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Inspection report

Date of Inspection: 11 January 2011
Date of Publication: 9 February 2011
Inspection Report published 9 February 2011 PDF

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The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Meeting this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

Our judgement

We found effective systems were in place to assess and monitor the quality of service provision so that people who use services will benefit from safe quality care, treatment and support due to effective decision making and the management of risks to their health, welfare and safety. No gaps in assurance or areas of concern were identified during the assessment of this outcome for this location.

User experience

It was not possible to gain the direct views of people who use the service for this outcome on this review. Of particular relevance to people who use services the provider explained how it has taken various active steps to involve and seek the views of people who use services (some examples have been outlined within other outcomes in this report). The provider’s Annual Quality Accounts 2009/10 was available on the trust website , and it was explained in the provider compliance assessment tool that the provider had been commended by the Audit Commission in an external audit for its involvement and inclusion of people who use services in its development.

Other evidence

The provider declared compliance with this outcome at this location at registration with CQC in April 2010.

Our provider level QRP for this outcome contained mostly positive information and the two negative pieces of information do not require further follow up in this review. We found the provider is meeting requirements regarding National Patient Safety Agency (NPSA) notification submissions, which form part of the required statutory notification alerts to CQC. None of the external stakeholders referred to within outcome one who responded raised any areas of concern specifically relating to this location or outcome.

There was two positive comments included in the QRP for outcome 16 from the Sheffield LiNK. The LiNK participants work on recovery wards has been fed back to managers and staff, leading to changes in care respect of service users' sexuality, spirituality and problems with social interaction. The LiNK also reported that the provider had cooperated with ongoing research involving members of LiNK which had lead to real care quality improvements in long term wards. It was noted with both these comments that further work is planned involving the acute wards.

NHS Sheffield contributed the following commentary relevant to this outcome regarding serious untoward incidents (SUI’s). The provider had reported SUI's timely and appropriately. High numbers of SUI’s had been reported, however though was in line with other mental health trusts. There was previously a backlog of open SUI's and during the last 6 months the provider has worked closely with NHS Sheffield to deliver action plans and a significant number have now been closed.

As part of the assessment of this location the provider submitted a provider compliance assessment which explained in detail against individual prompts how the outcome was being met. The self assessment set out a range of policies systems and processes that monitor and provide quality improvement and assurance. As part of the assessment process these explanations was reviewed against CQC’s individual prompts in the essential standards and no gaps of assurance were identified. The Quality Framework set out the provider’s vision and was available on the trust website

In a local engagement meeting held 21st October 2010 we found the board had received monthly performance reports and dashboards and relevant operational governance groups had monitored various outcomes of quality and patient safety along with key performance indicators. We also found that the provider had invested in “Inform”, a new web based system being introduced that captured a range of quality information from different sources.

A range of team level governance reports have been produced at least annually which the provider considered are crucial to ensure ongoing quality and safety of people who use services. These reports had been found to be reviewed by senior management team and clinicians as explained in the provider compliance assessment. Additional evidence was sought from the provider in the form of an annual team governance report for Rowan ward covering the period April 2009 to March 2010. We found the report to be a detailed and informative document containing a large range of information demonstrating how the area monitored and reported on quality for people who use services.