CQC%20Compliance

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CQC Compliance
Outcome 11 Safety, Availability and Suitability
of Equipment

• Presented By Alex Zarneh (Dr.)
• Head of Medical Physics Radiation Protection
  Services
• Medical Physics Department
• Mid Yorkshire Hospitals NHS Trust
• Incorporating Dewsbury District, Pinderfields
  and Pontefract Hospitals
• alex.zarneh_at_midyorks.nhs.uk
• MID YORKSHIRE HOSPITALS NHS TRUSTDEWSBURY AND
  DISTRICT HOSPITALMEDICAL PHYSICS
  DEPARTMENTHALIFAX ROADDEWSBURYWEST
  YORKSHIREWF13 4HS

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Take Your Seats, Sit Back, Relax And Enjoy
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 This presentation gives an overview from the
following points of view- Head of Medical
Physics with operational and professional
responsibility- Acting as out of hours on-site
duty manager- being accountable for patients
not having basic kit such as Static Mattresses or
Pillows
Neglect or Ignorance?
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 The Trust was inspected by Care Quality
Commission Assessors60 assessors arrived and
spent one week across 3 hospitals and care closer
to home premisesThey also came back at weekends
and did unannounced inspection
What Happened?
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 A lot of Evidence was presented prior to their
visit but was not Enough to satisfy the
requirements of outcome 11!
What Happened?
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The registered person, the Trust must make
suitable arrangements to protect service users
and others who may be at risk of using unsafe
equipment
Outcome 11 Safety, Availability and Suitability
of Equipment
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 To ensure that any devices isProperly
maintained and suitable for its purpose Used
correctly Is available in sufficient
quantitiesRole of Medical Devices Library
Availability Of Devices
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 The Device is Suitable for its
purpose Is properly maintained Is used
correctly and safely Promotes
independenceIN-HOUSE MANAGEMENT OF MEDICAL
DEVICES POLICY!
Fit For Purpose
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 Do You Know Who is responsible In Your Trust
for- Static / Foam Mattresses or Pillows-
Wheel Chairs? How many are lying around
broken?- Commodes? / Bariatric Equipment_
Pressure Relief Mattresses?- Decontamination /
Cleaning of Medical Devices?
Responsibilities?
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 - Who is responsible for Clinical Training?-
Who is responsible for managing external medical
devices contracts?-Who verifies the contractors
service reports? Ward clerk?- Who accepts the
device back into service? Ward Clerk / Domestics?
Responsibilities?
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 - Who decides on the level of contract needed?
-Is there a centralised database with full
visibility?- Is there a replacement programme
for all the devices?- What is your
standardisation Policy?- Who stands up to users
and clinical colleagues who are putting pressure
on to purchase the Deal of the Day?
Responsibilities?
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 - Assessors spent time on the wards- Command
centres were set up at each hospital site- Head
of Medical Physics - Director- Matrons-
Chief Nurse Deputy
CQC Assessment
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- Inventory ?- Training Records? How many were
in date?Some wards also created their own
folders Labeled CQC Evidence? Not
acceptable!
Yellow Folders!
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 We met with each other every two hours -
Kept in touch via text and mobile signal
issues- Walked round the wards and corridors-
Engaged with porters to move items from
corridors- Lots of biscuits / Fruit and
Chocolates- Created good relationship between
different colleagues
CQC Assessment
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 - Some staff not familiar with the sites-
Working for the same organisation?- Making
assumptions- What happened to day to day
tasks?- Tired - Having spent 4 weeks collecting
evidence!
Operational Issues
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 - Each day requests came from CQC for
information- Can you do it for now?- Remember
- All Information must be credible- We had a
lot of explaining to do!
CQC / Trust Expectations
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 What were the issues for Medical Physics?-
Labeling of service dates on devices- I sent a
global Email to other Trusts for comments-
Received some good and some rude and ignorant
Emails- Spot checking of service dates via
telephone call from the assessor
CQC / Trust Expectations
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- CQC asked for a list of outstanding jobs-
List of outstanding PVIs- High Risk, Medium
Risk and Low Risk- What is the problem?
CQC / Trust Expectations
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- The information was presented to CQC-
Decision made to withdraw the Yellow Folders
What happened Next?
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- No Formal feedback - Various informal
questions re Inventory for various areas-
!Number of NIBPs in a certain area!
Feedback?
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- Continue with achieving compliance (91)-
Debate re stickers and service lables?
What Have We Done?
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Thank you for your attention
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