Agenda item 12
Ref: CM/01/11/09 Annex A
Annex ASummary of progress against actions plans and position statements as at 1 February 2011
Many of the high level actions are common across the different position statements. Where actions relate to a specific position statement, this is indicated in brackets (). Some areas of progress address more than one objective within the position statement. Where this is the case, the entry is either abbreviated if slightly different, or a cross reference has been made to all the relevant objectives.
Key to cross references in column A is as follows;
Enabling activities:
A)Improving the information and intelligence we hold and making sure it is more widely available in the system
B)Building our capability as an organisation to understand the issues pertaining to each topic and to engage with people who use services
C)Engaging care professionals in achieving shared goals for service improvement, including profession training
Strategic priorities:
- Making sure that care is centred on people’s needs and protects their rights
- Championing joined-up care
- Acting swiftly to help eliminate poor quality care
- Promoting high quality care
- Regulating effectively, in partnership
Enabling activity/strategic priority / Specific actions / Progress
A, 3, 5 / Work with the Department of
Health/Information Centre, the Department of Health, the National Mental Health Development Unit, Social Care, regulatory bodies, other partner organisations and people who use services to enhance the information available to CQC and others that addresses quality and gaps in data, and make sure we measure what matters, for example:
- minimum datasets and support for Children’s services mapping (children, young people and maternity)
- the Child and Maternal Health Observatory (ChiMat) (children, young people and maternity)
- National Minimum data set for learning disabilities established (Learning disability)
- Development of new safety-related indicators (safe and effective care)
For example:
- Mapping of indicators used for screening in the Annual Healthcheck for the NHS to the QRPs
- Establishment of new data flows and indicators, including statutory notifications for NHS, safety alert monitoring data
- Development of new indicators relating to safety alert compliance and severity/timeliness of notifications
- Making recommendations to PEAT design team to improve monitoring information
- Work to establish data flows with Medicines and Healthcare Products Regulatory Authority for ongoing monitoring of compliance in relation to outcome 8
- learning disability data sources mapped and gaps identified
- On steering group of CHIMat and focussing on which outcome measures could be used in future compliance assessment.
- Incorporation of data from MHA visits and the mental health service user survey
- Meetings held with Royal College of Psychiatrists to scope potential for using information from accreditation schemes and national clinical audits. Initial mapping of first main accreditation schemes completed/potential indicators developed. Information sharing agreement drafted
- Meetings held with National Treatment Agency for Substance Misuse (NTA) about potential use of NTMDS data in QRPs.
- Discussions underway with the HPA regarding sharing information on mandatory surveillance programmes and local outbreaks with a view to developing an MoU and Data Sharing Agreement
Project to harness relevant information collected by Mental Health Act Commissioners, which can be used to inform registration and ongoing compliance. Building links with Intelligence to explore analysis and IT needs of Commissioners. Further analytical support needed to interpret data gathered and to identify ongoing IT needs of mental health act commissioners (learning disability)
CQC is involved with a number of specific workstreams –
- the development of national datasets for Children’s health, CAMHs and maternity services which are now nearing rollout (Children, young people and maternity)
- Intelligence capture tools in development for regional valuing people now programme boards (learning disability)
Discussions are taking place with the PEAT development team to explore how the assessment can be modified to provide additional intelligence to support QRPs. (safe and effective care)
Cross directorate meeting held to discuss the extension of outliers methodology to mental health (mental health).
A, 1 / Making sure our work on user voice is effectiveacross all sectors and acknowledges the views and opinions of children and young people or their representatives (Learning Disability and Children, Young People and Maternity) / Building capacity within the involvement team to seek views of CYP. Gathering information from other organisations that work with CYP such as Young Minds, and MHA Commissioner visits
A, C, 5 / Explore the potential to work with clinicians in training to identify safe and quality issues by using surveys and applying trigger tools (safe and effective care) / Agreement from PMETB/GMC to include 2 questions from CQC in the Trainee Survey. Being taken forward by the Surveys team.
Links made with clinician in training representative from GMC.
A / Enhance the analysis and use of the information and intelligence we already gather to develop our assessment of the provision and commissioning of services (learning disability and mental health). / Learning disability data sources mapped.
Major piece of work through the MHA modernisation programme to map data from new MHA visit forms to registration outcomes and to develop the processes/infrastructure for data sharing (mental health). Scoping underway for pilot of qualitative analysis of MHA visit data.
Report on final Count Me In census/trends due for publication in Spring 2011 (mental health)
Work to develop assessment of commissioning of services for people with mental health needs discontinued with changes to CQC role. (mental health).
A, 3 , 4 / Developing our approach to using and communicating the findings from our work and assessments (mental health). / Publishing the findings of our MHA Annual report 2009/10 included full and overview reports, a ‘thinkpiece’ placed in the national press and videos on key topics. Further work underway to identify ways of increasing impact
Forms for use on Mental Health Act Commissioner visits had been redesigned to produce quantitative data with content mapped to registration outcomes. Data could also allow comparisonand provide context for qualitative data in futureMHA Annual Reports.
Mental Health Information Development Project underway - aims to improve the security and quality of our information as well as enabling the information collected for the purposes of the mental health act to be used in our wider regulatory assessments – is being taken forward as part ofMHA Modernisation Programme.
Mental health engagement plan for 2010/2011 drafted & signed off. Good practice examples were included in MHA annual report 2009/10 publication.
A, 3 / Contribute to work on identifying new measures and goals (safe and effective care) / CQC has responded to Transparency in Outcomes, the new outcomes framework for the NHS (safe and effective care)
B,3 / Ensure that staff have access to appropriate advice and support, including training and policy briefings (safe and effective care, mental health, learning disability ) / ‘Cross sector fundamentals’ training rolled out in June.
Supporting notes to Guidance about compliance completed or prioritised e.g., a range of notes on children’s settings, equipment, openness, supervision of midwives, EC Working Time Directive, DNAR, the use of the MHA in non mental settings, supported living, learning disability, placement of young people on adult psychiatric wards etc. Following the HQ review, renewed impetus has been given to the development of supporting notesincluding clear guidance for production, training and evaluation of implementation. Ongoing review of requirements for additional supporting notes.
Development of observation tools for a number of outcomes to enhance the quality of observations and ability to focus on key aspects of service quality.
Toolkit of guidance being developed for Mental Health Act Commissioners to raise awareness of issues in learning disability services. Scoping work undertaken .
Safeguarding children training rollout completed. Dedicated children’s safeguarding email address in place and well known/used to provide support (). Safeguarding leads group also meets regularly with input from policy teams (children, young people and maternity)
FAQs on registration of substance misuse services developed in collaboration with the National Treatment Agency for Substance Misuse (NTA) for frontline CQC staff and substance misuse service providers which have been promoted by NTA.
B, 5 / Improve clarity for staff around registration ofchildren’s services, including overlaps andinformation sharing with other regulators suchas Ofsted (children, young people and maternity). / Project with Ofsted on children’s homes and registered activities going on there. Guidance re dual registration issued for comment and other materials in hand.
B, 3, 4, 5 / Ensure our staff work consistently to improve information sharing with other regulators and improvement agencies(safe and effective care) / Arranging information sharing agreements (ISAs), data specification and transfer with relevant stakeholders.A full list of the various agreements in place can be found on the intranet under Memorandum of Understanding and Information Sharing Agreements.
Work ongoing with HSE to clarify regulatory relationships
Additional work has been undertaken to put in place a system for regular reporting on the operation and effectiveness of memoranda of understanding, joint working agreements and information sharing agreements with external organisations (all sectors).
B, 1 / Employ a person with learning disabilities towork with the strategic lead to work to raiseawareness and support staff (learning disability). / Approval to proceed with recruitment was obtainedbut now on hold due to recruitment freeze.
B / CQC commits to becoming a MINDFUL EMPLOYER® (mental health). / On hold – to be reviewed.
B, 4 / To retain CQC’s current advisory board forlearning disabilities and ensure that there aregovernance processes to support it (learning disability). / The advisory board is in place and meeting quarterly, with membership including people with learning disabilities and carers in addition tomembers who represent people with learning disability.
B, 4 / Support the work of the Mental Health Improvement Board and ensure that there are governance processes to support it (mental health). / Five meetings held since September 2009; membership includes CQC Commissioner.
B, 1 / Develop user focused monitoring of the mental health action plan (mental health). / Plan developed for involvement of Service User Reference Panel members in MHA modernisation programme
Need to review involvement/ future opportunities across mental health work
Further work on hold.
C, 3 / Work with colleagues from Methods, Registration and the Department of Health to specify regulations relating to notifications of serious adverse events (safe and effective care, children, young people and maternity, mental health) / Work completed and regulations published in February 2010.
Significant input to definitions of serious harm and avoidable death.
Facilitated flows of data via National Patient Safety Agency for NHS.
Discussions with DH about how the MHA absence without leave (AWOL) notifications with the aim of reducing burden on providers.
Supported the Department of Health’s review of the regulations to ensure that they are fit for purpose, particularly for tranche 4 providers (primary medical services).
C, 3, 4 / Ensure that those who deliver care understand our systems and how they can support them to change poor practice, implement evidence-based practice and deliver better outcomes for people(safe and effective care) / Clinical engagement in QRPs project (Safe and Effective Care)
Ongoing presentations at conferences and professional meetings
Responses to queries received via NCC.
Contributions to guidance for providers, e.g. supporting notes to Essential standards of quality and safety and provider guidance on statutory notifications
Ongoing work with professional bodies to align systems of accreditation with our regulations and guidance about compliance (safe and effective care).
C, A, 3, 4, 5 / Work with health and social care professionals to further develop measures that differentiate good and poor care and safe from unsafe practice(safe and effective care) / As above
1, A / Develop effective systems to assess the performance of provision and commissioning of care to enable clear action and improvement as a result of findings from inspection, including joint inspections. (safe and effective care, children, young people and maternity) / CQC has contributed significantly to the impending commissioning guide for healthcare for children in secure settings building on the joint YOT inspection work with HMIProbation.
Legacy work under the children’s services inspections (with Ofsted) providing feedback to PCT commissioners on their safeguarding and LAC responsibilities. A process has now been developed to ensure that the findings from these inspections are fed into QRPs where relevant (children, young people and maternity).
Other work on the assessment of commissioning and of providers over and above essential standards has now ceased.
1 / Develop effective mechanisms for engaging with people who use services, particularly those who have been harmed or suffered poor outcomes or other distinct groups, e.g. children (safe and effective care, children, young people and maternity) / Children’s services inspection programmes (eg with Ofsted) include contact. Development of Healthwatch provides this opportunity
The management of the WHO Patients for Patients Safety Champions programme has transferred from AvMA to the National Patient Safety Agency. Since the transfer there have been no further meetings of the strategic advisory group. However, members of the network were invited to the engagement event for the safe and effective care position statement. Similarly feedback from engagement events with people who use services has been used to develop the safe and effective care position statement.
1, A / Thematic visits and analysis as part of annual reporting on the use of the Mental Health Act; development of indicators based on evidence from Mental Health Act visits incorporated into periodic review (mental health). / First CQC MHA annual report published in October 2010. Steering group led by Strategic Marketing and Communications established to oversee the production of the next report. Mental health operations are giving regular consideration to the follow up of the published report/key issues that should be covered in the next annual report to Parliament.
Indicators based on the information from MHA visits included within QRPs.
1, A, C, 2 / Consult on special reviews on the implementation of the refocused Care Programme Approach, the dementia care pathway, the use of restraint and the health and social care needs of offenders as part of the 2010/11 programme of special reviews and studies (mental health). / Topics were included in public consultation regarding special reviews. CQC has now reviewed its approach to special reviews.
1, A / Contribute to the development of the annual survey of people who use mental health services to ensure it reflects changes in national policy; analyse variations in experience by age, gender, ethnicity particularly in relation to the equivalence of care (mental health). / Analysis of revised survey for people who use community mental health services completed and results published in September 2010. Changes made to the sampling for, content and scoring of the survey. Results used for DH patient experience indicator and included within QRP.
Variations analysis unlikely to proceed due to changes in the PSA target.[n1]
1 / Contribute to monitoring of the provision of age-appropriate services for children and young people under the age of 18, including in whole life establishments (mental health). / Supporting note developed on the placement of under 18s on adult mental health wards. Specific guidance issued for MHA Commissioners on the duties under Section 131A of the revised Mental Health Act about the duty to provide age appropriate services.
1, 3 / Monitor placements for children andyoung people who are detained or usingmental heath services to receive safe,appropriate services, including anyplacements in adult settings (children, young people and maternity). / On hold. To be reviewed
1, 2 / Conduct further scoping work on