C&P CCG QUALITY INDICATORS FOR SMALLER CONTRACTS
July 2014
The Provider shall comply with the Quality Indicators given below, and provide:
 Initial evidence of systems in place to support delivery of these indicators
 Quarterly evidence of compliance, through exception reporting
1.
Quality Indicator
Compliance with CQC registration
requirements, as required
2.
Identification, reporting and
management of Serious Incidents in
line with CCG SI procedure
3.
Incident reporting system
4.
Status of complaints
5.
Service user experience
6.
Patient Safety Alerts management
7.
NICE and other national guidance
8.
Training
CP CCG Quality Indicators for smaller contracts
Requirements
Provider can evidence compliance with all CQC Quality
outcomes, or action plans showing progress towards
compliance
SIs reported, investigated and managed within agreed
timescales. The quality of the investigation reports are
to an agreed standard. Any learning and changes in
practice required are acted on
Evidence of incident reporting system. Review of
incidents identified, reported, investigated and learning
acted on
Review of complaints, actions taken, learning,
timescale for response
Details of service user experience issues, and action
plans, including survey results and examples of service
user engagement
Schedule of alerts, dissemination and progress against
action plans for implementation of alerts
Evidence of system for monitoring and implementing
NICE and other national guidance or patient safety
reports
A Training Needs Analysis is in place.
90% of staff up-to-date with mandatory training and
appraisals.
Evidence of appropriate training, continuous
professional development and clinical supervision for
clinical staff
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Evidence required for assurance
CQC registration
CQC compliance status
Action plans to address CQC concerns
SI reports
SI and incident reporting policy, or equivalent
Number of incidents reported
Quarterly review of incidents
Details of each complaint
Survey results
Examples of service user involvement
Any other service user feedback
Report of relevant alerts and action taken
Report of relevant guidance and action taken
Training Needs Analysis
Staff training records
Evidence of clinical supervision programme
July 2014
9.
Clinical Audit programme
10.
Workforce and staffing
11.
Safeguarding
12.
DNAR forms
13.
Health Care Acquired Infections
14.
Pressure ulcers
15.
Admission, Discharge and Transfer of
care
16.
Care of Equipment
Audits undertaken to evidence CQC compliance, and in Audit reports showing rationale for audit, learning
response to incident / complaints intelligence
and action plans
Evidence of re-audits
Establishment review undertaken 6-monthly or at any
Establishment review
major service development.
Workforce metrics such as sickness, turnover,
Staffing review at start of all shifts against agreed
vacancy rates, use of temporary staff.
establishment (dependent on patient numbers and
Escalation policy
acuity) to identify any gaps and allow escalation of
Recruitment policy
concerns.
Evidence of staff records showing qualifications
All staff appropriately recruited, trained and qualified for
the role undertaken.
Assurance of robust systems for safeguarding children Safeguarding policy
and vulnerable adults, including analysis and delivery
Details of any reported safeguarding issues
of safeguarding training, and compliance with the
principles of the “Delivering Dignity” report
Compliance of DNAR forms and care pathways are in
Number of DNAR forms in place.
place.
Annual DNAR audit
Assurance of robust systems for HCAI which ensure
Policy for managing HCAI
patient safety, including relevant training. Reporting
90% of staff trained in relevant HCAI procedures,
and Root cause analysis investigation of any MRSA
including hand washing
bacteraemia and C Difficile infection. Reporting and
Report on management of, and learning from,
management of outbreaks and infections of
any MRSA bacteraemia and C Difficile infection
significance
Report on management of, and learning from,
any outbreaks and infections of significance
Number of grade 2, 3 and 4 PUs, with details of root
Pressure ulcer guidance
cause analysis used to generate learning, action plans Numbers of PUs by grade
for improvement and evidence of implementation of
changes required.
Assurance of robust policies, procedure and criteria for Admission, Discharge and Transfer of care
Admission, Discharge and Transfer of care
protocol showing a collaborative approach with
other stakeholders
Evidence of an equipment protocol and regular checks Schedule for equipment checks
of equipment.
Audit of equipment checks
Evidence should be submitted to the C&P CCG Contract lead, XXXXXX
CP CCG Quality Indicators for smaller contracts
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July 2014