Following on from the CQC Inspection in 2023, the trust received 12 Must Do and 30 Should Do actions.
The actions have been progressed through the CQC action plan via Divisional oversight with reporting into the Trustwide CQC Action Plan Assurance Group.
We are now seeing continuing progress for CQC actions with many closed down or in the close down process.
To share the progress and extensive work that has been undertaken the Must Do's have been put together into a 'CQC Said...., We Did....' document - see attached.
In preparation for discussion at the next Trustwide CQC Action Plan Assurance Group meeting, divisions are asked to consider the following questions:
- Could the same CQC issue be picked up in other service areas within or across divisions?
- As a division have you rolled out the improvements across relevant service lines or services where the CQC issues could occur?
- What do we need to do to make this happen?
Newsletter
Our monthly update for everyone interested in health and social care
Ian Trenholm to step down
Ian Trenholm, our Chief Executive, has announced his intention to step down from his role of Chief Executive and as a Board member at the end of the month.
Reflecting on his decision, Ian said:
"During my six years leading CQC, we have made important changes to the way we work in order to help improve care and keep people safe. We are now in the final stages of delivering an ambitious transformation programme - this month saw the delivery of the last big milestone in a complex and challenging programme of work.
"While there will always be more work to do, the conclusion of this stage of the transformation feels like a good time to move on. It has been a privilege to work with such a passionate, committed and talented group of colleagues.
"I am incredibly proud of what we have achieved together, and I am confident that the organisation will continue to evolve to help support the health and care system to provide good, safe care for people."
Kate Terroni, CQC's Deputy Chief Executive will be appointed as Interim Chief Executive. A permanent appointment will be made in due course.
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Catch up with the latest blog posts from CQC
Take a look at our latest blog posts:
Exploring our community mental health survey results
In this blog from last month, Chris Dzikiti, our interim Chief Inspector of Health Care, explores the results of the latest community mental health survey, focusing on new insights on child and adolescent mental health services.
Progressing the Patient and Carer Race Equality Framework
Chris Dzikiti and Dr Jacqui Dyer, Mental Health Equalities Advisor at NHS England, talk about the work our two organisations are doing to implement the Patient and Carer Race Equality Framework (PCREF).
See our other blog posts
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Please see the below link to our CQC notifications guide, there will be no changes in here to what you are already doing as a division in terms of notifications to CQC but this slide deck will ensure that you have the current information and links all in one place. Guidance and forms can change regularly but the links on the page will always take you to the most recent updates and forms to be used.
Location code is something we are asked for quite frequently and so we have added these in (slides 11/12/13).
We hope this is helpful but if you do have any questions at all please let us know and we will be happy to talk you through any element of this.
Updated presentation - Managers Guidance to a CQC Inspection for 2024.
The QRV report is subject to ongoing review and consultation but we will be linking this review to the published reports that CQC make available following their initial inspections using the new Single Assessment Framework (SAF). We anticipate that the SAF will have a real focus on Safe and Well Led areas therefore we’re currently prioritising reviews of the following –
- S1. Learning culture (Safe) – went live 1 June 2024 replacing S1. Incident reporting, including Serious Incidents
- S3. Safeguarding (Safe)
- S7. Infection prevention and control (Safe)
- S8. Medicines optimisation (Safe)
- W7. Learning, improvement and innovation (Well Led)
- W8. Environmental sustainability – sustainable development (Well Led)
As part of the CQC teams’ regular updates and engagement sessions, please see the latest slide deck for information. If you have any questions, or need further support, please email CQCTeam
Guidance on visiting in care homes, hospitals and hospices
On 6 April, new regulations came into effect covering visiting and accompanying in care homes hospitals and hospices and will be part of Care Quality Commission (CQC) inspections going forward.
CQC has published provider guidance to explain how providers can meet the new standard. In addition, the Department of Health and Social Care recently held a series of webinars to help providers understand what is required under the new standard and how it will be enforced by CQC. The recordings of the webinars have been linked in the frequently asked questions document.
If you have any questions, please contact: visiting
Retaining our overall Good CQC rating and Outstanding for well led and caring - 14 April 2023
Mersey Care has again been awarded an overall ‘Good’ rating from the Care Quality Commission (CQC), following an in-depth inspection carried out between November 2022 to January 2023. The Trust continues to be recognised as ‘Outstanding’ for the ‘Well Led’ domain and has now also been recognised as ‘Outstanding’ for the ‘Caring’ domain.
We had two announced and four unannounced inspections at six of our mental health and community health services, as well as one unannounced inspection of Wavertree Bungalow. Across the Trust, 41 inpatient wards/teams were inspected in total. As a requirement of the external re authorisation process, Ashworth Hospital was also visited.
Receiving an overall ‘Good’ rating and improving on the number of overall ‘Outstanding’ domains is a real achievement and a testament to all the hard work and innovation to which every one of you has contributed. This outcome is good, given that the inspection was so soon after the pandemic and just a year after the acquisition of the former North West Boroughs NHS Foundation Trust (NWB) and Southport and Formby community services (SFCS).
Three of the mental health services inspected were rated ‘Good’ and one was rated ‘Requires Improvement’. Two of our community health services were also rated ‘Good’. Wavertree Bungalow was rated ‘Requires Improvement’.
The inspection was not only an opportunity to showcase our work but also to look at our organisation through a different lens. The report describes our organisation as well-managed, and highlights areas of ‘outstanding practice’ in: using data to generate new patient/service insights, allowing staff time to focus on continuous learning and innovation, listening to patients, embedding our reducing restrictive practice work, heading up the first NHS led Global Centre for Research on Mental Health Inequalities and introducing quality improvement initiatives into community inpatient services.
We have recommendations to address, such as improvements to our estate, role specific autism training, and - consistent with other NHS trusts - how we respond to recruitment and staffing challenges, and the impact these pressures have on our patients, service users and staff.
The former Liverpool Community Health NHS Trust inspection and ratings from 2018 have been incorporated into our new ratings, without an inspection of these services, which impacted on the safe and effective domain ratings. We look forward to a re-review of these services so that the great improvements that we know have happened are accurately reflected in our overall rating.
It is worth saying again that this is also our first CQC inspection since the COVID-19 pandemic and the acquisition of NWB and SFCS. We fully recognise it takes time to assimilate teams, services and align cultures. However, this inspection describes very well how we have managed to carry out this change whilst keeping a strong sense of continuous improvement in place.
The Board of Directors hugely appreciate your tremendous efforts to make sure our patients, service users, carers and families receive the treatment, care and support they need. Your dedication, kindness, professionalism and compassion shine through the report and we should all be rightly proud of our collective achievements and the difference we make to the communities we serve.
CQC will continue to monitor our Trust and check improvements have been made, where required.
A huge thank you for all you do, each and every day, and well done.
The Wavertree Bungalow and Well Led Reports are available on our website. New certificates will be distributed in due course.
Information Request System Development - 11 September 2023
As part of continuous improvement, in collaboration with IT colleagues, we are developing a new SharePoint based system to aid and streamline the CQC information request process.
The key objectives of this system development are –
- to standardise and automate Trust wide processes for responding to both ad hoc and inspection CQC information requests wherever possible whilst ensuring strict timeframes set by the CQC are met; and
- to streamline the divisional and corporate sign off process to improve transparency and efficiency.
The key outcomes of this system development are –
- that processing CQC information requests in a standardised and automated Trust wide process will become business as usual for all staff to avoid multiple processes being used. This will reduce confusion around processes, and improve clarity around timescales for responses to be provided and signed off; and
- that streamlined divisional and corporate sign off processes updated on the system at each stage of the information request will provide transparency for all staff involved with the information request as to its progress at any given time. This will significantly reduce email traffic and confusion around the progress of information requests and will provide clarity around accountability for the information provided.
This work is ongoing and we will keep you updated as progress is made. In the meantime, all CQC information requests continue to be disseminated by our team via email.
CQC Preparedness Sessions - 12 September 2023
The next CQC Preparedness Session, led by Sandra O'Hear, Deputy Director of Nursing and Quality, will be held on 24th October 2023. These sessions are to ensure that all managers and senior leads are informed of the latest developments from CQC and also receive key messages from corporate leads such as Estates and Patient Safety. If you would like more information or have any queries regarding this, please contact the CQC Team at CQCTeam@merseycare.nhs.uk.
Quality Review Visit (QRV) changes - 17 October 2023
Following the Care Quality Commission (CQC) inspection, we introduced changes to our QRV process to make sure QRVs continue to fully assist us to improve the quality of care we provide to our patients, service users and their carers. These changes also aim to help us prepare better for future inspections.
The additional three new Safe domain standards relate to patient harm, waiting times and caseloads and are subject to ongoing discussion. Whilst these new standards remain important and valid, we recognise that there is a need for greater understanding and clarity on what the gold standard looks like for rating and evidencing.
We want our leaders to feel better equipped to respond well to QRV standards and to engage in future changes to QRVs. Therefore, it’s been agreed that these new standards will be reviewed and redefined by senior Trust and divisional leads.
Although QRV leads will continue to ask teams to supply evidence and respond to questions in relation to the three new standards, this will be for the purpose of refining and defining exactly what’s required. Therefore, ratings for these standards will be paused and temporarily disabled (by rating them as N/A) until 1 January 2024.
Already published QRV reports which include the new Safe domain standards will be retrospectively re-rated over the coming weeks. As such, some team’s Safe domain and overall ratings may change - team leaders will be kept informed.
Alongside these changes, a record will be maintained of how the three new Safe domain standards have been rated. This will be a manual data set available for any required data analysis but it will not be accessible Trust wide.
Trust and divisional leads will be contacted to take part in these valuable ongoing discussions to make sure the clarified ratings and evidence requirements are confirmed and ready for the go live date on 1 January 2024.
Update - Since 1st January 2024, the new Safe domain standards relating to waiting times and caseloads were reintroduced. There are ongoing discussions regarding the new Safe domain standard relating to patient harm which is expected to be reintroduced later in 2024 as part of the new Learning Culture area of enquiry.
CQC Preparedness Session - October 2023
As part of the CQC teams’ regular updates and engagement sessions, please see the latest slide deck for information. If you have any questions, or need further support, please email CQCTeam
CQC's New Regulatory Approach - roll out January/February 2024
From 23 January 2024, CQC will start using the new regulatory approach with a small number of providers in the North and Midlands regions. From 6 February 2024 CQC will start using the new regulatory approach with all providers in the North and Midlands regions and will include NHS well-led assessments.
New poster for mental health wards - 11 December 2023
New poster for mental health wards
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CQC have recently updated their webpage about how people can make a complaint about the Mental Health Act. This includes care while:
- detained in hospital
- on a guardianship
- under a community treatment order.
The Trust has arranged for the posters to be professionally printed and will be sent out to team team in the coming days.
It is a requirement that anyone detained under the Mental Health Act must be helped to understand how to make a complaint if they wish to.
MHA patient information leaflet
CQC have shared some information for any patients detained under the Mental Health Act. The booklet aims to help our patients to understand their rights to meet one of our Mental Health Act Commissioners when CQC are visiting a hospital ward, and what they can expect from CQC.
The information also explains patient rights about taking medication and how to complain if they need to.