We are taking the issues raised by the Care Quality Commission (CQC) very seriously and have given our work to respond to the issues the highest priority possible. 

On 22 October the CQC published their focused inspection results which were based on unannounced follow-up inspections they carried out in August to check on the progress we've made since our original inspection between January and February 2020. 

We were pleased to be informed that they had seen enough evidence of improvement to lift their warning notice on us, and while it's clear we have lots of work to do still, we're really proud of the improvements we've made. 

On this page you'll see examples of the different work we've done to address concerns raised by the CQC, as well as things we already knew we wanted to improve, as part of our our journey to get Back to Good.

Back to good - improvement chart - 28 October 2020

What progress have we made?

Every month our Back to Good Board meet to check in on the progress we're making. 

During these meetings we review actions that have recently been completed and give the work the scrutiny it needs to ensure the changes that have been made are robust, sustainable and making the necessary changes.

After each Board meeting we update our progress chart so we can track how far we've come, and how far we have left to go. 

Quality Improvement Week

From Monday 19 October to Friday 23 October we held our annual Quality Improvement Week.

Quality Improvement Week is a chance for staff, service users and carers to come together and find out more about the range of projects of improvement projects we're running at the moment, contribute thoughts, share ideas and give feedback to the changes we're making.

The underlying theme throughout the week was our journey to get Back to Good.

To find out more about the week click here

Insight upgrade

The clinical system that we use to record every interaction with our service users, called Insight, is currently in the process of being upgraded. 

The upgrades will allow us to make a range of improvements to the system that staff have told us would make it easier to record data. 

Work has already begun to test different elements of the upgrade and we hope to have the work complete in the next couple of months. 

NEWS2 to be rolled out

In our most recent Care Quality Commission (CQC) inspection, inspectors told us that we needed to do more work to address the physical health needs of our service users and during our Back to Good work staff have also told us they need more support in this area.

To address these issues we're delighted to be rolling out a new tool that will give us an early warning on any deterioration in our service users' physical health. 

The National Early Warning Score, also referred to as NEWS2, is replacing our current Early Warning Score and will help standardise the physical health observations staff carry out. The tool is one that has been used across the NHS in acute hospital trusts, and is a proven method to help us provide the highest quality care to our service users. 

You can read more on the news here

Mental Health Act training

Staff in our North and South Recovery Teams have received training on the Mental Health Act, with positive feedback received from staff in both teams. With increased understanding of the Mental Health Act, and the associated Code of Practice, this will enable staff to ensure their practice is in line with the legal requirements and support our service users to better understand their rights. 

Our aim is to roll this training out to all of our community teams over the next few months. 

Changes to supervisions

Having regular supervisions is essential to support our staff to learn and develop in their role. Following feedback we received during Rapid Improvement Week we have proposed increasing the number of supervision sessions staff receive a year from four to eight. 

We have committed to ensuring managers are trained to deliver supervisions in flexible ways, that everyone understands the importance of supervisions and how supervisions can be diaried into busy clinical schedules in advance throughout the year. 

Fastrack Forms

Our Fastrack Forms are a way for service users, family, carers and staff to raise a concern, and for that concern to be responded to within 10 working days. We know that the forms aren't working as well as they could be, and this was something we've received lots of feedback on. 

It's really important that when concerns are raised they are responded to quickly and that issues are addressed as soon as possible. From the feedback we received we have committed to providing teams with monthly reports on Fastrack Forms they have received so we can better identify common concerns and to work with our Quality Improvement Team to make improvements to the form itself. 

Single sex wards

One of the themes that we focused on during Rapid Improvement Week was moving to single sex wards. A key driver behind this is sexual safety and this move will help to reduce some incidents, whilst accepting same sex or patient-to-staff incidents will still be a concern and risk. 

Staff from our wards came together to look at some of the challenges we face, such as how we manage capacity in situations where we don’t have a 50/50 split of beds.

The workshop looked at the positives and concerns of moving to single sex wards, and made a number of recommendations such as considering research and evidence from other Trusts.  

Our next steps are to: 

  • develop a clearer vision to guide the next steps and time frames
  • engage with staff and patients to achieve the vision.


We are a smoke-free organisation and offer all of our service users and staff support to quit smoking. This approach has been difficult, especially with service users on our acute inpatient wards and we acknowledge that there have been inconsistencies in how this has been implemented. 

During a workshop with staff we have reiterated our pledge to be a smoke free organisation and made the following recommendations:

  • better communication with service users and clear expectations about smoking before they are admitted
  • new nurses all attending smoke free training at the beginning of their placements
  • better resources to help staff who speak with service users about smoking
  • a revised policy on smoking so any ambiguity is removed.

Rapid Improvement Week

On 29 June we held our first Rapid Improvement Week which was designed to help us identify issues, look at what changes we need to make and commit to practical things that we can improve on quickly. 

Throughout the week we held workshops with staff to look at a variety of issues, including:

You can hear feedback from these workshops from our clinicians by clicking on each topic. 

Further down this page you can find specific progress updates on each of these topics, as well as other issues that were identified during Rapid Improvement Week. 

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