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

2. 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.

3. 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?

4. 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 s 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

5. 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

6. 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

7. 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

8. 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

9. 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 ing:
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