……………………………………………………………………………. Chief Inspector of Hospitals visit Quality Summit 11 June 2015

CQC observations and conclusions Clear safeguarding policies which staff understood and were accessible Reliable systems to prevent and protect people from a healthcare associated infection Reporting and learning from incidents and serious incidents was adopted throughout the organisation Staff demonstrated they were clear on Duty of Candour regulations Staffing levels for inpatient wards are monitored and maintained effectively. The trust demonstrated active recruitment to vacant posts BUT We need to strengthen actions and management of annual ligature audits Review the environment and facilities on Harvington Ward Address minor concerns around medicines management Review staffing on Harvington and in CAMHS Is it safe? Requires improvement

CQC Observations and conclusions Widespread adherence to evidence based practice Effective clinical audit strategy in place and participation in national audits and benchmarking groups Evidence observed of adherence with NICE guidance across a range of core services Most care records were up to date, personalised, holistic and recovery focussed with evidence of MDT and inter agency working Staff demonstrated a good understanding of the Mental Health Act and code of practice. Consent to treatment and capacity requirements were adhered to including good assessment BUT There was inconsistency in obtaining and recording of consent in Recovery Units and CAMHS (child and adolescent mental health service) Staff understanding of Mental Capacity Act and Deprivation Of Liberty need to improve Staff supervision was felt to be not taking place regularly and consistently in Recovery units Is it effective? Requires improvement

CQC observations and conclusions Patients told the CQC that staff treated them with dignity and respect Communication observed by the CQC was compassionate and demonstrated positive engagement and willingness to support patients There were good examples of patients engaged in care planning Staff told the CQC that they had an open culture for people to feedback how they felt about the service provided Access to advocacy services was available and well promoted BUT Some patients on Harvington said staff were too busy to spend time with them and the CQC observed that there was not always staff present in the ward lounge area Is it caring? Good

CQC Observations and conclusions The trust achieved all 18-week targets for average number of days waited between referral and assessment Services developed to encourage care as close to home as possible The CQC observed that patients diversity and human rights were respected and staff knew how to access interpreters and information was available in other languages Staff knew how to support people who wanted to make a complaint and learning was shared There was good discharge planning and liaison with community teams to ensure that the patient was supported on discharge BUT A review of the environment and facilities on Harvington Ward is required, including the lines of sight Staff were unclear about how to control the heating on Hill Crest and Harvington ward There was concerns around waiting times from referral to treatment in CAMHS and Psychology Services Is it responsive ? Requires improvement

CQC Observations and conclusions Trust vision and values were prominently displayed and staff were working to uphold these values The CEO and Chair had high visibility with staff, and staff were positive about Executive walkabouts. The senior leadership was well respected Effective governance arrangements are in place for the identification or risk and systems are in place for the measurement of quality and patient safety There were strong assurance layers in place to ensure learning from serious incidents and complaints Staff told the CQC that they felt that the welfare of the patients and wellbeing of staff was very important to the organisation The trust participates in a number of external peer review and service accreditation schemes Is it well led? Good