Deborah Pullen, Compliance & Assurance Lead at Wrightington, Wigan and Leigh NHS Foundation Trust, shares her experience of preparing for CQC Inspection against the KLOE framework
“Wrightington, Wigan and Leigh Foundation Trust is an acute Trust serving the people of the Borough of Wigan. Innovative and forward thinking, the Trust is dedicated to providing the best possible healthcare for the local population of over 300,000. Operating across 3 hospital sites, a state-of-the-art outpatient’s centre, a dedicated Eye Unit at the Wigan Health Centre and also working from offices at Buckingham Row in Wigan town centre, the Trust has 758 inpatient beds and invests over £220 million each year in a broad range of highly regarded general and specialist acute services.
Francis, Keogh and Berwick reviews illustrated the need for strong patient-focused leadership and accurate and useful information. Additionally they highlighted the need for leaders to fully understand improvements which can be made to patient safety, and to engage and empower staff to develop, by providing them with opportunities, making improvements to systems and processes within their working practice and environment.
The Trust was notified of its impending CQC Inspection during the Summer of 2015. Having joined the Trust in June 2015, one of my main objectives for the year was to identify and implement a way of reviewing compliance with the CQC’s Key Lines of Enquiry (KLOE) at ward and departmental level.
Whilst the 6-monthly internal inspections already undertaken by the Trust for several years were extremely valuable (and for each inspection we capture 10 things to celebrate and 10 things to improve), there was a real opportunity to delve much deeper into the wards and departments and to ask the key individuals in those teams to provide self-assessments of their own areas. The assessments would then be signed off by Sponsors. We aimed the assessments at highlighting any areas for improvement and capturing actions required to improve compliance, as well as highlighting areas which were good and outstanding.
The Trust received great support from Allocate Software in the setting up CQCAssure to match our services and sites so that we could start to use, in a short timeframe, CQCAssure as well as ongoing support and guidance. This mapping occurred during August and September 2015, with the deadline set for staff to complete the self-assessments of 13 November 2015. The Trust’s CQC Inspection took place during week commencing 7 December 2015.
Our CQCAssure system was set up with an “accountability owner” for each ward/department who was responsible for the self-assessment of the ward/department against the Key Lines of Enquiry. The “accountability sponsor” was able to monitor what progress the owner was making in completing the self-assessments. The sponsors were predominantly Heads of Nursing. The sponsor was alerted by email of any overdue actions by the “owner”. “Shared users” tended to be matrons and governance leads who had the same access as the owner and were able to input updates and submit the self-assessments to the organisation.
The individual KLOE ratings given by each ward and department were aggregated into ward, department, divisional and trust-wide compliance tables and can be displayed in various dashboards and reports. These were presented to our CQC Stakeholder Committee in advance of our CQC inspection. An Allocate Software representative was also invited to attend this meeting to demo our progress and celebrate our success.
The self-assessments undertaken by ward and departmental managers were linked within the system to the appropriate directorates, divisions, hospital sites and eight core services. The self-assessments required the key staff to make the same judgements used by the CQC in relation to individual areas. Staff found the system quite intuitive in the main and only required short, group training sessions and then they were provided with a hand-out with screenshots.
We experienced really great buy-in from our staff, including ward and departmental managers, matrons, governance colleagues, Heads of Nursing and Executives. Within an 8-12 week period, our staff completed 71 sets of clinical review, which comprised of the 5 KLOE, totalling an impressive 355 self-assessments.
I feel having the CQCAssure system really helped in our preparations for our CQC Inspection and enabled a wide range of staff to consider and self-assess their areas against the KLOE in advance of the CQC Inspection. This provided invaluable preparation and also organisational insight. It provided a fantastic opportunity for operational staff at ward and department level to really get into the detail of the KLOE which positively contributed to improving their confidence prior to and during our inspection. I’m eagerly awaiting receipt of our CQC report and then being able to compare our self-assessments against the final judgements of the CQC.”
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