Background Infrequent Care Quality Commission (CQC) inspections determine standards of care for patients. However, a system to measure CQC compliance in a contemporaneous way with monthly compliance data would provide assurance in a business as usual way. A process to do this has been developed at St Catherine’s Hospice, Preston and has evolved over the last seven months.

Aims To provide a monthly heatmap of compliance with standards and CQC requirements to demonstrate a journey to excellent care for patients and families.

Methods Key standards and KLOEs (Key Lines of Enquiry) were translated into a system to seek evidence in compliance. This was undertaken via weekly senior nurse visit and a separate wider team assurance visit led by the business manager and a clinical team. The compliance in these key standards was then converted into a heatmap which was RAG rated in each Domain, and an overall compliance also given. At the same time staff were interviewed as part of the ‘well led’ domain and training compliance tracked alongside any complaints and incidents. In addition a 15 steps approach to safety and quality was also undertaken. The heatmap was updated, a report was then produced which included the areas of good practice, and any areas requiring improvement tracked through an action plan. All published monthly for staff to see and have feedback and are visible on the safety, quality and performance board in the in-patient unit. This is also reported quarterly to the Board of Directors and Trustees.

Results Overall compliance with standards using the monthly heatmap

Conclusion Good progress has been made and this process has been transformational in its approach to understanding our current compliance with safety indicators, standards, and reporting from ward to Board.