New CQC standards for healthcare delivery Emeritus Professor Alan Glasper, at the University of Southampton, discusses the launch of the latest Care Quality Commission fundamental standards of care which are now the health and social care benchmarks. These new regulations became effective on 1 April 2015
The new regulations The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 can be read in full online (http://tinyurl.com/ plnxc3q). It is part three of the document— i.e. regulations 9 through to 20A, that are the most pertinent for the nursing and other caring professions. The crucial directive of the CQC in introducing these new fundamental standards is that these are the standards below which care must never fall (CQC, 2014).
9: Person-centered care The documentation of the new CQC policy offers significant guidance about how institutions can meet this standard in full. As
500
nurses make up the largest component of the NHS workforce, they are most involved in ensuring that this standard is met. The crux of the standard is to ensure that service users are offered and receive personalised care. Nurses have been using individualised plans of care since the early 1980s and it is therefore the care plan that is pivotal in providing the evidence that care is personalised. Patients who have an individual plan of care are less likely to suffer accidents in hospital such as falls (Lomas and Santry, 2010). Identification of patient health problems facilitated by an accurate assessment of their individual needs allows for goal-orientated health care in which nursing care is tailored to the person and not the illness. Suhonen et al (2012) have shown how individualised care planning allows nurses to reflect the patient’s own beliefs and personal needs, which in turn leads to a correlation between individualised care and patient satisfaction
10: Dignity and respect Whilst it is obvious that all service users must be treated with dignity and respect, there have been instances in recent nursing history where this has not been evident. The events that unfolded at Winterbourne View—a residential care home near Bristol where footage showed service users with severe learning disabilities being slapped and restrained and held down as medication was forced into their mouths— brought shame on the nursing profession and the healthcare assistant (HCA) workforce. The resulting governmental review into these events (Department of Health, 2012) made clear the lessons and the actions that must be taken to prevent such violations of human dignity and respect from happening again. In essence, the new regulations aim to promote a caring culture that constantly challenges poor practice and promotes compassionate care across the NHS and beyond.
11: Need for consent Clearly, a primary goal of this regulation is to ensure that service users’ consent to care
and treatment is always obtained under the jurisdiction of legislation and current professional guidance. Care and treatment of service users must only be provided with the consent of the relevant person. Nurses and other health professionals are mandated to support certain groups of patients in making decisions about their care. This can be challenging in certain areas of healthcare delivery but especially among the young who are not Gillick-competent and those who lack the mental capacity to make informed decisions about their own care. During inspections CGC specialist advisors and inspectors will monitor the processes used by staff in hospitals to ensure that these processes are adhered to. Alderson (2007) has explored the complexities of gaining children’s consent and how criteria for determining competence have changed over time. Healthcare organisations must work in partnership with patients who have compromised consent abilities to make reasonable adjustments and provide assistance to help them to understand more fully what is being proposed to enhance their abilities to make informed decisions pertinent to their care.
12: Safe care and treatment The CQC is determined to ensure that care and treatment for patients must be provided in a safe way.To ascertain that all patients are treated with kindness, dignity, respect and compassion, key lines of enquiry (KLOEs) are used by hospital inspectors to unearth evidence. Most nurses will be familiar with the 6Cs, launched by the English chief nurse (NHS England, 2012) and all nurses are encouraged to use the 6Cs framework to mitigate any potential for deterioration in care delivery. Hospitals must ensure that nurses and others who provide care have the qualifications, competence, skills and experience to do so safely. CQC inspectors and specialist advisors will examine the hospital risk register to determine if there are any risks to patients caused by skill-mix issues and will interview nurses and scrutinise a range of documents such as mandatory updating records to triangulate evidence that shows compliance with standards.
© 2015 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. The CQC assessed compliance by hospitals and other care environments with 28 regulations known as essential standards of quality and safety. The ‘GAC’ standards (guidance about compliance) were used by inspectors from 2009 to make judgements about how compliant organisations were in applying the standards. However, in June 2013, after recognition that some hospitals, such as the Mid Staffordshire NHS Foundation Trust, were not compliant with these fundamental standards, the CQC announced that the old system of inspections would be phased out and replaced by a new system, involving more highly focused questioning of the quality and safety of care during inspections in hospitals, and other health and social care institutions. The new standards came into force in April 2015, and reflect the more proactive stance of the regulator. The assessments of compliance with the new regulations will rely heavily on triangulated data evidence that does not simply reflect the opinions of one person.
British Journal of Nursing, 2015, Vol 24, No 9
British Journal of Nursing. Downloaded from magonlinelibrary.com by 155.198.030.043 on December 3, 2015. For personal use only. No other uses without permission. . All rights reserved.
HEALTHCARE POLICY 13: Safeguarding service users from abuse and improper treatment All hospitals must develop systems and processes that operate effectively to prevent the abuse of all service users. Nurses must do all that is reasonably practicable to mitigate any such risks. CQC inspectors will gather a variety of evidence pertinent to this regulation, including authenticating that all staff have been offered safeguarding training at the appropriate level and that they will inspect the records to verify this. In the case of children in hospital, the inspectors will also examine security measures related to ward access and the use of things such as CCTV.
14: Meeting nutritional and hydration needs During the investigation into the events at Mid Staffordshire NHS Foundation Trust, it was revealed in the popular press that some elderly patients were left so thirsty that they resorted to drinking water from flower vases (Daily Mail, 2010). Reflecting this and other incidents, the CQC is adamant that this new regulation protects the nutritional and hydration needs of service users at all times. It applies in all situations including neonatal units where inspectors will check, for example, the facilities to promote breast feeding, milk storage and preparation.
15: Premises and equipment NHS care facilities include premises built before the Second World War or even in the Victorian era. Such is the crisis with hospital accommodation in many parts of the NHS that, for example, Glasgow’s Victoria Infirmary was reportedly compelled to accommodate patients in an inappropriate storage area because of overcrowding in the emergency department (Aitken, 2015). The new regulation will ensure that hospitals are obliged to provide clinical facilities that are clean, secure, fit for purpose, and appropriately used and maintained. CQC hospital inspectors will inspect buildings and ask service users about their perceptions of the premises where they receive care.
© 2015 MA Healthcare Ltd
16: Receiving and acting on complaints This new regulation requires hospitals to have robust procedures in place to address service user complaints. They must be able to demonstrate to inspectors that any complaints are taken seriously and fully investigated. The processes of identifying and recording complaints will be ascertained and, among other activities, the CQC specialist advisers will meet with the Patient Advocacy and Liaison Service Lead and
British Journal of Nursing, 2015, Vol 24, No 9
will check the parameters of a full year’s record of complaints and how they were managed.
17: Good governance Good governance lies at the heart of a well-run hospital and inspectors will look for evidence that the hospital has an effective governance framework, visible in action from the ward to the board. The King’s Fund believes it imperative that quality emanate from the hospital boardroom and permeate the whole hospital, from catering and portering staff through to HCAs, nurses, medical staff and allied health professionals (Steward at al, 2009). Staff need to feel respected and valued if they are to embrace fully the vision and values of the hospital.
18: Staffing and 19: Fit and proper persons employed The care a patient receives may only ever be as good as the nurse or other health professional who delivers it. The CQC expects all staff to be of good character and have the qualifications, competence, skills and experience necessary for the role they undertake. Staff should be enabled, where appropriate, to obtain further qualifications appropriate to their role. Skill mix and staffing levels linked to patient acuity are essential to ensure safe care delivery, and CQC inspectors and their teams of specialist advisors will collect data from off-duty rotas and ascertain that staffing levels are linked to some measure of patient acuity. Actual staffing levels will be compared with national guidance from professional bodies, such as the minimum essential requirements for services for babies, children and young people set out by the Royal College of Nursing (2013).
20: Duty of candour In 2014 the CQC fully supported the introduction of statutory duty of candour, which was recommended by the Francis Report. In essence, the duty of candour has been introduced to ensure that all staff are required to disclose information about any incident of
poor care delivery they believe may have led to patient harm. The British Medical Association (2015) reports that it will be a criminal offence for staff to try to prevent someone exercising this duty. All healthcare staff must therefore act in an open and transparent way in relation to care and treatment provided to service users. Hospitals and other health and social care facilities should have strong procedures for ensuring that staff are open and honest when things go wrong and service users are harmed.
Conclusion The new CQC regulatory standards have been introduced to ensure that patients receive safe and compassionate care at all times. All 49 500 health and adult social care providers and services across the country are now required by legislation to follow these new regulations (i.e. the fundamental standards), which give detailed information about the care that people should always expect to receive. The new duty of candour requires staff to be open and honest about mistakes when they happen.All healthcare facilities must be dedicated to ensuring that service users are recipients of the best care BJN possible at all times. Aitken V (2015) Hospital bed crisis worsens as old Portakabin is used to cope with A&E overspill. Daily Record online, 8 Jan. http:// tinyurl.com/m89zqrw (accessed 5 Mary 2015) Alderson P (2007) Competent children? Minors’ consent to health care treatment and research. Soc Sci Med 65(11): 2272-83 British Medical Association (2015) Statutory duty of candour with sanctions. http://tinyurl.com/kak3vl5 (accessed 5 May 2015) Care Quality Commission (2014) Publishing of the new fundamental standards. http://tinyurl.com/psrkyrq (accessed 5 May 2015) Daily Mail (2010) Patients at scandal-hit hospital ‘forced to drink from vases after being left on ward without water’. Daily Mail online, 23 November. http://tinyurl.com/2ublov6 (accessed 5 May 2015) Department of Health (2012) Transforming care: A national response to Winterbourne View Hospital. Department of Health Review Final Report. http://tinyurl.com/kpwrver (accessed 5 May 2015) Lomas C, Santy C (2010) Safety fears prompt calls for more nurse led care plans. NursingTimes.net 30 March http://tinyurl.com/ mgavc5e (accessed 5 May 2015) NHS England (2012) Our Culture of Compassionate Care http:// tinyurl.com/ok9gyge (accessed 5 May 2015) Royal College of Nursing (2013) Defining staffing levels for children and young people’s services. http://tinyurl.com/bwlfutg (accessed 5 May 2015) Steward K, Machell S, Gough P (2009) From Ward To Board: Identifying Good Practice in the Business of Caring. http://tinyurl.com/nvmeroy (accessed 5 May 2015) Suhonen R, Papastavrou E, Efstathiou G et al (2012) Patient satisfaction as an outcome of individualised nursing care. Scand J Caring Sci 26(2):372-80. doi: 10.1111/j.1471-6712.2011.00943.x. Epub 2011
KEY POINTS n The Care Quality Commission (CQC) introduced new regulatory standards to improve health care delivery, which became effective on 1 April 2015 n CQC assessments of compliance to the new regulations will rely heavily on triangulated data evidence that does not simply reflect one person’s individual views n The new duty of candour has been introduced to ensure that all staff are required to disclose information about any incident of poor care delivery they believe may have led to patient harm n All 49 500 health and adult social care providers and services across the country are now required by legislation to follow these new regulations
501
British Journal of Nursing. Downloaded from magonlinelibrary.com by 155.198.030.043 on December 3, 2015. For personal use only. No other uses without permission. . All rights reserved.
The new regulations The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 can be read in full online (http://tinyurl.com/ plnxc3q). It is part three of the document— i.e. regulations 9 through to 20A, that are the most pertinent for the nursing and other caring professions. The crucial directive of the CQC in introducing these new fundamental standards is that these are the standards below which care must never fall (CQC, 2014).
9: Person-centered care The documentation of the new CQC policy offers significant guidance about how institutions can meet this standard in full. As
500
nurses make up the largest component of the NHS workforce, they are most involved in ensuring that this standard is met. The crux of the standard is to ensure that service users are offered and receive personalised care. Nurses have been using individualised plans of care since the early 1980s and it is therefore the care plan that is pivotal in providing the evidence that care is personalised. Patients who have an individual plan of care are less likely to suffer accidents in hospital such as falls (Lomas and Santry, 2010). Identification of patient health problems facilitated by an accurate assessment of their individual needs allows for goal-orientated health care in which nursing care is tailored to the person and not the illness. Suhonen et al (2012) have shown how individualised care planning allows nurses to reflect the patient’s own beliefs and personal needs, which in turn leads to a correlation between individualised care and patient satisfaction
10: Dignity and respect Whilst it is obvious that all service users must be treated with dignity and respect, there have been instances in recent nursing history where this has not been evident. The events that unfolded at Winterbourne View—a residential care home near Bristol where footage showed service users with severe learning disabilities being slapped and restrained and held down as medication was forced into their mouths— brought shame on the nursing profession and the healthcare assistant (HCA) workforce. The resulting governmental review into these events (Department of Health, 2012) made clear the lessons and the actions that must be taken to prevent such violations of human dignity and respect from happening again. In essence, the new regulations aim to promote a caring culture that constantly challenges poor practice and promotes compassionate care across the NHS and beyond.
11: Need for consent Clearly, a primary goal of this regulation is to ensure that service users’ consent to care
and treatment is always obtained under the jurisdiction of legislation and current professional guidance. Care and treatment of service users must only be provided with the consent of the relevant person. Nurses and other health professionals are mandated to support certain groups of patients in making decisions about their care. This can be challenging in certain areas of healthcare delivery but especially among the young who are not Gillick-competent and those who lack the mental capacity to make informed decisions about their own care. During inspections CGC specialist advisors and inspectors will monitor the processes used by staff in hospitals to ensure that these processes are adhered to. Alderson (2007) has explored the complexities of gaining children’s consent and how criteria for determining competence have changed over time. Healthcare organisations must work in partnership with patients who have compromised consent abilities to make reasonable adjustments and provide assistance to help them to understand more fully what is being proposed to enhance their abilities to make informed decisions pertinent to their care.
12: Safe care and treatment The CQC is determined to ensure that care and treatment for patients must be provided in a safe way.To ascertain that all patients are treated with kindness, dignity, respect and compassion, key lines of enquiry (KLOEs) are used by hospital inspectors to unearth evidence. Most nurses will be familiar with the 6Cs, launched by the English chief nurse (NHS England, 2012) and all nurses are encouraged to use the 6Cs framework to mitigate any potential for deterioration in care delivery. Hospitals must ensure that nurses and others who provide care have the qualifications, competence, skills and experience to do so safely. CQC inspectors and specialist advisors will examine the hospital risk register to determine if there are any risks to patients caused by skill-mix issues and will interview nurses and scrutinise a range of documents such as mandatory updating records to triangulate evidence that shows compliance with standards.
© 2015 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. The CQC assessed compliance by hospitals and other care environments with 28 regulations known as essential standards of quality and safety. The ‘GAC’ standards (guidance about compliance) were used by inspectors from 2009 to make judgements about how compliant organisations were in applying the standards. However, in June 2013, after recognition that some hospitals, such as the Mid Staffordshire NHS Foundation Trust, were not compliant with these fundamental standards, the CQC announced that the old system of inspections would be phased out and replaced by a new system, involving more highly focused questioning of the quality and safety of care during inspections in hospitals, and other health and social care institutions. The new standards came into force in April 2015, and reflect the more proactive stance of the regulator. The assessments of compliance with the new regulations will rely heavily on triangulated data evidence that does not simply reflect the opinions of one person.
British Journal of Nursing, 2015, Vol 24, No 9
British Journal of Nursing. Downloaded from magonlinelibrary.com by 155.198.030.043 on December 3, 2015. For personal use only. No other uses without permission. . All rights reserved.
HEALTHCARE POLICY 13: Safeguarding service users from abuse and improper treatment All hospitals must develop systems and processes that operate effectively to prevent the abuse of all service users. Nurses must do all that is reasonably practicable to mitigate any such risks. CQC inspectors will gather a variety of evidence pertinent to this regulation, including authenticating that all staff have been offered safeguarding training at the appropriate level and that they will inspect the records to verify this. In the case of children in hospital, the inspectors will also examine security measures related to ward access and the use of things such as CCTV.
14: Meeting nutritional and hydration needs During the investigation into the events at Mid Staffordshire NHS Foundation Trust, it was revealed in the popular press that some elderly patients were left so thirsty that they resorted to drinking water from flower vases (Daily Mail, 2010). Reflecting this and other incidents, the CQC is adamant that this new regulation protects the nutritional and hydration needs of service users at all times. It applies in all situations including neonatal units where inspectors will check, for example, the facilities to promote breast feeding, milk storage and preparation.
15: Premises and equipment NHS care facilities include premises built before the Second World War or even in the Victorian era. Such is the crisis with hospital accommodation in many parts of the NHS that, for example, Glasgow’s Victoria Infirmary was reportedly compelled to accommodate patients in an inappropriate storage area because of overcrowding in the emergency department (Aitken, 2015). The new regulation will ensure that hospitals are obliged to provide clinical facilities that are clean, secure, fit for purpose, and appropriately used and maintained. CQC hospital inspectors will inspect buildings and ask service users about their perceptions of the premises where they receive care.
© 2015 MA Healthcare Ltd
16: Receiving and acting on complaints This new regulation requires hospitals to have robust procedures in place to address service user complaints. They must be able to demonstrate to inspectors that any complaints are taken seriously and fully investigated. The processes of identifying and recording complaints will be ascertained and, among other activities, the CQC specialist advisers will meet with the Patient Advocacy and Liaison Service Lead and
British Journal of Nursing, 2015, Vol 24, No 9
will check the parameters of a full year’s record of complaints and how they were managed.
17: Good governance Good governance lies at the heart of a well-run hospital and inspectors will look for evidence that the hospital has an effective governance framework, visible in action from the ward to the board. The King’s Fund believes it imperative that quality emanate from the hospital boardroom and permeate the whole hospital, from catering and portering staff through to HCAs, nurses, medical staff and allied health professionals (Steward at al, 2009). Staff need to feel respected and valued if they are to embrace fully the vision and values of the hospital.
18: Staffing and 19: Fit and proper persons employed The care a patient receives may only ever be as good as the nurse or other health professional who delivers it. The CQC expects all staff to be of good character and have the qualifications, competence, skills and experience necessary for the role they undertake. Staff should be enabled, where appropriate, to obtain further qualifications appropriate to their role. Skill mix and staffing levels linked to patient acuity are essential to ensure safe care delivery, and CQC inspectors and their teams of specialist advisors will collect data from off-duty rotas and ascertain that staffing levels are linked to some measure of patient acuity. Actual staffing levels will be compared with national guidance from professional bodies, such as the minimum essential requirements for services for babies, children and young people set out by the Royal College of Nursing (2013).
20: Duty of candour In 2014 the CQC fully supported the introduction of statutory duty of candour, which was recommended by the Francis Report. In essence, the duty of candour has been introduced to ensure that all staff are required to disclose information about any incident of
poor care delivery they believe may have led to patient harm. The British Medical Association (2015) reports that it will be a criminal offence for staff to try to prevent someone exercising this duty. All healthcare staff must therefore act in an open and transparent way in relation to care and treatment provided to service users. Hospitals and other health and social care facilities should have strong procedures for ensuring that staff are open and honest when things go wrong and service users are harmed.
Conclusion The new CQC regulatory standards have been introduced to ensure that patients receive safe and compassionate care at all times. All 49 500 health and adult social care providers and services across the country are now required by legislation to follow these new regulations (i.e. the fundamental standards), which give detailed information about the care that people should always expect to receive. The new duty of candour requires staff to be open and honest about mistakes when they happen.All healthcare facilities must be dedicated to ensuring that service users are recipients of the best care BJN possible at all times. Aitken V (2015) Hospital bed crisis worsens as old Portakabin is used to cope with A&E overspill. Daily Record online, 8 Jan. http:// tinyurl.com/m89zqrw (accessed 5 Mary 2015) Alderson P (2007) Competent children? Minors’ consent to health care treatment and research. Soc Sci Med 65(11): 2272-83 British Medical Association (2015) Statutory duty of candour with sanctions. http://tinyurl.com/kak3vl5 (accessed 5 May 2015) Care Quality Commission (2014) Publishing of the new fundamental standards. http://tinyurl.com/psrkyrq (accessed 5 May 2015) Daily Mail (2010) Patients at scandal-hit hospital ‘forced to drink from vases after being left on ward without water’. Daily Mail online, 23 November. http://tinyurl.com/2ublov6 (accessed 5 May 2015) Department of Health (2012) Transforming care: A national response to Winterbourne View Hospital. Department of Health Review Final Report. http://tinyurl.com/kpwrver (accessed 5 May 2015) Lomas C, Santy C (2010) Safety fears prompt calls for more nurse led care plans. NursingTimes.net 30 March http://tinyurl.com/ mgavc5e (accessed 5 May 2015) NHS England (2012) Our Culture of Compassionate Care http:// tinyurl.com/ok9gyge (accessed 5 May 2015) Royal College of Nursing (2013) Defining staffing levels for children and young people’s services. http://tinyurl.com/bwlfutg (accessed 5 May 2015) Steward K, Machell S, Gough P (2009) From Ward To Board: Identifying Good Practice in the Business of Caring. http://tinyurl.com/nvmeroy (accessed 5 May 2015) Suhonen R, Papastavrou E, Efstathiou G et al (2012) Patient satisfaction as an outcome of individualised nursing care. Scand J Caring Sci 26(2):372-80. doi: 10.1111/j.1471-6712.2011.00943.x. Epub 2011
KEY POINTS n The Care Quality Commission (CQC) introduced new regulatory standards to improve health care delivery, which became effective on 1 April 2015 n CQC assessments of compliance to the new regulations will rely heavily on triangulated data evidence that does not simply reflect one person’s individual views n The new duty of candour has been introduced to ensure that all staff are required to disclose information about any incident of poor care delivery they believe may have led to patient harm n All 49 500 health and adult social care providers and services across the country are now required by legislation to follow these new regulations
501
British Journal of Nursing. Downloaded from magonlinelibrary.com by 155.198.030.043 on December 3, 2015. For personal use only. No other uses without permission. . All rights reserved.
