CQC Report Summary: Improving Picture, Areas for Improvement, and Outstanding Practice

1. 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

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 • 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 • 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

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?