Karen Bennett-WilsonHead of Inspection (MH, LD, SM)Care Quality Commission (CQC)

Nicola VickProvider Analytics Manager

Care Quality Commission (CQC)

governmentevents.co.uk | 0330 0584 285 | info@governmentevents.co.uk

Measuring progress against CQC Quality Ratings

Are you really listening?Review of children and young people’s mental health services

Karen Bennett-Wilson

Head of Hospital Inspection

Nicola Vick

Provider Analytics Manager

January 2019

3

• Key findings from CQC report on State of Mental Health Care (2014-2017)

• Lessons learnt from Inspections/programmes of work

• Examples of good and outstanding performance

• Measuring and monitoring progress

• CQC quality ratings

Outline

Why CQC?: Delivering our objectives…

4

1. Encourage improvement, innovation and sustainability in care

We will work with others to support improvement, adapt our approach as new care models develop, and publish new ratings of NHS trusts' and foundation trusts' use of resources.

3. Promote a single shared view of quality

We will work with others to agree a consistent approach to defining and measuring quality, collecting information from providers, and delivering a single vision of high-quality care.

2. Deliver an intelligence-driven approach to regulation

We will use information from the public and providers more effectively to target resources where the risk to the quality of care is greatest and to check where quality is improving, and introduce a more proportionate approach to registration

4. Improve our efficiency and effectiveness

We will work more efficiently, achieving savings each year, and improving how we work with the public and providers.

Sharing our findings: mental health reports

5

Driving Improvement: key factors

6

ReactivityGood

LeadershipEffective

governance

Good Culture

Staff engagement

Involvement

Outward

looking

Relationship with CQC

Continuous improvement

7

Our concerns with the mental health sector

Poor physical

environment of

mental health wards

Sexual safety

on mental

health wards

High number of

rehabilitation

wards out of area

High secure

hospitals

Use of

physical

restraint

Staffing

Physical health

of people with

mental health

problems

Clinical

information

systems

Mental

healthcare for

people with

physical health

problems

Mental health rehabilitation wards

8

What we said

‘Too often, these…rehabilitation hospitals are in fact long stay

wards that institutionalise patients, rather than a step on the road

back to a more independent life in the person’s home community.’

What we found

There are a ‘high number of people in ‘locked rehabilitation

wards’. ‘These wards are often situated a long way from the

patient’s home….In a number of cases we found that these

hospitals did not employ staff with the right skills to provide the

high-quality, intensive rehabilitation care required to support

recovery.’

Mental health rehabilitation wards

9

What we have done

In response to our report, NHSI has funded a ‘Getting it Right First Time’ (GiRFT) workstream to work with local systems to identify, assess and repatriate people placed in distant mental health rehabilitation beds.

Physical restraint

10

What we said

‘CQC is further strengthening its assessment of how and how

often services use physical restraint; we wish to send a clear

message….we will be subjecting services where staff frequently

resort to restrictive interventions to much tougher scrutiny’.

What we found

‘Great variation….in how frequently staff use…. physical restraint…[Wards]

where the level of restraint is low or where it has reduced over time have

staff trained in the specialised skills required to anticipate and de-escalate

behaviours or situations that might lead to aggression or self-harm’.

Physical restraint

11

What we have done

Flagged our concerns to NHSE which has set up three workstreams:

• Definition and reporting

• Training and accreditation

• Provider improvement programme through MHSIP

MHA team have published report describing good practice

Shared sleeping arrangements on mental heath wards

12

What we said

‘In the 21st century, patients, many of whom have not agreed to

admission, should not be expected to share sleeping

accommodation with strangers – some of whom might be

agitated. This arrangement does not support people’s privacy

or dignity’.

What we found

More than 1,000 mental health beds are in a shared room (a ‘dormitory’).

People who have slept in a bed of this type report an overwhelmingly

negative experience - disturbed sleep, personal safety, risk of theft,

proximity of other people and lack of privacy

Shared sleeping arrangements on mental heath wards

13

What we are doing

We have fed this information back to NHSE as part of our concern about the poor conditions on many mental health wards

Should CQC strengthen its response to such arrangements?

• Raise the bar with respect to regulatory action and ratings?

• Require providers to have a credible plan to eliminate within a stated time?

Sexual safety on mental health wards

14

What we said

[Services that admit] ‘both men and women to the same wards...

have a heightened responsibility to ensure that patients are safe

from sexual harassment and sexual violence. We have taken

action against services that did not follow NHS guidance on

eliminating mixed sex accommodation’.

What we found

‘Seven years after the NHS issued guidance to eliminate mixed sex

accommodation in all hospitals, we identified a number of acute

and rehabilitation wards that still did not comply’.

Sexual safety on mental health wards

15

What we are doing

In response to our report:

• RCPsych and RCN are developing guidance

• NHSI has funded a workstream to set up a collaborative of providers as part of the MHSIP

The Mental Health Safety Improvement Programme

16

What we said

‘Safety… is our biggest concern…particularly… for acute wards and

PICUs….in many cases, this was due to concern about the safety of the

ward environment, often compounded by deficiencies in staffing’.

What we found

4

1

1

1

36

24

4

16

21

59

71

88

78

74

1

4

9

5

4

0% 20% 40% 60% 80% 100%

Safe

Effective

Caring

Responsive

Well-led

The Mental Health Safety Improvement Programme

17

What have done

Joint programme with NHSI announced by Secretary of State

The overall aim is for every NHS mental health trust to have agreed their safety priorities and to have made a measurable improvement in at least one key area by 31 March 2020.

• Engineered around the new CQC annual inspection cycle:

o CQC contributes inspection findings to three-way engagement meeting

o NHSI provides improvement support

o CQC returns to re-assess at next inspection

• Will focus on a mix of trust-specific and national priorities

• National priorities include restrictive interventions and suicides on wards

• This is now business as usual

Residential substance misuse services that provide detox

18

What we said

‘Based on our inspections over the last two years, we are deeply

concerned about how people undergoing residential-based

medical detoxification from alcohol or drugs are being cared for in

many independent clinics across the country’.

What we found

‘Doctors and nurses that did not follow best practice guidance

when assisting clients to withdraw from alcohol and/or drugs.

Poor management of medicines…. Providers that did not provide

staff with the training required…. Failure to safeguard clients by

carrying out employment checks on staff’.

Residential substance misuse services that provide detox

19

What we are doing

We continue to work with Public Health England and are now rating substance misuse services.

Early signs are that the problem remains.

Learning disability

20

Challenges for transforming care:

• slow rate of bed closures – linked to poorly developed

community services

• risk of new residential services simply replicating the

features of the hospital institutions that they replace (role

of Registering the Right Support)

• out of area placements with poor oversight by

commissioners

• increasing development of services that we only partially

regulate eg. supported living schemes

High use of restrictive practices – including long-term

segregation

Mental Health Act

21

To complement the MHA annual report, CQC has published ‘independent voice’ pieces on:

• The rising rates of detention under the MHA

• The current state of Approved Mental Health Professional services,

And has started work on an independent voice piece on:

• An evaluation of the MHA Code of Practice 2015 (due soon)

This work has informed the MHA review for which we also have:

• Membership of advisory panel, working group and topic groups• Raised awareness of the review and ability to contribute with patients and

providers during our MHA visiting activity

22

Quality Improvement (QI) in hospital trusts

Available online now

Annual inspection cycle in the next phase

consultationSharing good and outstanding practice

• Huntercombe Hospital Stafford: redesign of the Eating Disorder Unit to

eliminate dormitories – overcoming challenges presented by an historic

building

• Dorset Healthcare University NHS Foundation Trust: The Retreat – delivered in

partnership with Dorset mental Health Forum. Provides somewhere for people

with MH problems to go when things start to go wrong – no referral needed.

Service provided by peer support specialists and MH professional

• Dorset Healthcare University NHS Foundation Trust: Pebble Lodge CMHT T4 –

CQC rated it as ‘outstanding’ – an excellent example of positive risk taking

shown to improve care and outcomes for children and young people

• Derbyshire Healthcare NHS Foundation Trust: Older adults Community health

services provision of rapid response teams

Sharing good and outstanding practice

• Birmingham and Solihull Mental Health NHS Foundation Trust: SOLAR -specialist community services for children and young people delivered in partnership with Barnardo's and Autism West Midlands – provide a range of services to support emotional well-being

• Elysium Healthcare: Ballington House – rehabilitation service for women with complex mental health needs – deliver innovative approaches to involving patients with a focus on sustainable recovery

• Nottingham Healthcare NHS Foundation Trust: Rampton Hospital -implementation of a smoke free environment

• Sussex Partnership NHS Foundation Trust: promoting public awareness and understanding of MH. Invited ITN productions to make a film at Langley Green Hospital, Crawley – broadcast as part of Channel 5s ‘health Minds’ series

24

25

Our vision for 2017/2020 is more targeted, responsive and

collaborative regulation so more people get high-quality

care.

Our next phase of inspections is a move away from large

comprehensive inspections towards leaner and more

targeted inspections, focused on individual core services

and the well-led aspect of a provider.

Inspection and regulation –direction of travel

Annual inspection cycle in the next phase

consultationCQC Inspection cycle: measuring

and monitoring progress

27

CQC Insight for NHS

Trusts and

Community Interest

Companies that

provide Mental

Health Services

28

CQC

Insight

is…

a monitoring tool which tracks trends in

quality (declining or improving) - at

provider, location, and/or core service

level to support decision making

The aim

is…

to make it easier for inspectors to

monitor their portfolio and identify

potential changes to quality by

having routine access to key

information. It will also contribute to

a shared view of quality across the

services.

<Date of publication>

29

What types of questions can it help answer?

What’s the profile of the provider/service? How

much activity does it undertake? What’s the

staffing capacity?

Which indicators are available at by key question /

provider, inpatient and community services level?

How do the last two years compare? Are there any

indicators that show the trust is statistically better/

worse than the national picture?

How is the Mental Health Act being used and what

notifications have we had about the experience of

detained patients? What is the pattern of incident

reporting for this trust? How has the staff survey

results changed over time?

What are the indicator definitions? What statistical

methodology has been used? What locations are

registered with CQC?

St Elsewhere Mental Health NHS Trust

31

St Elsewhere Mental Health NHS Trust

St Elsewhere Mental Health NHS Trust

St Elsewhere Mental Health NHS Trust

St Elsewhere Mental Health NHS Trust

The mental health patient safety improvement programme is underpinned by data and we want to develop a common set of indicators for safety

35

We are working to agree a definition of safety across ALBs and providers. It will also enable measurement to support improvement and allow us to make comparisons between Trusts. Indicators will be used to:

Core safety indicators include:

• Managing risks (staffing levels, staff working extra hours, and restrictive interventions)

• Track record on safety (suicide, self harm, assaults on patients)

• Reporting and learning from incidents when things go wrong (consistency of recording, deaths, staff survey: staff witnessing harmful events, effectiveness of reporting procedures, dealing with CAS alerts)

The indicators were shared with NHS Trusts and system partners at the end of July 2018 via CQC’s Insight Dashboard (below) and every two months since. We will seek feedback and continue to improve the measures and analytical methods throughout the programme. Use of the data will also help to drive up data quality for key sources.

Support CQC monitoring, inspections & ratings

Inform the Single Oversight Framework and MH Patient Safety Programme

Monitor FYFV delivery & populate NHSE Quality Dashboard

Restrictive interventions: Definitions and data recording workstream

36

Aim:• Introduce more i) consistency and ii) granularity to provider reporting to enable effective

benchmarking of practice and identification of services where more detailed focus may be required

• Ensure data on use of restraint and restrictive practice is analysed and presented in such a way as to enable benchmarking, and conversations about opportunities for improvement

Current positionA single very broad definition of physical restraint where the momentary use of a guiding hand is recorded in the same way as multiple staff holding a patient on the ground for an hour

Failure to report any restraint by some providers

By May ’19 the aim is to: :

• Begin to collect national data from every provider that provides more granularity about the type of restraint

• In addition to duration, to collect data on the timing of restraint incidents

• Records injury to patients, care personnel and others

• After restraint, records debriefing for patients and staff

• Develop an approach to benchmarking similar services with a view to introducing these into a CQC dashboard as part of a set of patient safety metrics

37

CQC ratings: October 2018

38

Core services ratings:

NHS and IH core services

39

Core services ratings:

NHS core services

40

Core services ratings:

Independent healthcare

Improvement in ratings

42

Questions?