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Local Accreditation at Gateshead Health NHS Foundation Trust


Providing the highest quality of care for
patients is at the heart of everything we do in Gateshead Health NHS Foundation Trust.
That’s why back in 2012 we developed our Care Quality Accreditation Programme. Our
programme helps us to ensure our wards and departments are the best they can be for our
patients. It also helps us to engage our staff in continuous improvement and to share their
learning with others. The accreditation works by providing wards
with a set of quality and safety standards and these are assessed through written evidence
through interviews with patients and staff and by observing. These standards are based
on a framework which was developed through our Nursing and Midwifery strategy. Our annual
assessment days are designed to give our staff the opportunity to demonstrate how they meet
the standards to provide the best care possible for our patients.
The ward sister or charge nurse is responsible for producing a portfolio of evidence that
demonstrates the standards. This also gives us the opportunity to demonstrate and showcase
any improvements we have made. The portfolios include a range of evidence from clinical
audit to patient experience feedback to workforce information such as sickness absence rates
and annual appraisal data. Observation gives the assessment team the
opportunity to review how the standards are met in practice. Assessors will also observe
how staff deliver care and respond to patients. A range of nursing records are reviewed in
real time. There’s also observation of the environment, compliance with infection control
policies and procedures. The team also assesses what information is being displayed for patients
and carers in the department. The assessment day is also an opportunity
for the assessors to talk to patients and staff about their experiences within the clinical
area. Information is gathered through several sources including the patients themselves,
as well as family and friends, tests, and other patient level data. At the end of the day, the panel will meet and discuss each standard, awarding a red,
amber, or green rating. This information is then collated and the final result is agreed.
Feedback is provided by the senior nurse on the panel to the ward sister unto their matron
and this is followed by a written reward accreditation report. On achievement of accreditation, the
certificate is presented by the Director of Nursing and that success is promoted across
the trust. The ward teams display their certificate proudly in their wards and departments.
As a ward sister, I pride myself in being a strong leader that motivates and empowers
the staff. I know my team do an excellent job every day. In the care quality accreditation
framework, it allows us to recognize and evidence this.
The Care Quality Accreditation Framework is a way as matrons that we can really showcase
the excellent work that’s going on at Gateshead and really ensuring that patients are receiving
safe and effective care and we really strive to provide that all of the time.
The excellent work we’ve been doing in the department was recognised and the staff felt
really proud to be able to showcase what we’ve been doing.
The ward staff really appreciates the interaction that senior members of the nursing team have
within the ward accreditation to really get to know what’s going on in the areas of
development as well as the areas of outstanding practice that we provide.


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