CQC Inspection Kathryn Singh Kathryn Singh Chief Executive What I - - PowerPoint PPT Presentation

CQC Inspection

Kathryn Singh Kathryn Singh

Chief Executive

What I will cover

• Understanding our history & our services
• Our ratings
• What the CQC said we do well
• What the CQC said we must improve
• Our approach and response
• Our governance arrangements
• Support with our action plan

2015 North Lincolnshire School Nursing Service 2011 Doncaster and Rotherham Community Health (TCS) 2010 Doncaster Tier 2 & 3 CAMHS

Understanding our history …

2008 North Lincolnshire Mental Health 2007 Foundation Trust Status Manchester EI 2002 Rotherham Mental Health Services

1999 Doncaster and Scunthorpe Health Care Trusts Merge

Our services in 2016 …

The services we provide in the different localities are presented in this map.

£155 Million Circa 200 Circa 4,300 (3,700 WTE) Employees

Facts about RDaSH …

Volunteers Annual budget

• Clinical Commissioning Groups (CCGs)

Commissioners

• Local Authorities
• Others, e.g. Drug Treatment Agency
• NHS England

RDaSH facts continued…

89 across 5 localities 347 beds on 21 wards 240 across 5 regional areas

Locations

Number of beds Community Teams Adult Social Care Learning Disability Domiciliary Services in Doncaster In 2014/15

• 82,356 people accessed our services
• 912,409 face to face contacts
• A further 143,363 non face to face patient contacts

Patient contacts and Rotherham Learning Disability Registered Homes: 88 Travis Gardens, Danes Court and Station Road

Our overall rating …

What the CQC said we do well …

• Solar Centre - commended by patients and carers
• 88 Travis Gardens – Outstanding for Caring

Learning Disability Services

• Mental Health Crisis Teams – Rated Outstanding Overall by CQC
• Mulberry House – Introduction of the ‘Perfect Week’
• Doncaster Perinatal Service
• Rotherham dedicated service for deaf patients with mental health problems

Adult Mental Health Services

• Safeguarding Advisor in post and training at a high level across all services
• Out of hours duty system provides excellent coverage of emergency/crisis calls

Children & Young People’s

• Peer Support Workers assist with transition to adult mental health services

Mental Health Services

• Peer Mentor Scheme developed, including training packages to provide service users

with the skills and knowledge to become Peer Mentors

• Peer Mentors from New Beginnings worked across the services in Doncaster and three

had progressed into paid employment

Drug & Alcohol Services

• Telehealth Services developed to respond to the needs of patients with long term

conditions

• Specialist Falls Service facilitates a Falls and Balance Group that has received positive

patient feedback

• Dietetics Service innovative use of the MUST Tool to support community nurses offering

‘Food First’ advice

Adult Community Services

What the CQC said we do well …

• Caring and compassionate staff
• Patients and relatives were empowered and supported to manage their own health
• Evidence of Lessons Learnt

End of Life Services

• Implemented Fall Safe
• Care records are comprehensive
• Staff were caring and respectful of patients privacy and dignity, patients were involved in

decision making

Community Inpatient Services

• Rated Overall by CQC as Outstanding
• Development of local education and health aids

Community Health for Children, Young People and Families

• Development of ‘Roots of Empathy’ to prevent bullying, funded by NHS England

Young People and Families

• Reducing Restrictive Interventions training introduced to assist patients to develop

positive ways to manage their aggression, resulting in a 50% reduction in physical interventions

Forensics

• Community-based services for Older People rated as Outstanding for Caring
• Young Onset Dementia Day Care offering carer respite and patient engagement
• Male Carers Support Group for patients with Huntingdon’s Disease
• Cognitive Stimulation Programme – support patients with cognitive functioning
• Kings Fund advice and guidance to make wards Dementia Friendly

Older People’s Mental Health Services

Our approach and response…

September 2015 - Immediate actions were taken and action plan drafted following initial feedback from CQC November 2015 - Trust Quality Improvement Plan developed following receipt of draft CQC reports December 2015 - Executive director leads identified for all quality improvement actions September 2015 - Immediate actions were taken and action plan drafted following initial feedback from CQC November 2015 - Trust Quality Improvement Plan developed following receipt of draft CQC reports December 2015 - Executive director leads identified for all quality improvement actions December 2015 - New Governance structure agreed (part of Well Led) January 2016 - Executive Director of Health Informatics post approved

• BoD approved our Listening into Action application

(next cohort will start April 2016) December 2015 - New Governance structure agreed (part of Well Led) January 2016 - Executive Director of Health Informatics post approved

• BoD approved our Listening into Action application

(next cohort will start April 2016)

Our action plan …

Safe: Community mental health services for people with learning disability or autism Action already underway:

• Ironstone Centre - our Trust has provided non-recurrent funding for additional staff

and a business case has been submitted to North Lincolnshire CCG to request additional staff resource. An external review of community LD services has been commissioned.

• Learning Disability Services – we have undertaken a review of the completion of

Safe: Community mental health services for people with learning disability or autism Action already underway:

• Ironstone Centre - our Trust has provided non-recurrent funding for additional staff

and a business case has been submitted to North Lincolnshire CCG to request additional staff resource. An external review of community LD services has been commissioned.

• Learning Disability Services – we have undertaken a review of the completion of

risk assessments across all learning disability community services and have implemented a revised monitoring, escalation and audit process.

• Rotherham Community Learning Disability Team - clinical environment assessed

and actions taken to ensure the safety of people who use services and staff. Psychiatry consulting rooms made safe by removing non-essential equipment and a clinical consulting room has been identified.

• Learning Disability Services – personal audible alarms provided to all staff working

in learning disability consulting rooms in Doncaster, Rotherham and North Lincolnshire. risk assessments across all learning disability community services and have implemented a revised monitoring, escalation and audit process.

• Rotherham Community Learning Disability Team - clinical environment assessed

and actions taken to ensure the safety of people who use services and staff. Psychiatry consulting rooms made safe by removing non-essential equipment and a clinical consulting room has been identified.

• Learning Disability Services – personal audible alarms provided to all staff working

in learning disability consulting rooms in Doncaster, Rotherham and North Lincolnshire.

Safe: Community based mental health services for working age adults Action already taken:

• Mandatory/statutory training compliance – fortnightly monitoring of

training compliance by team implemented and monitored by Assistant Director

• Access to Patient Information – training needs analysis underway to

provide targeted focused training based on individual staff competencies using IT Systems. Training to be completed during March/April 2016. Safe: Community based mental health services for working age adults Action already taken:

• Mandatory/statutory training compliance – fortnightly monitoring of

training compliance by team implemented and monitored by Assistant Director

• Access to Patient Information – training needs analysis underway to

provide targeted focused training based on individual staff competencies using IT Systems. Training to be completed during March/April 2016. using IT Systems. Training to be completed during March/April 2016.

• Medication Management – implementation of standard operating

procedures across adult mental health services to standardise recording of medication in relation to storage, prescribing, administration and recording

• f medicines.

using IT Systems. Training to be completed during March/April 2016.

• Medication Management – implementation of standard operating

procedures across adult mental health services to standardise recording of medication in relation to storage, prescribing, administration and recording

• f medicines.

• Physical Health Monitoring – A Trust wide Physical Health and Wellbeing

Strategy is in development and will continue to deliver physical health and wellbeing clinics in Early Intervention in Psychosis services and also introduce as part of the Nurse Led Clinics in all localities.

• Risk assessments – immediate action taken to review and identify

patients without a current risk assessment and complete risk assessments. A Community Managers Group to develop, implement and embed risk assessment and service specific care planning templates has been

• Physical Health Monitoring – A Trust wide Physical Health and Wellbeing

Strategy is in development and will continue to deliver physical health and wellbeing clinics in Early Intervention in Psychosis services and also introduce as part of the Nurse Led Clinics in all localities.

• Risk assessments – immediate action taken to review and identify

patients without a current risk assessment and complete risk assessments. A Community Managers Group to develop, implement and embed risk assessment and service specific care planning templates has been established. established.

• Patient Engagement – Our Trust is committed to working and engaging with

patients, carers and the public in a wide range of ways. However, we recognise that our current approaches to ensuring that people’s views are heard needs

• reviewing. This will be a CEO led piece of work and our partners will be

encouraged to participate in the development of our NEW Patient & Public Engagement Strategy

• Mandatory/Statutory Training Compliance – continues to be reported monthly
• Patient Engagement – Our Trust is committed to working and engaging with

patients, carers and the public in a wide range of ways. However, we recognise that our current approaches to ensuring that people’s views are heard needs

• reviewing. This will be a CEO led piece of work and our partners will be

encouraged to participate in the development of our NEW Patient & Public Engagement Strategy

• Mandatory/Statutory Training Compliance – continues to be reported monthly

Actions already underway …

to the Board of Directors. Compliance as at 28 January 2016 is 88.06%. The Trust has implemented a robust system of monitoring compliance by individual staff, by business division and Trust wide in order to achieve 90% compliance by 31 March 2016.

• Duty of Candour – DoC Action plan implemented in September 2015 to improve

documentation, recording, medical involvement and reporting. An Internal Audit will be completed by 31 March 2016 to the Board of Directors. Compliance as at 28 January 2016 is 88.06%. The Trust has implemented a robust system of monitoring compliance by individual staff, by business division and Trust wide in order to achieve 90% compliance by 31 March 2016.

• Duty of Candour – DoC Action plan implemented in September 2015 to improve

documentation, recording, medical involvement and reporting. An Internal Audit will be completed by 31 March 2016

• Clinical Environment - Trust to re-define the terms of reference for the

Environment Risk Group and provide clear guidance to encompass all aspects of risk related to the clinical environments area

• Risk Assessment/care planning – Immediate action taken to review patient risk

assessments in identified services, complete risk assessments and monitor compliance locally. In addition, a Trust wide FACE Risk Assessment audit to be undertaken during quarter 2, 2016/17

• Clinical Environment - Trust to re-define the terms of reference for the

Environment Risk Group and provide clear guidance to encompass all aspects of risk related to the clinical environments area

• Risk Assessment/care planning – Immediate action taken to review patient risk

assessments in identified services, complete risk assessments and monitor compliance locally. In addition, a Trust wide FACE Risk Assessment audit to be undertaken during quarter 2, 2016/17

Actions already underway …

• Medicines Management – Reviewing Trust wide Safe and Secure Handling of

Medicines Policy, including the revision of medicines management forms. Audits regarding omitted/unsigned prescriptions, dosage and fridge and room temperatures strengthened

• Venous Thromboemolism (VTE) – All patients are now risk assessed on

admission or transfer to community health inpatient wards for VTE. VTE is recorded as part of the monthly Patient Safety Thermometer.

• Medicines Management – Reviewing Trust wide Safe and Secure Handling of

Medicines Policy, including the revision of medicines management forms. Audits regarding omitted/unsigned prescriptions, dosage and fridge and room temperatures strengthened

• Venous Thromboemolism (VTE) – All patients are now risk assessed on

admission or transfer to community health inpatient wards for VTE. VTE is recorded as part of the monthly Patient Safety Thermometer.

Our governance arrangements …

• Published CQC Reports to the Board of Directors meeting on 28 January

2016

• Integrated CQC Improvement plan (progress report) to Board of Directors

(monthly)

• Overall monitoring and oversight undertaken by Executive Management

Team (EMT)

• Published CQC Reports to the Board of Directors meeting on 28 January

2016

• Integrated CQC Improvement plan (progress report) to Board of Directors

(monthly)

• Overall monitoring and oversight undertaken by Executive Management

Team (EMT) Team (EMT)

• Must do action plans monitored through Board of Directors Sub Committee

Structure

• Divisional-level action plans to address local issues and share learning

Team (EMT)

• Must do action plans monitored through Board of Directors Sub Committee

Structure

• Divisional-level action plans to address local issues and share learning

• Ironstone Centre Staffing – temporary funding

required whilst service is reviewed

• Electronic Patient Record – our Unity

Programme

Support with our action plan …

Programme

• Developing an RDaSH approach to PPE
• Recognition of partnership priorities and joint

working

• We have reviewed our vision, values and strategic objectives
• We will continue to focus on our patients
• Our services were rated as Good for being Caring, Responsive

and Well-led

• 13 out of 17 services rated Good or Outstanding

Finally …

• We have listened to the CQC feedback and recognise the

areas where we are required to make improvements:

» Safe » Effective

• We are sharing CQC findings with our staff and will ensure

that we taken action and learn.

Thank you

Any questions?