Dear Team/Ward Manager,
You will have been notified that a Quality Review Visit (QRV) will shortly be undertaken. As a part of the review, the QRV Lead will look at a large volume of data. It would be helpful if the information listed below could be prepared in advance so that this is readily available, electronically or as a paper copy, on the day of the QRV.
SAFE
- Please provide the last three months of Datix reports and evidence that these are discussed at team huddles/ meetings and actions cascaded to the team, including any common themes, lessons learnt and any changes in practice
- Details of any SUI/ 72 hour reviews and learning from these
- Evidence that 7 minute briefings, good catches, QPAs are cascaded to the team and stored appropriately for all staff to access
- BiT/ performance data including compliance that will be needed in an overall team percentage including: mandatory training, role specific training, safeguarding training, data awareness/IG training, infection control training, suicide training, MHA/MCA/DOLS training, Medicines management training, equality and diversity training, clinical supervision and PACE
- Any Training Needs Analysis you keep of role specific training for the service
- Evidence that reflective practice sessions take place
- Provide evidence of how your team safeguards service users by following Trust polices, giving examples
- Evidence of adherence to IPC guidelines (including audits undertaken)
- A PLACE report if appropriate (inpatient services only)
- Although you may not have direct responsibility to complete estate reports, as a team you need to demonstrate that you have access to and awareness of the Fire Risk Assessment, Fire Alarm testing, Work Place Inspections and Cleaning Schedules (if the files are not kept on the premises, please locate this information).
- Fire Risk assessment
- Work Place Inspection (WPI)
- ESRA if appropriate and any action plans (inpatient services only).
- PGDs if used by the service
- Evidence of Non- Medical Prescribing updates and supervision
- Evidence of prescribing audits
- Evidence of appropriate clinical content/ record keeping audit
- Evidence of safer staffing, recruitment plans and escalation processes
- Evidence of local induction for all staff including bank staff and new starters
- Safety huddle/ shift handover documentation and audit
- Evidence of appropriate escalation of the deteriorating patient
- Staff noticeboards are available with relevant Trust information
- Evidence of risk assessments for individual patients/ service users and for the service as appropriate.
EFFECTIVE
- Evidence of a holistic patient assessments underpinned by evidence-based guidance and pathways
- Evidence of FRAT and MUST compliance where appropriate
- Evidence of patient activity programmes (mental health services only)
- Patient information Leaflets and other patient information literature used by team and that is available/ accessible in different formats
- A record of audits for the last year, including cascading results to the team, improvement plans, any changes made and plans for re-audit (local and national audit and benchmarking)
- Evidence of outcome measurement monitoring processes
- There is evidence that a MHA monitoring visit has taken place
CARING
- Evidence of patient feedback: FFTs/ patient surveys/ Datix compliments/ patient forums
- Privacy audit compliance (if relevant to the service)
RESPONSIVE
- Evidence of KPIs/ how performance is managed including waiting times/ delays in accessing the service
- Evidence of any service user complaints, actions and learning from these
WELL LED
- Notes and minutes are available of team meetings, including an action log
- Evidence of MDT meetings, care plans and care pathways with clear evidence of patient/ carer involvement
- Team building/ team development/ team canvas/ work supported by OE
If you have any queries please email the Quality and Compliance Team (CQCTeam
Many thanks,
Quality & Compliance Team