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CQC Update

25 January 2021

During November and December, the Medicine Care Group, the Critical Care and Surgery Care Group, the Women and Children Care Group and the Trust's Governance team undertook work to review, update and complete recommendations made by the Care Quality Commission (CQC) to enable Care Groups to focus on COVID.

From this process a total of 18 recommendations (3 Must Do Recommendations and 15 Should Recommendations) were completed.

There now 28 Recommendations left on the CQC Improvement Plan, 17 of these are Trust Wide Actions managed by Corporate Functions with only 11 still being managed by Clinical Care Groups.

Five “Should Do” recommendations allocated to the Medicine Care Group and Critical Care and Surgery Care Group related to staff recruitment – and these have now been integrated into the Trust wide action to increase staff recruitment and retention

The Trust Wide action is managed by People and Organisational Development and aligns with the Trust's Recruitment Strategy and Processes

One “Should Do” recommendation in the Medicine Care Group to improve Patient Access in ED has been closed following a Trust Wide review and update of the Emergency Care Admissions Protocol

Two “Must Do” recommendations in the Women and Children Care Group (WACS) to improve Medical Device Training Records, have been closed at Care Group level and have been made into a single Trust Wide Action. To address the Trust Wide Action, a Task and Finish Group has been set up to identify and address technical issues with the Medical Device Training Records in our Training Management System.

The WACS care group have completed two “Should Do” recommendations to improve the visibility of the senior management team across WACS services

Amongst other measures, they will hold regular 'Tea and Talk' meetings to increase scope for face to face interaction with frontline staff.

The care group has also have completed two recommendation related to Maternal, Peri-natal and Paediatric mortality processes, the Trust processes have been confirmed as being consistent with national and regional requirements

Further work will now take place to integrate the Maternal, Peri-natal and Paediatric mortality processes into the wider Trust mortality processes as part of larger national project to align mortality processes within the new national Medical Examiner System

There now 28 Recommendations left on the CQC Improvement Plan, 17 of these are Trust Wide Actions managed by Corporate Functions with only 11 still being managed by Clinical Care Groups.

The Key Trust Wide Actions are detailed below.

High Level Corporate Actions:

  • Improving Staff Recruitment and Retention
  • Improving Staff Appraisal Rates
  • Improving Staff Development and Training
  • Improving (reducing) Staff Absence Rates
  • Improving ED Performance
  • Improving RTT Performance
  • Improving the Trust's Financial Position
  • Improving the Trust Operational Efficiency
  • Through the work of the Inpatient, Outpatient and Theatre Transformation Cells
  • Improving the Trust's Estates

Further work will take place on the following actions that colleagues across the Trust can help with:

  • Improving Medicines Reconciliation within 24 Hours of admission
  • Improving the recording of Oxygen Prescribing and Administration in Lorenzo
  • Improving the completion, review and update of VTE Risk Assessments in Lorenzo
  • Improving the completion, review and update Patient Risk Assessments Improving Information Governance and Data Confidentiality

View the Trust-wide CQC Improvement plan here.