Head of Compliance, Assurance & Quality 2018 CQC Report Summary Trust Board 4 December 2018 Tracey McKenzie Head of Compliance, Assurance & Quality

Overall Rating

Ratings statistics – an improving picture 6 of the 15 core services have improved their overall rating, 8 remained the same,1 went down 26 core service domain ratings have improved, 43 remained the same and 6 have gone down 1 warning notice – Bluebird House (staffing) and Leigh House (ligatures) – lifted within 3 weeks Warning Notice – issued 29 June 2018. Re-inspected 3 weeks later on 18 July and warning notice lifted

3/5 have improved their overall rating

Eating disorders and perinatal services were not inspected & although rated in 2014 their ratings do not form part of the aggregation for the overall ratings 3/10 have improved overall ratings – LD have gone up from RI to O 6/10 have remained the same – 4 have seen improvements within one or two of the domains 1/10 have gone down (OPMH inpts)

CQC 2018 in numbers

Areas for Improvement 20 ‘must do’ actions (7 Requirement Notices); 74 ‘should do’ actions Quality improvement plan developed - focused on Themes with a work stream approach to understand and address root causes QI methodology to be used to support improvements Monitored via Quality Improvement & Planning Delivery Group

CQC Themes & Reporting Structure

Improvement Themes Workforce Safeguarding Medicines Management Safer staffing levels Staff supervision – clinical and management Access to psychological therapies Safeguarding Mental Capacity Act Safeguarding reporting processes Medicines Management Storage environment

Improvement Themes End of Life Care Records Management Completion of do not attempt resuscitation forms Gathering of patient, carer & family experiences of end of life care Records Management Care planning Access & storage of records Privacy & Dignity Ward environments Completion of DNACPRs & care planning are themes from previous inspections. Care planning also picked up in MHA visits. QI approach will be taken to understand root causes.

Areas of Outstanding Practice Learning Disability Services Patients at centre of all the care provided - individualised care plans clearly displayed in patients’ rooms, displayed in a way that patients could understand Schedules of activities focused on providing meaningful and helpful activities / therapy to help prepare for discharge Long Stay / Rehab Mental Health Wards Wards tailored to meet needs of individual patients - recovery orientated with planned discharge from point of admission Good multi-disciplinary teams who worked collaboratively

Well-led - highlights Positive, strong senior leadership team Clear vision and values communicated throughout organisation Quality, care and sustainability were the top priorities Staff felt respected, supported and valued Comprehensive serious incident reporting & investigation process Significant improvement in use of people’s views & experience Significant programme of quality improvement (QI) training for staff

Well-led - areas for improvement CQC felt that the trust did not have a real appreciation of how challenging and stressful the situation at Bluebird House had become for staff Governance systems did not always provide robust assurance to the trust board about issues within services - the trust collected large amounts of data, and the data collection was not always reliable There was still some work to do in improving the image of the trust The trust faced significant financial challenges

CQC – latest approach On-going engagement with Trust Relationship management CQC ‘Insight’ Quarterly engagement meetings Annual Provider Information Request (PIR) Annual Well-led inspection Annual Core Service inspections

Thank You Any questions?