The Atlas of Shared Learning

Case study

The CARE excellence accreditation scheme in Surrey and Borders NHS Foundation Trust

Leading change

The Head of Accreditation in the Quality Directorate at Surrey and Borders NHS Foundation Trust led on the development and implementation of a CARE Excellence Accreditation Scheme to support quality improvement across the Trust.

Where to look

The Keogh Review (2013) considered the quality of care and treatment provided by hospital Trusts with persistently high mortality rates, following quality concerns at Mid Staffordshire NHS Foundation Trust. Although the review found some evidence of excellent practice in all 14 sample Trusts in the review, there was also significant scope for improvement, with each needing to address an urgent set of actions to raise standards of care. The Review highlights that these organisations needed a renewed sense of ambition, with staff empowered and confident to achieve excellence.

The review made recommendations in utilising a quality improvement methodology, including a common, streamlined and easily accessible data set on quality which can then be used by providers, commissioners, regulators and members of the public in their respective roles.

At Surrey and Borders NHS Foundation Trust, services undertook a more traditional annual quality assurance process, which although well-established within the organisation provided opportunity for improvement and redesign. The Head of Accreditation saw an opportunity to adapt and develop this process, moving towards ‘Foundation Standards’ – the first step towards an internal accreditation. The standards were strengthened, utilising the recommendations of the Keogh review.

What to change

The Trust’s existing service review had been in place for several years. However, at the Trust, areas such as care planning or risk assessment were not explicitly measured or reported, rather they were embedded within an overall score. This presented an opportunity for closer focus – to reduce unwarranted variation in clinical practice and to standardise monitoring and reporting across the Trust. The change presented an opportunity to align to the Care Quality Commission’s (CQC) key lines of enquiry, which would support the Trust to prepare for an inspection.

The senior nursing team identified areas for improvement and to support the Trust in delivering high quality care and reflecting national standards. They also introduced a self-assessment to support staff and teams to reflect on performance. The standards captured would be identified as ‘Foundation Standards’, for all services to strive for and meet.

The next stage was the development of a CARE excellence accreditation scheme pilot, to facilitate a quality assurance process, supporting the services to strive for excellence.

How to change

To create the new accreditation programme, the nursing leads collaborated with nine teams across different disciplines and services – this partnership approach advocated a bespoke set of standards. The programme includes a stepped approach to accreditation, starting with complying with the ‘Foundation Standards’:

  • Self-assessment undertaken as a team approach. This helps prepare the team for the peer review and encourages ownership of the quality improvement. This is then submitted to the Divisional Director to review and sign off.
  • Peer review is then completed within six months of the self-assessment. All services must complete their action plan following the review.
  • Services must achieve a ‘good’ rating in their Foundation Standards peer review to progress through the process.
  • Services must meet all the observation standards stemming from the CQC observation tools and an adapted form of the NHS 15 steps challenge.
  • A portfolio of evidence is required to demonstrate excellent overall compliance and to identify any possible areas of development.
  • Services attend a panel consisting of senior managers to review the evidence and to give a 20-minute presentation to demonstrate the quality improvement the team has embedded.

Adding value

Better outcomes – The CARE excellence accreditation programme is supporting teams to move through the process and begin to demonstrate improvements in practice. To date, 11 services have successfully achieved accreditation and a further four services are undertaking the improvement process. Following implementation of the ‘Foundation Standards’, there has been overall improvement, but more specifically in care planning and health and safety standards. Further, in the recent CQC inspection, the accreditation programme has been identified as an area of outstanding practice.

Better experience – People using services and carers have been integral to the accreditation process. Their feedback on the service and care supports decision making at every step of the review. Ongoing feedback has been positive and is also supporting further improvements based on received suggestions. Staff have welcomed the changes and the focused effort on improvements. This is particularly apparent in the receptiveness to the ‘awareness raising’ sessions and these will be re-run for staff based on the demand.

Better use of resources – The Foundation standards process has proved beneficial to new managers. It provides them with a guide to focusing their resources, supporting them to use resources more effectively in practice. A review of the wider impact of the programme is planned.

Challenges and lessons learnt for implementation

A pilot to this accreditation process has been imperative. It has allowed the development to be adapted and tweaked at each stage as needed.

An essential component of the programme was developing the process with services, which enhanced buy in and commitment to the programme. Further, ensuring that people who use services were involved in all aspects of the process ensured that it was meaningful to all stakeholders.

It is important to allow time to reflect on progress, as well as to ensure clear advice and guidance is available to services prior to them starting the programme.

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