Trust Board Meeting: Wednesday 8 July 2015
TB2015. 97
Title
Progress report on implementation of CQC’s Fundamental
Standards
Status
For information
History
Trust Management Executive
Board Lead(s)
Key purpose

12 March 2015 and

25 June 2015.
Eileen Walsh, Director of Assurance
Strategy
Assurance
TB2015.97 CQC Regulation Update Board July 2015
Policy
Performance
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Executive Summary
1. This is a progress report on the implementation of the CQC’s Fundamental Standards,
within the Trust’s system for assessing compliance with CQC regulations.
2. The trust system, CQCAssure, has been set against the new regulatory framework and
work is underway to migrate relevant self-assessment results from the existing system
across to the new system.
3. Relevant leads have been identified within the Divisions to support the completion of
self-assessments and are specifically being asked to co-ordinate this review for
completion by 31 July 2015.
Recommendation
4. The Board is asked to:

Note the progress made with migrating relevant narrative across to the new
regulatory framework.
TB2015.97 CQC Regulation Update Board July 2015
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Progress report on implementation of CQC’s Fundamental Standards
1.
Introduction & Background
1.1. The purpose of this paper is to provide an update on the progress being made with
the implementation of CQC’s Fundamental Standards.
1.2. From 1 April 2015 the new care regulations laid down in the Health and Social
Care Act 2008 (Regulated Activities) Regulations 2014 came into force.
1.3. These regulations introduced the new ‘Fundamental Standards’ which describe
requirements that reflect the recommendations made by Sir Robert Francis
following his inquiry into care at Mid Staffordshire NHS Foundation Trust.
1.4. The Assurance Directorate have reviewed the new regulations and mapped the
previous outcomes to the new standards as per the table below:
New regulations
Previous outcomes/regulations
Regulation 5: Fit and proper persons: directors
N/A – This is a new regulation
Regulation 9: Person-centred care
Outcome 1: Respecting and involving people who use
services
Regulation 10: Dignity and respect
Outcome 1: Respecting and involving people who use
services
Regulation 11: Need for consent
Outcome 2: Consent to care and treatment
Regulation 12: Safe care and treatment
Outcome 4: Care and welfare of people who use
services
Outcome 8: Cleanliness and infection control
Outcome 9: Management of medicines
Outcome 6: Cooperating with other providers
Outcome 21: Records
Regulation 13: Safeguarding service users from
abuse and improper treatment
Outcome 7: Safeguarding people who use services
from abuse
Regulation 14: Meeting nutritional and hydration
needs
Outcome 5: Meeting nutritional needs
Regulation 15: Premises and equipment
Outcome 10: Safety and suitability of premises
Outcome 11: Safety, availability and suitability of
equipment
Regulation 16: Receiving and acting on
complaints
Outcome 17: Complaints
Regulation 17: Good Governance
Outcome 16: Assessing and monitoring the quality of
service provision
Regulation 18: Staffing
Outcome 13: Staffing
Outcome 14: Supporting workers
Regulation 19: Fit and proper persons employed
Outcome 12: Requirements relating to workers
Regulation 20: Duty of candour
N/A – This is a new regulation
1.5. The CQC have linked each of the new regulations to a key question, which forms
the basis of their inspection methodology. These key questions are :




Are services safe?
Are services effective?
Are services caring?
Are services responsive to people’s needs?
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
2.
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Are services well-led?
Migration of Information within CQCAssure
2.1. The system that the Trust uses as a repository for the self-assessment of
compliance with the CQC’s regulations is provided by Allocate Software within the
specific CQCAssure application (the system).
2.2. The current assessment of compliance takes the form of a:



Narrative describing the key processes in relation to the questions the CQC
posed in relation to the original essential standards / outcomes.
Supporting evidence.
Rating of each of those questions.
2.3. Development work has been undertaken to ensure the regulatory framework is
represented within the system is in accordance with the Trust’s specifications.
2.4. In line with the mapping exercise undertaken the existing narrative in the system is
being transferred from the previous outcomes to the CQC’s new Key Line of
Enquiry questions. As at 23 June 2015 the transfer of the narrative responses was
70% complete.
2.5. Relevant Trust-level information which has been submitted as part of the recent
Monitor and the CQC requests will be uploaded to the system so that a pool of
information is available at all times.
2.6. In preparation for the new system, the Executive Directors have taken Executive
Lead for new regulations. As displayed below:
Regulation 9: Person-centred Care
Regulation 10: Dignity and Respect
Regulation 11: Need for Consent
Regulation 12: Safe care and Treatment
Regulation 13: Safeguarding patients/users from abuse
and improper treatment
Regulation 14: Meeting nutritional and hydration needs
Regulation 15: Premises and equipment
Regulation 16: Receiving and acting on complaints
Regulation 17: Good governance
Regulation 18: Staffing
Regulation 19: Fit and Proper Persons Employed
Regulation 20: Duty of Candour
3.
Chief Nurse
Chief Nurse
Medical Director
Medical Director
Chief Nurse
Chief Nurse
Director of Development
and the Estate
Chief Nurse
Medical Director
Director of Workforce
Director of Workforce
Medical Director
Next steps
3.1. Relevant leads have been identified within the Divisions to support the completion
of self-assessments. These leads are specifically being asked to co-ordinate the
following:




Check that the narrative as moved is valid for each of the questions,
Edit the narrative, as required,
Complete the narrative for any new questions.
Complete the rating for each of the Key Line of Enquiry questions using CQC’s
criteria of Outstanding, Good, Requires Improvement or Inadequate.
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3.2. The timeline for completion is 31st July 2015. Alongside this there will be a
requirement for linking of relevant evidence to the narrative with the aim of using
the reporting function within the system as part of the Q2 performance review
meetings. From this the reporting function will be extended to the Board and subcommittees.
3.3. Training is being made available on the new system as well as support by the
Assurance Directorate to identify what makes good evidence.
3.4. Work is underway with Allocate to establish a more integrated dashboard system
that will display a risk register dashboard, the overview of ratings within
CQCAssure and the safe staffing information.
3.5. The peer review programme is being developed in alignment with the new
Fundamental Standards. To ensure that the results of the peer review process
adds to the evidence within the CQCAssure system.
4.
Recommendation
4.1. The Board is asked to note the progress made with migrating relevant narrative
across to the new regulatory framework.
Clare Winch
Deputy Director of Assurance
July 2015
Report prepared by:
Lucy Parsons
Accreditation and Regulation Manager
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