Where are we?

Post CQC fatigue…..

The informal feedback was provided on the day which indicated that:

Very positive feedback was received from our patients and carers around the service they received.

The inspectors were made to feel welcome, and found very committed and dedicated staff members that were welcoming, open and helpful.

There were services in the Trust that showed exemplar levels of care and patient involvement e.g. CAMH’s in-patient service was very child-centred with excellent school in-reach.

The community services were able to deliver a wide ranging variety of evidence based interventions suited to the patient’s diagnostic needs.

There were innovative projects and service delivery that were considered good practice e.g. GP receptionist training Samaritans partnership working

The good….

Areas of Concern related to

Derwent centre Hub: The use of the Derwent Centre ‘hub model’ for patients during the day as the

building work is undertaken to provide new wards and the assurance to maintain a safe and therapeutic environment during this period.

S136 facilities Seclusion/de-escalation rooms The provision of the correct design and fabric of the 136 suites ‘Places of Safety’ and

seclusion facilities that meet the compliance standards as set out by the New Code of Practice February 2015.

Ligature Risk assessments and organisational response Ligature risk management within the in-patient facilities across the Trust that can

evidence residual risk management and action. Care plans and individual risk assessments

Risk assessment and care plans need development to be more personalised with patient consent and depth of content.

Therapeutic environment of inpatient facilities Improving the therapeutic environment of in-patient units and practise of

individualised care. It was recognised progress had been made towards Eliminating Mixed Sex-

Accommodation as per national guidance but this requires progression from the initial stages.

The bad….

The Trust will require an enhanced structure of quality governance that progresses improvement against these areas of concern and risk action plans providing rapid improvements.

The ugly………………..tempted?

The purpose of the Quality Summit, which is the final part of the inspection programme, is to formally hand over the inspection reports to the Trust and partner organisations. It also serves to agree a plan of action based on the CQC inspection team’s findings as set out in the draft inspection reports.

The Quality Summit considers whether the actions planned by the Trust to improve quality are sufficient to bring about the required improvements or whether additional steps need to be taken.

The Trust will receive the final reports and will be given a period of time approximately 4 weeks to respond to the CQC with a compliance action plan describing the improvements we would make to improve outcomes for people who use the services and achieve compliance with the regulations.

CQC Inspection of NEP

Initial feedback was received on the final day of the inspection from the Chair and Lead Inspector to members of the Trust Board. To note the feedback is minimal, not in detail, but does provide a focus on areas of good practice and concerns that the Trust can immediately respond to improve care to our patients.

Quality Summit

So we have an initial Quality Improvement Plan…..

Quality Improvement Framework

1. Quality Improvement Framework

The Quality Improvement Framework is based on the Institute for Health Improvement (IHI) principles of creating a High Reliability Culture across the Organisation. The Trust recognises the need to confirm its Strategic Direction and the need for a programme of sustained improvement which will focus on Quality Improvement, Quality Assurance, and the management of risk.

To promote responsive quality governance from Board level to Ward level Quality Improvement Panels (QUIP’s) will operate at all tiers of the organisation to fulfil quality governance requirements

Quality Governance Arrangements

The term quality governance refers to the values and behaviours and the structures and processes that need to be in place to enable the board to discharge its responsibilities for quality. The board’s responsibilities for quality are threefold:

• to ensure that the essential standards of quality and safety (as determined by CQC’s registration requirements) are at a minimum being met by every service that the organisation delivers to ensure that the organisation is striving for continuous quality

• improvement and outcomes in every service; and to ensure that every member of staff that has

contact with patients, or whose actions directly impact on patient care, is motivated and enabled to deliver effective, safe and person centred care‐

• The arrangements for quality governance should complement, and be fully integrated with, the

governance arrangements for other aspects of the board's responsibilities, for example, finance governance and research governance.

We need a structure…..Quality improvement Panels

Quality Improvement Panels

They are • Patient and care focused • Supportive• Challenging• Encouraging• Scrutinising• Providing assurance and

progressing risk management

In order to track ongoing quality performance and work to drive up improvement relative to quality goals this will be achieved by:

Review of a quality dashboard for board as an early warning system against quality indicators

Ensuring there are more detailed sets of ward to board quality indicators at lower levels with clear procedures for escalating to the board

Review of ward risk registers Quality Improvement Methodology is established with the Plan Do Study Act (PDSA) Model.

They are not Prime Minister ‘s question time……………

Quality improvement panels

PDSA model

Staff Enablement

Improvement

‘That’s been one of my mantra’s focus and simplicity. Simple can be harder than complexity: you have to work hard to get your thinking clean to make it simple. But it’s worth it in the end because once you get there you can move mountains’Steve Jobs

Keeping it simple is the aim…..

Go on…you know you want to…

Do we really have permission…????

Quality Improvement is not just thinking outside the box its changing the box….

Diagnosing the system • We need data to understand the system

5 Ps

Purpose

Establishes belief in the change…

Recognising followership

That’s all folks….