OPEN BOARD OF DIRECTORS’ MEETING                              Open BoD: 24.11.10
                                                                                    Item:     6
                              24 November 2010

TITLE OF PAPER        Briefing on Care Quality Commission (CQC) Planned Review 2010

TO BE PRESENTED BY    Liz Lightbown, Executive Director of Nursing and Quality

ACTION REQUIRED       The Board is asked to discuss this briefing paper

OUTCOME               Following the planned review, the Trust will receive a ‘Review of Compliance’
                      for each registered location

                      Action will be required where outcomes are judged as non-compliant and
                      ‘improvement’ or ‘compliance’ actions are issued.

TIMETABLE FOR         Discussion at November’s Board meeting

LINKS TO OTHER KEY    CQC Guidance about compliance: Essential standards of quality and safety,

LINKS TO OTHER        Any risks of non-compliance are recorded on the Board Assurance Framework

IMPLICATIONS FOR      Continued non-compliance against the essential quality and safety outcomes
SERVICE DELIVERY      may result in the termination of the registration of particular regulated activities
AND FINANCIAL         at a registered location.

CONSIDERATION OF      ‘Enforcement action’ will be taken by the CQC which will result in criminal
LEGAL ISSUES          and/or civil proceedings where services are deemed to be failing.

Author of Report      Tania Baxter
Designation           Head of Integrated Governance
Date of Report        November 2010
                  Board Briefing on Care Quality Commission (CQC)
                                Planned Review 2010
1.      Background

In order to meet the requirements of the Health and Social Care Act 2008 (Regulated
Activities) Regulations 2009 and the Care Quality Commission (Registration) Regulations
2009, providers must comply with the Essential Standards of Quality and Safety. These
standards are focused on outcomes and places the views and experiences of people who use
services at its centre.

The 16 outcomes are grouped into 6 sections (as shown in Diagram A below).

         Diagram A - Sections in the Essential Standards with Key Outcomes

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2.    Monitoring Compliance

      Quality Risk Profile

      In order to continuously monitor providers’ compliance with the essential standards, the
      Care Quality Commission (CQC) has developed a Quality Risk Profile (QRP) which is
      issued to Trusts on a monthly basis and is built by sourcing and analysing a range of
      data sources, both qualitative and quantitative, from their own and other regulatory
      bodies. QRPs are a tool to support teams and providers in assessing where risks lie
      when monitoring compliance against the new essential standards.

      Planned Review

      The CQC will carry out a planned review on all providers of NHS and social care
      services on a rolling programme. All registered providers will have a planned review
      between 3 months and 2 years following registration.

      As SHSC was registered for NHS services from 1st April 2010, the planned review that is
      currently ongoing is for NHS services only, based on 11 registered locations. The
      planned review for social care services (ie those registered on 1st October 2010, is
      currently suggested to be scheduled for January 2012, this is based on 6 registered

      Format of a Planned Review

      The planned review has a number of stages:

      1.    Stakeholder feedback requested on how we engage, partnership arrangements,
            performance etc
      2.    Quality Risk Profile assessed for potential/likely areas of risk of non-compliance
      3.    Intelligence/information gathered from SHSC’s website and other publicly available
      4.    Provider Compliance Assessments requested (one for each outcome)
      5.    Team governance reports requested – one example from each registered location
      6.    Additional information sought re declarations of non-compliance at registration
      7.    Unannounced site visits involving team of assessors checking records, site
            walkaround and staff and service user discussions

3.    Current Position

The CQC have completed their remote review of SHSC; ascertaining feedback from
stakeholders, assessing our QRPs and gathering information.

16 Provider Compliance Assessments (PCAs) have been written and submitted to the CQC.
These documents are self assessments that provide outcome based evidence to support our
declaration against each quality and safety outcomes. One PCA per outcome has been
submitted, that provided evidence for all 11 registered locations.

One example of team governance report per registered location has also been submitted to
the CQC.

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4.    Next Steps

      Additional Information/Evidence Collection

      The CQC have begun to request additional information in relation to areas where non-
      compliance was declared against particular outcomes at registration. This is in addition
      to questions that we expect to receive following their assessment of the PCAs, as well as
      the request for some supporting evidence.

      Unannounced Site Visits

      For our ongoing review, it is likely that unannounced site visits will take place at Michael
      Carlisle Centre, Longley Centre and Fulwood House (for community services).
      However, the CQC may still visit any location at any time during the review period.
      Given that the PCAs were submitted week ending 19th November, it is likely that site
      visits will not commence before December. SHSC has been advised that the review will
      be completed by January 2011.

      The reviews (site visits) will probably be undertaken by a team of 4 assessors:

       Brian Silverwood
       Nick Smith (involved in the inpatient review in 2008)
       2 social work professionals

      Site visits will involve a tour of the premises, checking for such things as outside safety,
      ligature points, as well as detailed ward visits. Whilst carrying out site visits, it is
      anticipated that 2 assessors will concentrate on the paperwork side (ie checking case
      notes, records etc) and 2 will talk to staff and service users.

      Learning Disability Services (LDS) Potential Site Visit (possibly ATU)

      We are informed that should a site visit be deemed appropriate and/or necessary within
      LDS, it is likely that an announced visit will take place. The CQC will, where deemed
      necessary, organise a service user forum to collect views, opinions and feedback from
      service users and carers in a supportive manner. SHSC will be involved in organising
      such a forum, should this be required. Due to preparation and planning time, it is likely
      that this would not take place until January 2011.

5.    Outcome of Planned Review

Following the planned review, the Trust will receive a ‘Review of Compliance’ for each
registered location, which will be published on their website. It is anticipated that this will take
approximately 3 months following the review. The reports will provide details of where we are
deemed to be ‘compliant’, or where there are ‘minor concerns’, ‘moderate concerns’ or ‘major
concerns’ against each outcome. ‘Improvement’, or ‘compliance actions’ will be issued, with
stipulated timeframes for compliance, where compliance is not met. Where services are
deemed to be failing people, ‘enforcement action’ will be taken by the CQC which will result in
criminal and/or civil proceedings.

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6.    Ongoing Assurance

EDG Weekly Exception Reports

EDG has requested that weekly exception reports are provided on the planned review
process. It is not yet known how the CQC will inform us if there are any major concerns in
respect of our completed PCAs. However any additional requests for information/evidence
will be brought to EDG’s attention through this agreed process, together with a progress
report on any site visits etc.

Quality Check Meetings

Quality Check meetings will continue on a bi-monthly basis to tease out and check our
assurance and evidence against all outcomes within a specific theme. All 16 outcomes will be
addressed through this process every 12 months.

Tania Baxter
Head of Integrated Governance
17 November 2010

For more information on the CQC Planned Review, of if you have any queries, please contact:

Tania Baxter, Head of Integrated Governance
Tel: 0114 2263279 or email

Brian Hockley, Project Development Manager
Tel: 0114 2716394 or email

Tina Ball, Director of Quality
Tel: 0114 2716393 or email

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