UNIVERSITY HOSPITALS OF MORECAMBE BAY NHS TRUST

TRUST BOARD MEETING

To be held on 29 September 2010 Agenda 9a

Report of: / Jackie Holt
Paper Prepared by: / Graham Hall
Date of Paper: / 1 September 2010
Subject: / Care Quality Commission Notifications Policy
CQC Standards / All
Assurance Framework Link: / Strategic Objective 1
Principal Objective 1.1
Auditors Local Evaluation (ALE) Link: / N/A
Background Papers: / N/A
Item Considered at Earlier Committees
(pls detail mtgs): / N/A
Patient & Public Involvement: / N/A
In case of query, please contact: / Graham Hall
Ext 46640
Purpose of Paper:
The aim is to ensure that the Trust meets the statutory duty to notify Care Quality Commission (CQC) in writing about certain important events that affect people who use the service or the service itself. The events are:-
·  Changes to the statement of purpose or an activity
·  Notice of changes
·  Certain deaths of people who use a regulated activity
·  Deaths and unauthorised absences of people detained or liable to be detained under the Mental Health Act 1983
·  Applications to deprive a person of their liberty
·  Serious injuries
Existing arrangements for reporting serious and deaths to the National Patient Safety Agency (NPSA) will continue and the NPSA will inform the CQC on behalf of the Trust.
New arrangements need to be implemented to ensure all other requirements are met.
The Clinical Quality and Safety Committee approved the policy on 15 September 2010
The Board are asked to note the content.
Care Quality Commission Notifications Policy
Version / 1.0
Date / 26/08/2010
Review Date / 26/08/2012
Author / Governance Manager
Change Approver / HMT, CQSC
Reference
Filename


CHANGE CONTROL SHEET

This is a Controlled Document. The definitive version is on the intranet. Printed versions should be verified as valid with the intranet version.

POLICY DEVELOPMENT TEAM

Name Job Title Division/Department

J Holt Director of Nursing Trust Board

G Hall Governance Manager Integrated Risk

AMENDMENT HISTORY

Revision No. / Date of Issue / Page/Section Changed / Description of Change / Review Date

DISTRIBUTION LIST

·  Hospital Management Team

·  Divisional General Managers (for onward distribution to managers within the division)

·  Trust Headquarters (File Copy)

·  Medical Director

·  Associate Medical Directors

·  Director of Nursing and Modernisation

·  Assistant Director of Nursing (for onward distribution to Divisional Nurses, Lead Nurses and mental health Capacity Leads)

·  Divisional Nurses & Lead Nurses (for onward distribution to Matrons)

·  Director of Operations & Performance

·  Deputy Director of Operations & Performance

·  Department Managers (Clinical Risk, Governance, Health & Safety)

·  Departmental intranet editor

APPROVAL FOR ISSUE

Chief Executive / Director
Signature: / Signature:
Date: / Date:


EQUALITY & DIVERSITY IMPACT ASSESSMENT TOOL

ASSESSMENT QUESTION AGAINST POLICY / YES/NO / COMMENT / ACTION POINT
Does the policy, or any part of it (particularly any access criteria) discriminate on the grounds of any of the following criteria:
Age / Yes/No / Religion / Yes/No / If so please give further details:
Race / Yes/No / Sexual orientation / Yes/No
Gender / Yes/No / Disability / Yes/No
Culture / Yes/No / Yes/No
Does the policy relate to the broader aims of the Trust / Yes/No
Does the policy relate to other agencies within the community / Yes/No
Does it promote equality and enhance community relations / Yes/No
Does it influence relations between different groups / Yes/No
Could some groups be affected differently / Yes/No
Is there any evidence that some groups are affected differently / Yes/No
Do we need to gather evidence? What data is required / Yes/No
Is the impact of the policy likely to be negative / Yes/No
If so can the impact be avoided / Yes/No
Is it unlawful / Yes/No
Can it be justified / Yes/No
What alternatives are there to achieving the policy without the impact / Yes/No
Can we reduce the impact by taking different action / Yes /No
How to consult with those groups likely to be affected by the policy / Yes/No

REFERENCES (Include references to all relevant Trust Policies and Guidelines)

Number / References
1 / Risk Management Policy & Strategy
2 / Maternity Risk Management Strategy
3 / Serious Untoward Incident Policy
4 / Patient Safety Incident Policy
5 / StEIS procedure
6 / NPSA National Reporting and Learning System
7 / Mental Capacity and Deprivation of Liberty Policy
8 / The Mental Capacity Act 2005 (MCA 2005)
.

GLOSSARY

Abbreviation / Definition
NPSA / National Patient Safety Agency
CQC / Care Quality Commission
MCA / Mental Capacity Act


Contents

Page
Title / 1
Change Control / 2
Policy Development Team / 2
Amendment History / 2
Distribution List / 2
Approval / 2
Equity & Diversity Impact Assessment / 3
References / 4
Glossary / 4
Contents / 5
1 / Introduction / 6
1.1 / Development Process / 6
1.2 / Scope / 6
1.3 / Aims and Objectives / 6
1.4 / Outcomes / 6
2 / Policy statement / 6
2.1 / Duties / 6
2.1.1 / Director of Nursing & Modernisation / 6
2.1.2 / Governance Manager / 6
2.1.3 / Divisional Management & Clinical Directors / 6
2.1.4 / Trust Mental Capacity Leads / 7
2.1.5 / All staff / 7
2.1.6 / Formal Committees and Sub-Committees / 7
2.2 / What should be reported? / 7
2.3 / Who should report? / 7
2.4 / How should reports be made? / 7
3 / Implementation / 7
3.1 / Policy dissemination / 7
3.3 / Version control and archiving / 8
3.4 / Monitoring / 8
3.5 / Audit / 8
3.6 / Review / 8
Checklist / 9
Appendix 1 – Links to CQC website and reporting forms / 10
1 / Introduction
This document gives details of the types of notifications that must be made to the CQC and how this should be done.
1.1 / Development process
The policy has been developed in line with the requirements of the CQC publication:
“A new system of registration
Notifications required by the Health and Social Care Act 2008
Guidance for NHS providers”
1.2 / Scope
This policy applies to all registered locations and activities within the Trust.
1.3 / Aims and objectives
The aim is to ensure that the trust meets the statutory duty to notify CQC in writing about certain important events that affect people who use services or the service itself. The events are:-
·  Changes to the statement of purpose or an activity
·  Notice of changes
·  Certain deaths of people who use a regulated activity
·  Deaths and unauthorised absences of people detained or liable to be detained under the Mental Health Act 1983
·  Applications to deprive a person of their liberty
·  Serious injuries
1.4 / Outcomes
Implementation of the policy will lead to the Trust complying with statutory obligations in relation to the notifications requirements
2 / Policy Statement
2.1 / Duties
2.1.1 / Director of Nursing and Modernisation.
Is the Trust “nominated individual” for all matters relating to CQC.
2.1.2 / Governance Manager
Responsible for:
·  Overseeing the application of the policy and reporting any issues to Director of Nursing and Modernisation.
·  Providing advice and guidance to staff on notification processes.
·  Coordinating and submitting all notifications to CQC
2.1.3 / Divisional Management and Clinical Directors
Ensure that all their staff are familiar with the content of this policy and therefore applying it in their area of practice as appropriate.
Ensure that all relevant events are notified.
2.1.4 / Trust Mental Capacity Leads
Ensure that all applications to deprive a person of their liberty under the Mental Capacity Act 2005 are reported to the Governance Manager.
2.1.5 / All staff
Responsible for complying with this policy.
2.1.6 / Formal Committees and Sub-Committees
The Clinical Quality and Safety Committee will receive regular reports on all notifications made to the CQC.
Individual notifications will be monitored via the committee structure.
2.2 / What events should the CQC be notified about? / Timescale
The following should be reported direct to CQC.
·  Changes to the statement of purpose for an activity or location
• a provider to carry on a new activity
• a new provider carries on an activity
• a provider stops carrying on an activity
• change of a provider’s main address
• change of nominated individual or chief executive / Within 28 days
·  Deaths and unauthorised absences of people detained or liable to be detained under the Mental Health Act 1983 / Without delay
Other incidents: Applications to deprive a person of their liberty under the Mental Capacity Act 2005, and their outcome / Without delay
The following will be reported to the NPSA via the existing incident reporting arrangements. The NPSA will inform the CQC.
·  Certain deaths of people who use a regulated activity
·  Serious injuries / Without delay
2.3 / Who should report?
All staff who are aware of any of the above changes should inform the Governance Manager in the Integrated Risk Office, WGH.
2.4 / How should reports be made?
Reports should be made using the appropriate CQC proforma from the intranet or from the CQC website ( Links and forms at Appendix 1). Contact the Governance Manager directly.

Tel 01539 716640 (Internal ext 46640)
3 / Implementation
The policy will be implemented from 01/09/2010.
3.1 / Policy dissemination
The policy will be distributed as outlined in the list on page 2.
A copy of the policy will be available to all staff on the trust Intranet, with links from the Trust Policy pages.
3.3 / Version control and archiving
The Governance Manager will hold a password protected electronic copy of the policy in addition to file copies held at Trust headquarters. As a version is superseded, the old version will be securely archived in accordance with normal trust practice.
3.4 / Monitoring
The effectiveness of this policy will be monitored through the Patient Service & Experience Sub-Committee with any concerns being escalated as necessary to the Clinical Quality and Safety Committee. Records of relevant events will be compared to the number of notifications on a quarterly basis.
3.5 / Audit
Adherence to the policy will be periodically audited by the internal audit department as part of the review of internal controls.
3.6 / Review
The policy will be subject to formal review by the HMT and Clinical Quality and Safety Committee after a period of 2 years.

Checklist for the Review and Approval of Procedural Document

To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval.

/ Title of document being reviewed: / Yes/No/
Unsure / Comments /
1. / Title
Is the title clear and unambiguous? / Yes
Is it clear whether the document is a guideline, policy, protocol or standard? / Yes
2. / Rationale
Are reasons for development of the document stated? / Yes
3. / Development Process
Is the method described in brief? / Yes
Are people involved in the development identified? / Yes
Do you feel a reasonable attempt has been made to ensure relevant expertise has been used? / Yes
Is there evidence of consultation with stakeholders and users? / N/A
4. / Content
Is the objective of the document clear? / Yes
Is the target population clear and unambiguous? / Yes
Are the intended outcomes described? / Yes
Are the statements clear and unambiguous? / Yes
Has an Impact Assessment been completed for the policy content? / Yes
5. / Evidence Base
Is the type of evidence to support the document identified explicitly? / N/A
Are key references cited? / Yes
Are the references cited in full? / Yes
Are supporting documents referenced? / Yes
6. / Approval
Does the document identify which committee/group will approve it? / Yes
If appropriate have the joint Human Resources/staff side committee (or equivalent) approved the document? / N/A
7. / Dissemination and Implementation
Is there an outline/plan to identify how this will be done? (include in Team Brief / Intranet / Weekly Messenger) / Yes
Does the plan include the necessary training/support to ensure compliance? / Yes
8. / Document Control
Does the document identify where it will be held? (Authors responsibility) / Yes
Have archiving arrangements for superseded documents been addressed? / Yes
9. / Process to Monitor Compliance and Effectiveness
Are there measurable standards or KPIs to support the monitoring of compliance with and effectiveness of the document? / Yes
Is there a plan to review or audit compliance with the document? / Yes
10. / Review Date
Is the review date identified? / Yes
Is the frequency of review identified? If so is it acceptable? / Yes
11. / Overall Responsibility for the Document
Is it clear who will be responsible for co-ordinating the dissemination, implementation and review of the document? / Yes
Individual Approval
If you are happy to approve this document, please sign and date it and forward to the chair of the committee/group where it will receive final approval.
Name / Date
Signature
Committee Approval
If the committee is happy to approve this document, please sign and date it and forward copies to the person with responsibility for disseminating and implementing the document and the person who is responsible for maintaining the organisation’s database of approved documents.
Name / Date
Signature

Acknowledgement: Cambridgeshire and Peterborough Mental Health Partnership NHS Trust

Appendix 1.

Links to CQC website

www.cqc.org.uk

Link to CQC notification forms web page.

www.cqc.org.uk/guidanceforprofessionals/nhstrusts/registration/notifications.cfm

Copies of all forms are attached below.

Statutory notification

Regulation 12(3), Care Quality Commission (Registration) Regulations 2009