CQC Compliance

Presented By: Alex Zarneh (Dr.)

Head of Medical Physics & Radiation Protection Services

Medical Physics Department

Mid Yorkshire Hospitals NHS Trust

Incorporating Dewsbury & District, Pinderfields and Pontefract Hospitals

alex.zarneh@midyorks.nhs.uk

• MID YORKSHIRE HOSPITALS NHS TRUSTDEWSBURY AND DISTRICT HOSPITALMEDICAL PHYSICS DEPARTMENTHALIFAX ROADDEWSBURYWEST YORKSHIREWF13 4HS

Outcome 11

Safety, Availability and Suitability of Equipment

 

Take Your Seats, Sit Back, Relax And Enjoy Take Your Seats, Sit Back, Relax And Enjoy

 This presentation gives an overview from the following points of view:

- Head of Medical Physics with operational and professional responsibility

- Acting as out of hours on-site duty manager

- being accountable for patients not having basic kit such as Static Mattresses or Pillows

Neglect or Ignorance?

 The Trust was inspected by Care Quality Commission Assessors

60 assessors arrived and spent one week across 3 hospitals and care closer to home premises

They also came back at weekends and did unannounced inspection

What Happened?

 A lot of Evidence was presented prior to their visit

but was not Enough to satisfy the requirements of

outcome 11!

What Happened?

The registered person, the Trust must make suitable arrangements to protect service users and others who may be at risk of using unsafe equipment

Outcome 11 – Safety, Availability and Suitability of Equipment

 To ensure that any devices is:

Properly maintained and suitable for its purpose

Used correctly

Is available in sufficient quantities

Role of Medical Devices Library

Availability Of Devices

 

The Device is: Suitable for its purposeIs properly maintainedIs used correctly and safelyPromotes independence

IN-HOUSE MANAGEMENT OF MEDICAL DEVICES POLICY!

Fit For Purpose

 Do You Know Who is responsible In Your Trust for:

- Static / Foam Mattresses or Pillows

- Wheel Chairs? How many are lying around broken?

- Commodes? / Bariatric Equipment

_ Pressure Relief Mattresses?

- Decontamination / Cleaning of Medical Devices?

Responsibilities?

 - Who is responsible for Clinical Training?

- Who is responsible for managing external medical devices contracts?

-Who verifies the contractors service reports? Ward clerk?

- Who accepts the device back into service? Ward Clerk / Domestics?

Responsibilities?

 - Who decides on the level of contract needed?

-Is there a centralised database with full visibility?

- Is there a replacement programme for all the devices?

- What is your standardisation Policy?

- Who stands up to users and clinical colleagues who are putting pressure on to purchase the “Deal of the Day”?

Responsibilities?

 - Assessors spent time on the wards

- Command centres were set up at each hospital site

- Head of Medical Physics

- Director

- Matrons

- Chief Nurse Deputy

CQC Assessment

- Inventory ?

- Training Records? How many were in date?

Some wards also created their own folders:

Labeled – CQC Evidence? – Not acceptable!

Yellow Folders!

 

We met with each other every two hours

- Kept in touch via text and mobile – signal issues

- Walked round the wards and corridors

- Engaged with porters to move items from corridors

- Lots of biscuits / Fruit and Chocolates

- Created good relationship between different colleagues

CQC Assessment

 - Some staff not familiar with the sites

- Working for the same organisation?

- Making assumptions

- What happened to day to day tasks?

- Tired - Having spent 4 weeks collecting evidence!

Operational Issues

 - Each day requests came from CQC for information

- Can you do it for now?

- Remember - All Information must be credible

- We had a lot of explaining to do!

CQC / Trust Expectations

 What were the issues for Medical Physics?

- Labeling of service dates on devices

- I sent a global Email to other Trusts for comments

- Received some good and some rude and ignorant Emails

- Spot checking of service dates via telephone call from the assessor

CQC / Trust Expectations

- CQC asked for a list of outstanding jobs

- List of outstanding PVIs

- High Risk, Medium Risk and Low Risk

- What is the problem?

CQC / Trust Expectations

- The information was presented to CQC

- Decision made to withdraw the “Yellow Folders”

What happened Next?

- No Formal feedback

- Various informal questions re Inventory for various areas

- !Number of NIBPs in a certain area!

Feedback?

- Continue with achieving compliance (91%)

- Debate re stickers and service lables?

What Have We Done?

14

Thank you for your attention