CQC Challenges and Successes


Ensuring single-sex accommodation is provided

This involves redesign of the ward buildings and building new wards, therefore this cannot be completed until building works are undertaken. This is estimated to be completed in 2020. Interim measures have been put in place to prioritise people’s dignity around sharing mixed accommodation as well as safety (see full action plans).

Mandatory training

This was identified as a theme across most services. The trust has set a target of 80% of staff trained as the measure of this being completed, however this number can alter on a monthly basis due to factors such as training expiring (needing refreshing) and new staff members joining the Trust. The training data is monitored on a monthly basis by the Trust.


Restrictive practices reduction

A ‘Reducing Restrictive Practice Group’ has been set up and chaired by the Medical Director to review all restrictive interventions and blanket restrictions. A ‘Task and Finish Group’ also looks at all the existing restrictions on wards including restricted items lists to ensure that they are reviewed on a regular and individual basis.

Risk assessment

The Health Based Place of Safety has introduced a new procedure to ensure all people are assessed for risk. This is being audited on a monthly basis and the results for July 2017 were 100% compliant. This is being monitored through the Trust ‘Service User Safety Group’.

Substance Misuse Services have now risk assessed 89% of people using the service, which was identified at inspection as being at 65%. The service is on track to deliver 100% by September 2017.

Please email CQCsupport@shsc.nhs.uk if you have any questions related to any of the action plans or their content.