced, or denied care and treatment without my consent or the proper legal authority. The CQC appointed Professor Sir Mike Richards as the new Chief Inspector of Hospitals. Starting in the final months of 2013 and extending into this year, he is leading significantly bigger hospital inspection teams that consist of prominent clinical and other experts, and include trained members of the public. These inspection teams are spending longer periods of time—measured in days— inspecting hospitals, and cover every site that delivers acute services and eight key service areas: ■■ Emergency departments ■■ Maternity
© 2014 MA Healthcare Ltd
T
he Health and Social Care Act 2008 established The Care Quality Commission (CQC) as the principal regulator for health and adult social care in England, with stringent powers to ensure that safe and high-quality services were provided to patients. Its primary mission is to facilitate improvements, champion the rights of the people who use services, acting promptly to address any poor or underperforming areas of practice and gather and share knowledge and expertise.The CQC assessed the compliance of hospitals and other care environments to specified regulations, 28 in total, called ‘essential standards of quality and safety’, known colloquially as ‘GAC’ or ‘guidance about compliance’ (CQC, 2010). These regulations are widely available and have been used by CQC inspectors since 2010 to judge how compliant organisations are in applying the standards. However, in June 2013, the CQC announced that the old system of inspections was to be phased out. It would be gradually replaced by a new system that posed more highly focused questions about the quality and safety of care during inspections in hospitals, care homes and other health and social care institutions (CQC, 2013).
British Journal of Nursing, 2014, Vol 23, No 2
British Journal of Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 27, 2015. For personal use only. No other uses without permission. . All rights reserved.
HEALTHCARE POLICY ■■ Paediatrics ■■ Acute
medical pathways ■■ Acute surgical pathways ■■ Care for the frail elderly ■■ End-of-life care ■■ Outpatients. With regard to end-of-life care, it is important to stress that despite much negative media attention and terminology, such as the ‘road to death’ (BBC News, 2013), the Neuberger Review, led by Baroness Neuberger, has recognised the positive contribution that the Liverpool Care Pathway and similar approaches to end-of-life care have made to clinical decision-making (DH, 2013). These new-style inspections are designed to facilitate the acquisition of a much more detailed picture of care in hospitals than was possible in the past. To this end, inspections will be supported by a better method for identifying risks and with much more information directly from patients, their families and hospital staff. These new-wave hospital inspections are configured as a mixture of unannounced and announced visits. They also include inspections in the evenings and weekends, when care delivery practices are believed to be often less than optimal.
© 2014 MA Healthcare Ltd
What should nursing staff do if they encounter a CQC inspector or specialist advisor in practice settings? Crucially, nurses have nothing to be apprehensive about in the event of a CQC inspection visit to a clinical area. Their focus is always on the impact of care on patients and it is their role to ensure that all patients receive safe and high-quality care wherever and whenever it is provided. CQC personnel are always courteous and will introduce themselves by name to all staff and patients. On arrival to a patient area, they will normally seek out the nurse in charge of that shift and explain their mission. All official CQC personnel carry a CQC warrant, which a nurse on duty should ask to see. CQC inspectors also wear a purple lanyard (neck cord) with photographic identification. This warrant gives CQC personnel a legal right to be there; to request to speak to patients and staff; and to inspect all relevant hospital notes and other documentation. The CQC visitor will explain which of the standards they will be inspecting against, but they may decide to check on additional standards during the inspection. Throughout their time spent in a clinical area, the inspector will crosscheck what they see and hear against other
British Journal of Nursing, 2014, Vol 23, No 2
evidence, such as records or other information, to judge whether or not the regulations are being met. But it is important to stress that, where they see, hear or find evidence to show that the care being provided is what should be expected for people in hospital, or where they see excellent or innovative practice, CQC inspectors will reflect this in their reports. In other words, their job is also to praise examples of good practice, not merely to identify examples of the bad. Many of the specialist CQC advisors will be nurses themselves and will adhere to hospital/ ward protocols concerning safety, infection control, privacy and dignity, among others. For example, all CQC personnel will: ■■ Observe ‘bare below the elbow’ guidance in all patient areas; leave unnecessary clothes/ coats and bags in a secure area before they enter a patient area; wear minimal jewellery; and be mindful of nail decorations, long hair, ties and badges ■■ Use the hand-washing facilities and alcohol dispensers frequently during the carrying out of their duties ■■ Be instructed not to visit the patient areas during protected times (such as meals), unless they are specifically reviewing the management of mealtimes (for example, in elderly-care environments) ■■ Keep notes of their meetings, in accordance with enforcement guidance. A major aspect of a CQC inspection is talking to patients. Inspectors/advisors will endeavour to ask a nurse if an individual patient is well enough to be interviewed, and to accompany them and introduce them to a named patient. It is not the intention of the CQC team to interfere with the smooth running of a ward or department, and CQC personnel will always excuse themselves if a patient needs to be seen by a doctor/nurse or needs a clinical
intervention. Should a patient need nursing or medical attention during an interview, CQC personnel will seek help for them immediately.
CQC inspection timetable The new-style inspections started in October 2013 but will be rolled out nationally throughout 2014 and, over the next three years, the CQC will develop a rating system based on the judgements made by their hospital inspectors. These ratings will also reflect other sources of data, such as findings from clinical audits and from inspections carried out by other professional bodies, such as royal colleges. It is the CQC’s intention (they started in December 2013) to rate providers of acute services with the objective of rating all hospitals by the end of 2015. This new rating system will be a single authoritative assessment of the quality and safety of care of the services regulated under the mandate of the CQC.
Conclusion The CQC wants to make changes to NHS culture that will stop another care catastrophe like that at the Mid Staffordshire NHS Foundation Trust from happening again, and to save other people and other places from similar harm. Nurses already play a major role in all aspects of quality care management, and will welcome this new set of measurable standards BJN and outcomes from the CQC. BBC News (2013) Liverpool Care Pathway: ‘They told my family I was dying’. 15 August 2013. http://www.bbc. co.uk/news/health-23698071 (accessed 8 January 2014) Care Quality Commission (2010) Essential Standards of Quality and Safety. CQC, London Care Quality Commission(2013) A New Start. Consultation on Changes to the Way CQC Regulates, Inspects and Monitors Care. CQC, London Department of Health (2012) Transforming Care: A National Response to Winterbourne View Hospital. DH, London Department of Health (2013) More Care, Less Pathway. A Review of the Liverpool Care Pathway. DH, London
KEY POINTS n The old system of CQC inspections is being phased out and replaced by a new system based on highly-focused questions about the quality and safety of care in hospitals n Changes to CQC hospital inspections are needed to avoid a repetition of the events uncovered at the Mid Staffordshire NHS Foundation Trust n As well as the introduction of five key questions that will be asked of any health and social care organisation, the CQC will develop new standards of care n New-style inspections of hospitals are designed to create a much more detailed picture of care than was previously possible n Nurses should not feel apprehensive about CQC inspection visits, since the CQC’s focus is always on the impact of care on patients
111
British Journal of Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 27, 2015. For personal use only. No other uses without permission. . All rights reserved.
