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

2. Overall Rating

3. 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 Re-inspected 3 weeks later on 18 July and warning notice lifted

4. 3/5 have improved their overall rating

5. 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)

6. CQC 2018 in numbers

7. 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

8. CQC Themes & Reporting Structure

9. 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

10. 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.

11. 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

12. 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

13. 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

14. 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

15. Thank You Any questions?