A new system of Regulation for providers of Health and Social Care

From April 2010, the regulation of health and adult social care will change. Legislation has brought in a new registration system that applies to all regulated health and adult social care services. From April 2010, all health and adult social care providers who provide regulated activities are required by law to be registered with the Care Quality Commission.

The Trust has registered the following regulated activities *:

• treatment of disease, disorder or injury
• surgical procedures
• diagnostic and screening procedures
• maternity and midwifery services
• termination of pregnancies

* categories determined by CQC

What does registration involve?

To continue to be registered with the Care Quality Commission, the Trust must show that it is meeting new essential standards of quality and safety across all of the regulated activities we provide. There are 28 standards and 16 of these will be used by the Care Quality Commission to form a judgement about the Trust’s compliance. These are the standards that relate most directly to the quality and safety of care. Click on the links below to learn more about the essential standards of quality and safety:
 

Why has the System changed?

The new system of registration marks a significant shift for NHS providers and independent providers of healthcare. For the NHS, the previous system of compliance with core standards of care (known as Standards for Better Health) overseen by the Healthcare Commission had a strong component of self-declaration and was largely self-reported and retrospective. Therefore, a new system which requires providers of services to have a more dynamic and responsive approach to the continuous monitoring of compliance with essential standards is required. The new system is focused on outcomes, rather than systems and processes, and places the views and experience of people who use services at the centre. Underpinning all of the standards is the requirement to consider equality, diversity and human rights so that the needs of people are considered in every aspect of the Trust’s activities

What is the aim of the new system?

The new system will make sure that people can expect services to meet essential standards of quality and safety that respect their dignity and protect their rights, regardless of the service provider. The system will promote good practice and provide information to improve services where development is required.

How will the Care Quality Commission assess the Trust?

The Care Quality Commission will collate all of the information they have about the Trust in a Quality and Risk Profile. This will include the results from national patient and staff surveys, performance against national standards such as incidence of MRSA, waiting time in A&E and 18 week referral to treatment pathway, level of incident reporting, and achievement of national priorities such as stroke care and cancer treatment, etc. The Care Quality Commission will also gather information from other organisations who have an opinion on the services we provide such as the Local Involvement Networks (LINks). In addition, the Care Quality Commission will undertake short unannounced visits to the Trust to observe the delivery of care.

What will happen if a health or social care organisation does not meet any of the essential standards of quality and safety?

From 1 April 2010, the CQC will be able to take direct enforcement action against any health or social care provider that fails to meet any of the essential levels of safety and quality set by the system of registration. The CQC has a range of enforcement powers that it can use. It can:

• issue a warning notice;
• impose, vary or remove conditions on registration; 
• issue a monetary penalty notice; 
• suspend registration; 
• prosecute for offences; and 
• cancel registration

The Trust must be able to demonstrate that it is meeting the requirements of the essential standards of quality and safety on an on-going basis to retain its registration with the CQC.

Our Trust's assessments can be found below. They are in PDF format - you will need to have Adobe Reader installed on your computer.

What can I do to ensure that the essential standards of quality and safety are met?

Everyone working in the Trust has a responsibility to contribute to the achievement of the essential standards of quality and safety that respect the dignity of people who use or services and protect their rights. For example:

• provide effective, safe and appropriate personalised care, treatment and support to people who use our services by establishing their individual needs from when they are referred or begin to use the service
• promote and respect the privacy, dignity, independence and human rights of people by placing the needs, wishes, preferences and decisions of people who use services at the centre of assessment, planning and delivery of care 
• provide people who use our services with the information they need to make choices 
• report and learn from adverse events, incidents, errors and near misses that have occurred within the service so that the risk of these being repeated is reduced to a minimum 
• deal with any comments or complaints in a sensitive and timely manner by taking into account the individual circumstances 
• identify, report and respond appropriately to suspected or actual abuse of people who use our services 
• comply with hand hygiene requirements, support compliance by patients and visitors and report breaches of hygiene and cleanliness 
• administer medicines at the times when patients need them, and in a safe way, and provide information about the medicine prescribed 
• identify where the person who uses services is at risk of poor nutrition, dehydration or has swallowing difficulties when they first begin to use the service and as their needs change 
• support people who use our services to meet their eating and drinking needs with sensitivity and respect for their dignity and ability 
• use medical devices and equipment in the treatment and support of people who use services in a way that has regard to their dignity, comfort and safety and promotes their independence 
• keep accurate personalised care, treatment and support records secure and confidential for each person who uses the service 
• share information in a confidential manner with all relevant services, individuals, teams or agencies to enable the care, treatment and support needs of people who uses services to be met.

These are just some examples of the standards that certain staff groups will be responsible for achieving. Click on the links above to find out more about each of the essential standards of quality and safety.

How will the Trust help me to meet the essential standards of quality and safety?

The Trust also has a responsibility to you as an employee to provide you with the necessary skills and support to enable you to meet your responsibilities under the new essential standards of quality and safety. This includes:

• Making sure that there are sufficient staff with the right knowledge, experience, qualifications and skills to support people who use our services
• Ensuring that you are properly trained, supervised and appraised 
• Enabling you to acquire further skills and qualifications relevant to your role

Providing mechanisms for you to raise concerns where there is a risk of failing to meet the essential standards of quality and safety

Maternity Services Review
The Healthcare Commission also reviews specific clinical services on a national basis. The most recent review was the quality of Maternity Services in NHS Trusts in England. Our Trust was the sixth-best performing Trust in the country for the quality of its services, as assessed by families who have used our Maternity Services.

For further details, please see the Healthcare Commission’s full publication on the Maternity Services review