Commissioner Feedback for SLAM CQC Inspection in September 2015 Engagement with Member Practices

South London & Maudsley NHS Foundation Trust (SLaM) will be inspected by the CQC week beginning 21 September 2015 A previous inspection of SLaM in March 2015 at Bethlem Royal Hospital raised concerns over care planning and patient involvement in care planning; risk assessments; awareness of safeguarding processes; and inpatient planning meetings. A comprehensive action plan is in place with good progress being made towards implementation.

The inspection will be conducted by asking questions against the 5 key areas: 1) Is the service safe? 2) Is it effective? 3) Is it caring? 4) Is it responsive to peoples needs? 5) Is it well led?

The CQC will gather information through: A 4-Borough Commissioner Response, co-ordinated by Southwark CCG (Lambeth, Southwark, Lewisham, Croydon) Comments CQC receive through phone calls, letters and emails or through ‘share your experience’ pages Information from Healthwatch and other organisations Feedback from public listening events encouraging patients and carers to share their experiences of care Information from staff who raise concerns Detailed Information from the care provider

Evidence & Feedback sought may include: Concerns or changes in governance, leadership or service delivery models Serious incident themes Current areas of concern and good practice Complaints and feedback (inc. PALS data) Results of clinical reviews and audits (e.g. ‘walking the service’ reports) Outcomes of CCG risk summits Service reviews Summary of safeguarding concerns Any serious case reviews regarding the provider in the last 18 months

Good Practice identified at SLaM Duty of Candour - The Trust has taken a proactive approach to fostering a culture that promotes duty of candour and has appointed a Candour Guardian Commissioners consider there to be robust clinical governance arrangements, including clinical engagement with commissioners SLaM has taken proactive action to improve the number of pressure ulcers due to an increase in early identification whereby each patient undergoes a body map upon admission and weekly thereafter Progress around Physical Health Checks Learning from Serious Incidents

Concerns: The Trust has had significant challenges due to staff shortages The trust continues to perform below target of 90% only achieving highs of 81% - an increase of 1% from previous year - in response to patients asked “Do you feel safe” Discharge summaries, care plans, and risk assessments have been a focus of improvement with further work required CPA compliance & risk assessments being in place for current patients Safeguarding – The trust needs to build more effective safeguarding processes and capturing of activity data for assurance Out of borough residential placements commissioned by the High Support Team required further focus to ensure reviews happen in a timely way

Areas for continuing focus and development: Core national performance targets – A&E: quality KPIs in A&E, clinical review of long waiters, analysis of 12-hour breaches Physical Health Monitoring – commissioners implemented a physical health CQUIN to improve screening for early detection of long term physical health conditions Delayed Discharges – SLaM achieved this target in 14/15 but there is a significant rise since April 2015 where performance is above 10.4% against the 7.5% national target. The delays are due to the high demand and pressure in the system, some earlier and more robust identification Serious Incident Investigations: Work is underway to ensure compliance with the new national framework and ensure there are enough trained investigators

What now? gwen.kennedy@nhs.net and rabiaalexander@nhs.net Stakeholders including the Local Authority, Healthwatch and Primary Care will feed their views into the evidence gathering phase Each Borough will make arrangements for briefing their CCG Governing Body / Integrated Governance & Performance boards in respect of the process A final Health Commissioner’s Response will be agreed across the 4 Boroughs for submission to the CQC prior to the Inspection Your chance to provide feedback: Please send any views and comments you wish to make about SLaM’s services direct to Southwark CCG by e-mailing: gwen.kennedy@nhs.net and rabiaalexander@nhs.net