Making improvements

A logo containing icons which visually describe our 5 pillars of improvement under the heading 'Working together for better mental health'

We welcome the feedback that we have had from the Care Quality Commission (CQC) inspection. It means we know exactly where we need to improve.

Our first job has been to focus on immediate safety and quality concerns. Within the report, we received a section 29a notice. It lists the things we must do to meet our legal obligations to the people we care for. 

Our timeline for this evolving work

Phase one: Now until August 2022

We’re in the middle of this important period of action, delivering actions to improve safety, focusing on seven service lines of concern in the Section 29a notice. We are also developing our overarching improvement plan with partners and the public, which will be delivered during phase two.

Phase two: September 2022 – September 2023

This will be about sustaining improvements – focusing on how we work and what we do. This work will be grouped into five pillars (see below), delivered with rigorous scrutiny.

Phase three: September 2023 onwards

Our positive changes must last. From September 2023 we’ll focus on continuous improvement and innovation based on a strong foundation.

Our 'must do' actions

Provided below is a summary of actions for each of the seven service areas. These summaries are designed to give you an easier to read overview of what we are doing, they do not cover every action at this time - we will build on them in the near future.

Acute wards for adults and psychiatric intensive care units (PICUs)

These are just a few examples for Acute wards for adults of working age and psychiatric intensive care units (PICUs)

The CQC told us we must ‘ensure staff are completing physical health assessments with patients on admission, and regularly reviewing patient’s physical health care needs.’

In response, we have:

  • Launched new training on management of conditions such as delirium, epilepsy and blood clots (venous thromboembolism (VTE))
  • Developed better information for staff toclarify our care for inpatients and community patients
  • Formed a Monthly Physical Health Committee for governance and oversight.

The CQC told us we ‘must ensure carers and relatives are kept informed about patient care and treatment, where consent permits, and are provided opportunities to feedback about the service.’

In response, we:

  • Co-produced a welcome pack for service users 
  • Co-produced welcome packs for carers.

The CQC also identified we ‘must ensure staff are able to safely manage aggressive behaviours displayed by patients and that staff can evidence consideration of a range of interventions as identified in patient care plans, when met with aggression from patients.’

We know our work environments can be incredibly rewarding, but also extremely challenging at times. In response, we will:

  • Some 80% of post-incident debriefs are taking place, involving staff and patients. These are used to share learning and review care and treatment plans
  • we have increased the range of activities included in ward activity programmes for service users
  • implemented a Violence Reduction Collaborative, where staff share experiences and ideas on how to maintain a safe environment for all.

Long stay or rehabilitation mental health wards for working age adults

These are just a few examples for long stay or rehabilitation mental health wards for working age adults:

The CQC told us we ‘must ensure environmental risks to the health and safety of patients are assessed, managed and mitigated. This must include comprehensive assessments of all the potential ligature anchor points and the timely removal of potential ligature anchor points which can reasonably and practicably be removed.’

In response, we have:

  • identified and removed all ligature anchor points that can be easily removed. We have put mitigations in place for where it is not possible to remove anchor points.
  • completed ligature competencies with all our staff and achieved 100% compliance in March 2022 – this is reviewed on a monthly basis to ensure we continue ongoing compliance
  • identified risks and actions required, and conduct walk arounds monthly, which are supported by ongoing monitoring.

The CQC told us we ‘must ensure the safe and proper management of medicines. This must include the regular review of the use of “as and when required” medicines.’

In response, we:

  • have changed the multi-disciplinary team (MDT) review notes template to include evidence of medications reviews every two weeks at a minimum by the responsible clinician
  • use our daily reviews process (Monday to Friday) to discuss ‘when required’ (PRN) medications by the MDT in our daily huddles, particularly if used regularly enough to be considered for regular prescription
  • are asking our teams detail the reason where ‘as required’ medication is felt to be needed, the actions taken to address any distress/reason and, when administered, the effect of the medication.

The CQC also identified we ‘must review and consider how staff will ensure patients are safe and well in their bedrooms without unnecessarily disturbing the patients.’

In response, we:

  • introduced hourly observations in November 2021, and enhanced observations are implemented if there is clinical need
  • installed personal alarm systems in December 2021, and portable alarms are available to ensure safety of service users
  • are installing new anti-barricade doors with observation panels by November 2022.

Child and adolescent mental health wards

These are just a few examples for child and adolescent mental health wards:

The CQC told us we must ‘ensure all staff have the required training, skills and experience to safely manage patients’ risk in a timely manner.’

In response, we are:

  • making sure that our compliance against targets for training, appraisals and line management is continually improving
  • developing our skills and competencies, including ligature assessment, management of self-harm, and therapeutic interventions, including Dialectic Behavioural therapy. We’ve also booked training from the British Institute of Human Rights to support our team skills related to issues of high-risk management and reduction
  • We’ve recruited an occupational therapist, dietician and have advertised for a family therapist to support our existing psychologist, as well as filling all our nursing vacancies.

The CQC told us we ‘must ensure that staff know how to implement the model of care used on the ward.’

In response, we:

  • have now recruited a fulltime clinical nurse specialist staff member trained in Dialectical Behavioural Therapy (DBT)
  • provide DBT skills training for all staff on a weekly basis
  • have introduced ‘bitesize’ training on searches and reducing restrictive interventions, as well as discussing with our teams.

The CQC also identified we ‘must ensure staff administer medicines at the times prescribed and review the effects of the medicines on patient’s health and function, to prevent over sedation’

In response, we:

  • have recently recruited a registered paediatric nurse to enhance our multi-disciplinary team, including awareness and understanding of physical health medications
  • had our standard operating procedure reviewed by our clinical nurse specialist and responsible clinician
  • have agreed that medication competency assessments for all qualified staff will be completed, with review dates, by the clinical nurse specialist (a non-medical prescriber).

Wards for older people with mental health problems

These are just a few examples for wards for older people with mental health problems:

The CQC told us we ‘must ensure care plans are updated, are personalised, holistic and recovery oriented.’

In response:

  • we have reviewed equipment availability to ensure that each ward has a designated laptop to complete care plans and risk assessments with patients and carers.
  • We are reiterating the importance of care plans must being person-centred, using DIALOG+ and further training is taking place to support this, including a ‘bitesize’ package for all registered staff.
  • Our teams will also liaise with wards who are further along the process of implementing DIALOG2+, to enhance learning and application to practice.

The CQC told us we ‘must ensure environmental risks including ligature anchor points are identified and mitigated against at Blickling ward; and include checks of the communal garden at Carlton Court Laurel ward.’

In response:

  • We have updated comprehensive risk assessments for Blickling ward and Laurel ward.
  • The ligature assessment for Laurel ward includes the garden area, noting patients are escorted at all times in this area.
  • We have planned improvement work on Blickling ward, which will include boxing in pipework, and making adjustments to windows, sinks and taps. Due to extended lead times for materials, this work is planned for September 2022.

The CQC also identified we ‘must ensure patients are given their medicines on time.’

In response:

  • all registered nurses and nursing associates have completed medicines administration training
  • the critical medicines list has been distributed to all departments and is available in every clinical area where administration of medicines occurs.
  • individual medicine reviews are being undertaken for patients where delays to administration of non-critical medicines have been identified, to prevent future delays.

Community-based mental health services for adults of working age

These are just a few examples for community-based mental health services for adults of working age:

The CQC told us we must ‘must ensure all patients have a care plan and that this addresses their needs.’

In response, we are:

  • ensuring patients are allocated a lead care professional to ensure continuity of care
  • ensuring that service users and their lead care professional develop their care plan within the first few appointments supporting effective monitoring of their care plan
  • helping colleagues identify protected time to support care planning
  • auditing care plans monthly as part of supervision, and monthly Care Process Audits to ensure good quality, patient safety and co-production.

The CQC told us we ‘must ensure that staff use recognised rating scales to assess and record the severity of patient conditions and care and treatment outcomes.’

In response:

  • all areas will be using DIALOG+ as a monitoring and outcome tool which is recognised by NHS England and NHS Improvement as a valid Patient Reported Outcome Measure (PROM) and Patient Reported Experience Measure (PREM)
  • currently 2,361 staff are trained, leaving 700 colleagues yet to be trained – although all have access to a trained mentor. Training is due to restart in August 2022 and will become part of the Trust induction for clinical staff from July 2022.

The CQC also identified we ‘must ensure physical health checks are undertaken and recorded on their electronic system.’

In response:

  • we will further engage with our primary care colleagues and utilise their expertise in physical health to improve physical health monitoring for our patients
  • in addition to our Physical Health Champions, who cascade training from their team, our new induction for staff will include a dedicated session on physical health
  • we will also regularly audit how we are performing in this area, for example ensure there is a physical health component in all our service users’ care planning.

Mental health crisis services and health-based places of safety

These are just a few examples for mental health crisis services and health-based places of safety:

The CQC told us we ‘must ensure that all patients have a care plan which encompasses their needs and is updated.’

In response:

  • all colleagues have been trained in DIALOG+ and ongoing training includes ‘My Recovery Plan’, as well as specific care plans. The quality of care plans is now discussed at team meetings
  • crisis teams have introduced a new process of patient support, to ensure all patients receive a comprehensive care plan, highlighting their individual needs
  • future away days will feature safety briefings, including a focus on care planning.

The CQC told us we ‘must ensure staff follow the trust policy when prescribing and dispensing medicines.’

In response:

  • the crisis team now has a pharmacist in place to monitor and ensure prescribing and dispensing conforms to Trust standards
  • the team has also been working with pharmacy colleagues and GPs to put new actions in place
  • we have completed a medications quality safety review, and created an action plan.

The CQC also identified we ‘must ensure there are enough nursing staff to meet the needs of the service.’

In response:

  • we have started new approaches to improve recruitment rates, and we know we need to do more
  • The Trust is offering incentives, relocation packages and taster days to give people an idea of what it is like to work in the Trust
  • we are in the process of developing a rotational post to enable nurses to work as part of the ward, Crisis Resolution and Home Treatment and psychiatric liaison teams.

Specialist community mental health services -children and young people

These are just a few examples for specialist community mental health services -children and young people:

The CQC told us we must ‘ensure care plans are updated, are personalised, holistic and recovery oriented’

In response, we:

  • have drafted a new care plan. This is still in development, but the new care plan will be being added to Lorenzo once it is finalised and approved.
  • are developing a guide for all colleagues around completing paperwork in line with Trust policy, as well as offering refresher training on care planning to all teams.
  • ensuring teams have regular ‘shut down’ days to complete paperwork with business support.

The CQC told us we ‘must ensure crisis plans are completed where appropriate.’

In response:

  • we have coproduced business cards with service users, which have useful numbers to use in a crisis, and are given out after assessments.
  • agency colleagues working with us who offer assessments are included in our training offers around crisis plans.
  • we are reviewing how we work with the all age crisis team, to ensure plans are completed, communicated and recorded.

The CQC also identified we ‘must ensure young people have a physical health assessment where required.’

In response, we:

  • have drafted a Physical Health Strategy (a ‘plan on a page’) for all staff and identified a care group lead.
  • we will establish a Physical Health forum / Clinical Effectiveness group.
  • are advising prescribers to ensure relevant physical health checks are done and any medications recorded on Lorenzo.

Our longer term improvement plan

Our long term improvement actions will be centred around five pillars of work. Membership includes key staff and is coordinated via dedicated working groups: 

Safety for all
An icon showing a person surrounded by caring hands and the words 'Safety for All'

We’ll develop and support our caring staff to ensure we follow safety and medicines guidance, whilst minimising any risks to safety in the places we offer our care.

Timely access

An icon of person with a clock and the words 'timely access'

We’ll make sure we have enough staff in the right places, whilst working with our partners to ensure people receive care in a timely manner.

Making your voice count 

An icon showing a person with sound waves and the words 'Making your voice count'  

We’ll communicate and engage with our staff, leading honestly and sharing positively as a team, whilst delivering jointly owned and understood aims.

Improving governance and leadership 

An icon of a person with a graph and an upward pointing arrow with the words 'Improving governance and leadership'

We’ll improve our processes along with the information we record and share, ensuring this is recognised and agreed across our services whilst taking responsibility for, and learning from, our mistakes.

Changing services to meet people’s needs 

An icon showing an outline of a person with an arrow with the words 'Changing services to meet peoples needs'

We’ll listen to those who use our services and work with them and our partners to improve the quality, safety and consistency of their care and experience. 

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