CQC Inspection_Staff Handbook

Preparing for our CQC Inspection Staff Handbook

We found good quality community treatment order (CTO) reports written by the assessing approved mental health professional in most of the records we examined. The reports covered the patient’s medical and social background and explained why the use of the CTO framework was justified.

Community Treatment Order focused visit CQC Inspectors 2021

Contents Introduction 4 Key leaders during the preparation

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Who we are and what we do

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Our strategic priorities and cultural pillars underpin what we do as an organisation

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Our four priorities

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What the CQC does and how

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The five CQC Domains/Standards

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Outcome from 2019 inspection

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Where are we now?

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What has changed since the last inspection?

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What are we currently working on?

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Workforce Wellbeing

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Preparing for CQC visits

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Our ongoing preparedness for inspections

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CQC inspection guidance

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What happens during the CQC’s visit?

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During the CQC inspection

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Top tips during the inspection process

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Our successes

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CQC inspection guidance

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Notes and reflection

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Preparing for conversations with the CQC

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Introduction The Care Quality Commission (CQC) can visit us at any time so this guidance should help you and your team prepare for any future inspections. It has been developed with subject area experts, team leaders, clinicians and line managers from across the Trust and with reference to the CQC standards.

The contents of this handbook will provide support in preparing you to have positive conversations with the inspectors, as well as providing a reflective tool across the Trust to ensure that our practice is qualityassured and evidence-based.

The handbook will also assist you throughout the CQC preparation process. For example, providing information on what to expect during the inspection, how to showcase the high-quality work you do, what to think about after the inspection and how to make any improvements sustainable.

Key leaders during the preparation Our Trust’s Non-Executive Directors will play a key role in the preparation by visiting staff and helping with well-led assessments.

If you have concerns or questions about anything in your area, please speak to your manager.

Our Quality Assurance & Compliance Team, in the Quality Governance Department, is also available to support you with your preparations. You can contact them by emailing cqchelp@candi.nhs.uk

Our Executive Directors will ensure delivery against six core workstreams and will also be visiting teams across the Trust.

The Divisional Directors and Clinical Directors for each division will ensure CQC preparation becomes a priority for their teams.

We all have a role to play in this inspection. The Trust leadership at all levels will be available to provide support wherever needed.

Regular CQC updates will also be published in the weekly bulletin, via all staff emails, and on the intranet for your information. However, it is you, the frontline teams, who are key to our success in this inspection. The CQC is here to see what we do every day, and you are the experts.

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Who we are and what we do Our strategic priorities and cultural pillars underpin what we do as an organisation We all face a multitude of challenges at work every day and the culture we create can make these challenges positive, or sometimes overwhelming.

Our success as an organisation starts with being able to identify what our focus should be long-term.

We worked hard, collectively, to decide what Camden and Islington NHS Foundation Trust’s focus should be. We decided on the following four priorities:

Our four priorities Early and effective intervention

Helping people to live well

Research and innovation

Keeping our service users and staff safe

As a workforce, we identified four cultural pillars to help us achieve these. They are:

1

We value each other – t his involves supporting each other’s wellbeing and development

2

We are empowered – t his means taking action and responsibility to do what is best for your services and team

3

We keep things simple – t his means cutting out bureaucracy when it adds nothing

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We are connected – t his means working collaboratively across services and organisations, rather than in silos

The Ministry of Defence presented our veterans’ service with a Gold Award in recognition of our ‘forces-friendly’ initiatives in the workplace, commitment and support to armed forces veterans and their families.

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What the CQC does and how The five CQC Domains/Standards The CQC is the independent regulator of health and adult social care in England. It monitors and inspects services to see whether they are safe, effective, caring, responsive and well-led.

When the CQC visits us, it will assess our services and care asking these key questions:

The inspection team will combine the evidence from the inspection with a range of other information including:

Are we Safe?

• National databases

People are protected from abuse and avoidable harm.

This will allow the CQC to decide on a rating for the organisation:

• What the public, external partners in the public sector, carers and staff say about us • Complaints • Information from stakeholders • Service users’ and staff surveys • Peer review schemes

Are we Effective?

Outstanding

People’s care and treatment achieves good outcomes, promotes a good quality of life, and is based on the best possible evidence.

Good Requires Improvement

Are we Caring?

Staff involve and treat people with compassion, kindness, dignity, and respect.

Inadequate

Are we Responsive?

Services are organised so that they meet people’s needs.

Are we Well-led?

The leadership, management, and governance of the organisation assure the delivery of highquality person-centred care, supports learning and innovation, and promotes an open and fair culture.

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Mark Peacock and Dr Thomas Elliot (seated). Islington Learning Disability Partnership (ILDP) and Islington CCG led the way vaccinating service users with learning disabilities through an innovative Covid-19 vaccination clinic and outreach programme.

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Outcome from 2019 inspection The last inspection on 1 October to 13 November 2019 resulted in an overall rating of “Good”. The CQC issued a list of MUST-DO and SHOULD-DO actions for the Trust to address. As a Trust, we have collectively filled many of the gaps which the CQC identified.

Overall rating

g

Requires improvement

Good

Outstanding

Ratings for mental health services

Acute wards for adults of working age and psychiatric g downone-rating intensive care units

g

Inadequate

Long-stay or rehabilitation

mental same-rating ––– health wards for

working age adults Wards for older people with mental health problems

Community-based mental health same-rating ––– services for adults of working age Mental health crisis services

and––– health-based places of same-rating safety

Community-based mental health services for older people Community mental health services for people with a learning disability or autism Substance misuse services

Safe

Effective

Caring

Responsive

Well-led

Overall

Requires improvement

Good

Good

Requires improvement

Good

Requires improvement

Jan 2020

Jan 2020

Good

Good

Jan 2020 Good

Jan 2020

Jan 2020

Jan 2020

Good Mar 2018

Good Mar 2018

Jan 2020 Good

Jan 2020 Good

Jan 2020 Good

Jan 2020

Jan 2020

Jan 2020

Good Mar 2018

Good Mar 2018

Good Mar 2018

Good Mar 2018

Outstanding Mar 2018

Good Mar 2018

Good Mar 2018

Good Mar 2018

Good

Good

Good

Good

Good

Good

Jan 2020

Jan 2020

Jan 2020

Jan 2020

Jan 2020

Good Mar 2018

Outstanding Mar 2018

Outstanding Mar 2018

Outstanding Mar 2018

Outstanding Mar 2018

Outstanding Mar 2018

Good Mar 2018

Outstanding Mar 2018

Good Mar 2018

Good Mar 2018

Good Mar 2018

Good Mar 2018

Good Mar 2018

Good Mar 2018

Outstanding Mar 2018

Outstanding Mar 2018

Outstanding Mar 2018

Outstanding Mar 2018

Requires improvement Jan 2020 Requires improvement Jan 2020

Jan 2020

8 ratings for services. Our decisions on overall ratings take Overall ratings for mental health services are from combining into account the relative size of services. We use our professional judgement to reach fair and balanced ratings.

Where are we now?

What has changed since the last inspection?

• We have employed a Violence Reduction Specialist / Reducing Restrictive Practice Lead to focus specifically on embedding a culture of identification and prevention by reviewing causations and using evidence-based interventions to reduce challenging behaviours.

• Physical health - throughout the pandemic; nursing and support staff were trained in phlebotomy, ECG monitoring, inpatient assessment and oxygen therapy.

• We have developed a North Central London (NCL) Suicide Prevention Initiative, communitybased suicide prevention strategy led by Public Health, and an NCL-wide bereavement service.

• We commissioned Leeds Beckett University to undertake a review of our approach to utilising service users’ experience and engagement to improve services; and developed our overarching Patient and Carer Experience and Engagement Strategy.

• We refreshed our Clinical Strategy and implemented interventions to support effective discharges and focused specific interventions on high-intensity users.

• Peer coaching has been identified as an integral part of our Clinical Strategy and there have been some developments with regards to its use in the Trust.

What are we currently working on?

• In July 2021, we launched a joint review with Barnet, Enfield and Haringey NHS Mental Health Trust (BEH) to find areas where we can work more closely together. This will possibly lead to joint working across a number of areas such as acute and community services.

develop a more comprehensive and systemic approach to service user and carer engagement and experience, developing and implementing an overarching Service User Experience and Engagement Strategy.

• We are addressing inequalities with our FourYear Objectives (2020-2024) to enable better community engagement with local ‘seldom heard’ communities to better understand how to overcome any barriers to receiving care. We will access the North Central London (NCL) inequalities fund to target Serious Mental Health (SMI) checks for local communities most affected by deprivation; choose a set of metrics that feed into a dashboard, Board committees and the Board performance reports.

• The Trust is working with the Mental Health Police Liaison Team and has agreed a Memorandum of Understanding (MoU) on how healthcare staff and the police will manage incidents of aggression and violence through the criminal justice system. Any staff member or service users wishing to report incidents, will be supported to do so through our security manager.

• Our Community Services Transformation Programme is progressing well and will change the way that community mental health services are delivered and accessed as well as how and where our staff and partners work together.

• We are working on a proposal to change our operational divisions and management to a more geographically-based structure to help us meet our obligations as set out in the NHS Long Term Plan and Community Mental Health Framework for Adults and Older Adults and Clinical Strategy.

• We are building on the successful work already being done around service user involvement to 9

Workforce Wellbeing At C&I, we believe that our staff are the foundation for all that we do. We recognise that a positive staff experience is essential for good patient outcomes, and we are committed to improving the working environment and opportunities available to staff. Our aim is for our staff to be able to lead healthier and happier lives as a direct result of working for this Trust. Some of the ways we can achieve this are by: • Creating a safe and healthy working environment where staff have access to good occupational health and wellbeing services

• Supporting people with manageable health problems or disabilities to maintain access to or regain work

• Promoting good practice in physical, emotional and psychological health activities

The Trust’s workforce wellbeing is the responsibility of each staff member. Our Workforce Wellbeing Team works closely with our Human Resources, Occupational Development and Equality, Diversity and Inclusion colleagues, providing wellbeing expertise, guidance and signposting to individuals, managers and teams. The Wellbeing Team also arranges onsite physical health checks for all staff. You can contact the Wellbeing Team at wellbeing@candi.nhs.uk

• Encouraging and support staff to develop and maintain a healthy lifestyle and act as role models to both colleagues and patients

Employee Assistance Programme All staff members have access to our Employee Assistance Programme (PAM Assist) and Occupational Health (PAM). You can access these services for financial and basic legal advice, counselling sessions, as well as treatment for work-related injuries. Contact them at ithelpdesk@pamgroup.co.uk

Guardian Service You can access our externally commissioned, confidential, Guardian Service if you have concerns about your working environment and/or being negatively impacted by a situation at work.

Contact them at contact@guardianservice.co.uk

Physical health checks are offered to staff via five kiosks in place at five of our sites, and one-to-one physical health checks with a nurse, are offered at our two main sites.

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Preparing for CQC visits Our ongoing preparedness for inspections General housekeeping

Self-Assessment by teams

• Always wear your name badge and alarm

There are self-assessment checklists that the Trust has produced to help support our readiness for the inspection. These assessments have been sent out to teams. If you need a copy please email cqchelp@candi.nhs.uk

• Check noticeboards are up-to-date, information leaflet stands are current and stocked – the CQC may ask you about information that is displayed

Focus groups/talks

• Ensure hand sanitiser is available and use on entering and leaving the premises

Over the coming months, various members of the Trust CQC Preparation Team will be meeting staff, service users and carers to talk about the CQC plan.

• Make sure all areas including offices/reception areas are clean and tidy • Make sure your email inboxes are clear enough to allow for information flow during the visit

If you have any suggestions for groups that we could visit, please do not hesitate to let us know by emailing cqchelp@candi.nhs.uk

• Replace broken furniture or items no longer used

Service user engagement

• Make sure your appraisal and core skills training are up-to-date

We would like staff to proactively encourage service users to speak honestly and openly with the CQC about their experiences at C&I. The CQC will treat all comments in strict confidence. Service users can give their feedback via various groups/ platforms including the Service User Alliance or the Patient Council.

• Know how to find Trust policies and be aware of the content of those pertinent to your role

15 Steps Challenge This is an unannounced review which will be completed by a team, consisting of either a Trust Governor or Non-Executive Director, service user or carer and one clinical and one non-clinical member of staff. The purpose of the visit is to capture how people using our services, and carers, experience our inpatient teams. They will complete a walk around the ward with a member of your team and then provide feedback. They will carry forward any learning that can be shared with other teams across the Trust.

If you’d like further information on the different ways service users can speak with the CQC, please contact the CQC Preparation Team via the contact details above.

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CQC inspection guidance What happens during the CQC’s visit?

What happens during the CQC’s visit?

Should the CQC request formal copies of information, please inform them that you will provide a copy via the Quality and Governance Team.

To assess our compliance against Fundamental Care Standards, the CQC will undertake inspections and assess the Trust against the five key domains.

Confidentiality and consent

If the CQC arrives at your place of work, what should you do?

The CQC will always maintain the confidentiality of any information reviewed during the inspection.

You should welcome and greet the inspectors with courtesy in the same way that we would greet any visitor to the hospital.

Inspectors will ensure prior consent of patients is sought when necessary.

What happens after the CQC’s inspection?

• All CQC staff will wear an identification badge showing their name and, on the back, their authorisation to enter and inspect regulated premises

At the end of the visit, the CQC inspectors will give initial feedback to the executive and senior leadership teams who will then cascade information, informing staff of the CQC team’s first impressions. Additional evidence may be requested by the inspectors during and after the inspection. Any requests for such evidence must be prioritised.

• Inform your manager straight away • Contact the Quality Governance Team cqchelp@candi.nhs.uk

During the inspection The CQC has a legal right to enter and inspect our premises. During their visit, they will: • Talk to staff, patients, families and carers • Review patient and staff records • Review documentation e.g. policies, training records, audits, patient information, records of supervision

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During the CQC inspection Top tips during the inspection process • Provide security alarms if in an inpatient setting, Keep informed: During outline security protocols and fire exit and assembly points the inspections, do attend • Answer their questions openly and honestly briefing sessions, talk to • If you don’t know the answer, don’t panic – your team/manager, and explain who you would ask and where you would go for the information, and offer to look out for updates via the provide it as soon as possible weekly staff Bulletin and • Business as usual – behave as you would normally do Trust intranet.

• If you are dealing with patients, continue to do so and explain this politely to inspectors – Share best practice and they will understand that your service users learning with your team come first • Respect patient confidentiality and always and other colleagues check with service users and gain their consent if inspectors want to observe your interaction with them

Most of all, be proud of the work you, your team and the Trust does and use this as an opportunity to showcase it.

You do not have to wait to be asked; where appropriate, mention some of the good things that have been achieved.

• The inspectors have the right to access all health records. However, they will need to be supervised. Staff can log them in using their details but must always stay with them. Do not share your login details or hand over your CareNotes access card to anyone

You can even share with them outcomes from your peer reviews, feedback received from service users and carers and examples of our successes at the end of this booklet.

• Service user files may be viewed by inspectors but must not be removed Work through this handbook with your supervisor/manager in team meetings and individually.

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Staff on Ruby Ward, our Women’s Psychiatric Intensive Care Unit (PICU), at their team meeting.

Helen Master and Violet Kporvie each won an iPad in our flu vaccination programme prize draw.

More than 61% of staff had the flu vaccine in our 2020/21 campaign.

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Our successes Great work is already happening around the Trust which we should celebrate and share. Here are some of the fantastic examples and achievements:

Responsive

Well-led

The number of formal complaints received on the Trust in 2020-21 (135) was slightly less than last year’s (138), and a reduction in the number of concerns received (198) via the Advice and Complaints Service and resolved informally, compared with 218 in the previous year, was also seen. This only represents a proportion of the issues that staff resolved directly with service users daily.

The Young People’s Advisory Board for young adults, ages 1824, encourages feedback and involvement. The Board is looking into co-producing videos with adult mental health professionals to inform young people about different services in the Trust.

Caring Through a partnership with Look Ahead, a third sector provider, we have been working closely with service users, wards, and community teams to enable timely discharges from hospital. Excellent knowledge of local accommodation pathways, and expert social work input, have led to much smoother transitions from hospital.

Effective The CQC rated our Camden Learning Disabilities Service’s leadership as outstanding in their December 2017 inspection and in 2020 the Royal College of Psychiatrists presented them with the Psychiatric Team of the Year- Intellectual Disabilities award.

This has been part of the continued focus to reduce length-of-stay, hospital occupancy rates and improve patient flow, enabling the Trust to accommodate all acute admissions into our local beds.

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Safe

Well-led

In a study of outcomes of older adults in mental health facilities during COVID-19, our services emerged as a significant outlier in the good quality of care as a few of our service users required transfer to an acute setting and none of our service users in our wards died from COVID-19.

The CQC Mental Health Insight report published in April 2021 indicated that: Inpatient services performance is improving; Responsive performance is improving; Safe and Well Led performance is stable Trust wide indicators performance is stable.

Effective Establishing the Mental Health Crisis Assessment Service (MHCAS) at the end of March 2020 in response to the COVID-19 pandemic was a key achievement.

The Trust mobilised the service quickly and had a 24-hour, 7 day-a-week unit fully functioning in temporary premises on the St Pancras site at the beginning of lockdown.

Above: Some colleagues from the Camden Learning Disabilities Service receiving the Intellectual Disability Team of the Year award from the Royal College of Psychiatrists 16

Safe

Caring

We have continued to encourage the reporting of incidents across the Trust. The numbers of reported incidents has steadily increased over the last four years, with a corresponding decrease in the number of incidents resulting in serious harm. This is indicative of a good culture of reporting and safety consciousness in the Trust.

We introduced DIALOG+, which is a co-produced assessment and care planning system which will be shared across all providers involved in a service user’s care and support.

An artists impression of our new hospital in Highgate 17

The Mental Health Crisis Assessment Services (MHCAS) celebrated its first birthday in March 2021, after being set up in just 10 days in response to the COVID-19 pandemic as well as to support the wider NHS system.

Well-led

Effective

A recent internal audit of risk management concluded we are operating a mature and integrated risk management system that identifies bottom-up and top-down risks. During 2020-21 the Trust established a COVID-19 risk register to identify risks that arise specifically due to the pandemic. We reduced these risks are monitored weekly by the Executive team and they are also fully incorporated into the Trust’s regular risk monitoring cycle.

As part of its commitment to support mental health research, the Institute of Mental Health (IoMH) has established a small grants scheme of £25,000 a year. Awards are made for up to £10,000 to UCL early career researchers and must include interdisciplinary approaches.

Well-led We have secured NHS England (NHSE) transformation funding for the next three years which means we can proceed with the development of new and integrated models of primary and community mental health care for adults with severe mental health problems in Camden and Islington.

Effective Reduced the number of beds occupied by patients in our acute pathway and the dementia diagnosis prevalence rates. These have declined across all of London, and Nationally.

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CQC inspection guidance Notes and reflection Use this section to note any questions you may have about the visit. Talk to other team members and your line manager about any questions or concerns you have.

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Preparing for conversations with the CQC This grid is designed to help you prepare for conversations with the CQC. Complete each part of the grid by answering all four questions.

You can do this within your teams or individually.

What are the 3 to 4 top things (at the minimum) that you are proud of in your service and work?

What new things have you learnt in the last 12 months? Think about your learning from various sources e.g. feedback from service users, incidents and audits.

What do service users appreciate about your service?

Tell us some of the challenges you have faced in your service and how you have overcome them.

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Notes

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Notes

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List of additional resources For additional support and information do not hesitate to contact the CQC Preparation Team at: cqchelp@candi.nhs.uk