COG 6/2014
COUNCIL OF GOVERNORS
CQC UPDATE
Objective:
The objective of this report is to update the Council of Governors on the progress of the Campbell
Centre Special Measures Programme, Beatrice Place Accelerated Service Improvement
Programme and all other activity between the Care Quality Commission and the Trust within the
preceding month.
The Council of Governors is asked to:
Note the report for information.
Summary:
This report gives the Council of Governors an indication of the work being undertaken to ensure
that the trust is compliant with CQC standards. The trust is confident that we are compliant at
Beatrice place and the Campbell centre although further work is ongoing in both units to ensure
that improvements are fully embedded.
Responsible Director: Robyn Doran, Chief Operating Officer
13th June, 2014
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1. Introduction
This paper updates the Council of Governors on the progress of the ongoing special measures
action plan which is overseen by the programme board, Beatrice Place ASIP progress and also
highlights the wider activities of Care Quality Commission (CQC) in the past month, specific issues:
 CQC Reviews of Compliance
 CQC Mental Health Act Visits
 CQC Enquiries
 CQC Quality & Risk Profile
This is the first time that this report provides feedback from the CQC Mental Health Visits and the
enquiries the Trust receives from the CQC. The information will also be used to inform the Trust’s
‘Learning Walks’ where services peer–review each other’s services.
Please note that the Trust has not received an updated Quality and Risk Profile from the CQC in
the last month
2.
Campbell Centre Special Measures
This paper provides a progress update on the Special Measures Programme, which was initiated
at the Campbell Centre, on the 14th April 2013. Each month, a report detailing progress and
exceptions is presented to the Special Measures Programme Board, The CNWL Quality and
Performance Committee as well as the CNWL Trust’s Board, the CQC and the Milton Keynes
Commissioners.
Key areas of progress since the report of the 28th April 2014 (previously circulated to
council of Governors)
 All actions identified in the Campbell Centre Action report of 20th March 2014 (written to the
CQC in response to the Inspection report published March 2014), have now been
completed.
 A three month pilot for the management of patients admitted to the Campbell Centre out of
hours under section 136 of the Mental Health Act has been initiated.
 A Dual Diagnosis policy is now in place at the Campbell Centre.
 The Audit of 1st April shows that all Section 17 Leave forms are being fully completed.
 As agreed in the last Programme Board and documented in March’s report, the action
regarding PbR clustering has been removed from the report as it is being managed as part
of the wider transformation project.
The Campbell Centre are awaiting re-inspection from the CQC
3.
Beatrice Place ASIP
The 3BP ASIP, is accountable to the 3BP Programme Board, which reports to the Executive board
on a monthly basis. In turn a summary of these reports are included in the regular reporting to the
Quality Committee and the Trust Board. The ASIP has now been in place for six months and has
continued to progress during that time.
The key objectives of the ASIP are to ensure 3BP meets the CQC essential standards for safety
and quality. As a consequence of the ASIP, an additional £400,000 has also been invested in
additional staff for the unit, and additional funding has been agreed this year from our
commissioners. We have commissioned an independent review of the service by a senior nurse
who has completed the first phase of his review which was a stock take of the current service.
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We believe 3BP is now CQC compliant, and are awaiting feedback from the recent re inspection.
However there remain some outstanding actions (developed as part of the ASIP) which need to be
completed. The next phase of the ASIP will be to follow up on the issues identified in the stock
take, ensuring the remaining actions are completed as well as ensuring those changes made to
improve the quality of patient care are sustained.
4.
St Charles
St Charles continue to make progress against their CQC Action Plan. Re-fresher Safeguarding
training and MCA training has been completed and staff competency is tested on an ongoing
basis. A weekly audit tracker has been designed to review electronic notes to ensure that Capacity
assessments are being carried out effectively and in a timely manner, so any areas of concern can
be picked up with the clinical team. To assess staff’s knowledge and understanding of the
Capacity Assessments, the SMT, as part of their night visits, audits the records. These night visits,
have been scheduled for the rest of the year. Feedback and learning from the night visits is
discussed in local meetings and at the SMT to ensure that lessons learned are shared across all
sites.
A multi-disciplinary care plan has been developed and piloted on the PICU wards, with an aim to
roll it out across the wards and all other sites. The new care plans guides staff to ensure that the
risk management plan is clearly outlined in the care plan. This is used as the basis in ward rounds
and management reviews to ensure that risks are reviewed regularly and also up to date on the
system. Audits are carried out to ensure that risks identified are clearly documented in the care
plan and other relevant parts of the patient system.
As part of the drive to ensure that there is sufficient senior nursing presence on the unit, a senior
nurse will oversee all S136 patients brought into the unit, and if appropriate will seek support from
colleagues in the site to help in the management of these patients. Medical cover is 24/7 to ensure
that new admissions are assessed appropriately and also to support patient flow for patients who
are ready for discharge, particularly at weekends.
Other actions taken include setting up coffee mornings to gather feedback from patients, carers
and staff so that outcome focussed actions can be identified and implemented.
5. CQC Reviews of Compliance
HMP Wormwood Scrubs was inspected week commencing 12th May 2014 in a joint inspection with
Her Majesty’s Inspectorate of Prisons (HMIP).
3 Beatrice Place was re-inspected on 20th May 2014.
The draft reports and compliance judgements from these inspections have not yet been received.
6.
CQC Mental Health Act Visits
CQC MHA Visits since April 2014
There have been 6 CQC MHA Visits since April 2014. These were to the following wards: Tasman
ward, Caspian ward, Ellington ward, Gerrard ward, Frays ward and Vincent ward.
The Trust is waiting for the written feedback from these visits.
The Trust is also expecting a joint inspection by HMIP and CQC at HMP Elmley in June 2014.
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7.
Themes from CQC Information
Some of the themes identified here reflect what the Trust has found during ‘Learning Walks’, Areas
identified for focus are
 Safeguarding,
 Management and reporting of Pressure ulcers,
 Section 132 rights ( telling people their rights when they are admitted)
 Consent and capacity.
Themes identified from this information will be regularly monitored in the Operations Board and the
Quality and Performance Committee and we will track this information to ascertain whether or not
actions are effective.
8. CQC Enquiries (May 2014 to date)
The CQC contacts the Trusts with enquiries received in relation to feedback, complaints, whistleblowing and other concerns that are reported directly to them. They also sometimes request
further information on incidents that are routinely reported to them through the National Reporting
and Learning System (NRLS).
From May 2014 to 11th June 2014 the Trust received 2 enquiries from the CQC. These were:
Site and date
enquiry received
from CQC
Addictions
services, West
Sussex:
07/05/2014
Butterworth
Centre:
09/05/2014
Main concerns / issues
Trust response
CQC contacted CNWL with regard to
recently acquired services from
Addiction. Previous inspections under
the old provider found a couple of
locations which were not compliant
with CQC standards. The Trust were
asked to provide the CQC with an
update on what plans are in place to
address this and when we expect to
be compliant.
The CQC received information about
a safeguarding incident via the
NRLS updates and asked for further
information about the incident in
addition to the information received
via NRLS as outlined below:
Details: Alleged incident occurred on
10 February 2014 - ‘’Staff A of St
John and Elizabeth Hospital reported
that they witnessed two staff, B and
C, of Butterworth Centre restraining
patient D inappropriately while D was
escorted for cardiology appointment.’’
The Addictions Service Line have
reviewed the action plans that were
put in place by Addiction, and have
developing a CNWL action plan to
address the compliance issues at the
service the Trust has taken on. This
was sent to the CQC on 22nd May and
we believe that we will be compliant
by the third week of August 2014.
CQC were updated on the action that
the Trust had taken with regard to
this. There is a CNWL Disciplinary
Investigation taking place into this
incident. Both staff members were
immediately suspended from clinical
duties at the Butterworth Centre – one
of these staff members is suspended
from all duties. The safeguarding
investigation is running in tandem to
this. Disciplinary Investigation
findings are recommending that this
case progresses to a full disciplinary
hearing for both staff members. The
safeguarding investigation report is
being finalised. Following this a Case
Conference will be held.
The case is currently open
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The Trust is in dialogue with the CQC about their expectations of us when we take over services
that are not CQC compliant. We consider ourselves to be good at improving quality, turning
around services but cannot do this if the CQC penalise us, without giving us enough time to make
improvements.
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