Compliance with Care Quality Commission Standards
For 2009/2010 North Bristol NHS Trust is declaring compliance
with 23 Care Quality Commission Core standards, including all of
the sub-sections, totalling 43 "standards" in all.
However, for 1 core standard only (C21), North Bristol NHS Trust
is declaring non-compliance. This is with regard to the element of
C21 that relates to the Trust being 'well designed'. The other 2
elements of C21, are compliant (cleaning and maintenance).
North Bristol NHS Trust scored "Weak" in 2008/2009 for Quality
of Services in CQC Annual Health Check. This rating was driven by
self-assessment of Core Standards, where 4 standards were
"non-compliant" and 5 had "insufficient evidence", partly driven
itself by an improvement notice placed on the Trust by the CQC.
Robust action, led by Trust Board and the Chief Executive, has
subsequently been taken by North Bristol NHS Trust to address all
the concerns of the Care Quality Commission (CQC), Strategic Health
Authorities and Primary Care Commissioners, to ensure compliance
with 23 Core Standards (43 "standards sections" out of 44) by the
December 2009 submission.
Since the "Weak" rating for Quality of Services within the
Annual health Check Rating for 2008/09 and the self-declaration
around the core standards, the Trust's action plan and rigorous
approach to addressing issues has seen:
- The issues raised by the CQC effectively addressed and
consequently their improvement notice lifted.
- The conditions placed upon the Trusts registration lifted, so
that North Bristol NHS Trust is unconditionally registered as a
Healthcare Provider with the CQC.
- The Trust had a very positive "surprise visit" from the CQC in
September in relation to the duties of the hygiene code, and
received a clear bill of health for 2009/2010.
- The single standard the Trust will not be compliant with has
been declared non-compliant previously, and is a key reason driving
the need for the new PFI Super Hospital at Southmead.
The Board has taken a range of actions to assure itself of the
integrity of compliance with core standards;
- A robust assurance programme and completed action plans for
last years non-compliant and insufficient assurance standards,
including external validation
- Validation of evidence submitted by the central team.
- Independent audits of some core standards evidence by the
Trust's Internal Auditors
- Participation of two non-executives in an in-depth validation
process, looking in detail at certain standards
These sessions included:
- Safeguarding children, mandatory training and medical devices,
as well as other core standards
- Review meeting with the South West SHA which endorsed the
Trust's actions
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