CQC Core Service Action Plans in Full

The CQC categorise the Trust’s services into 10 ‘Core Services’ (described below).

There is also an overall ‘Provider Report’ which includes some actions from the individual Core Service Reports as well as additional provider-wide actions.

The table below summarises the main issues raised by the CQC and the progress being made by service area.

Please click the Core Service name to see the full action plan.

Core Service

As described by the CQC

Issues Raised by CQC % of Actions Completed as at July 2017
Acute wards and PICUs for adults of working age
  • Ensuring single-sex accommodation is provided and eliminating shared bed bays (on track)
  • Mandatory training (on track)
  • Ligature points (completed)
  • Seclusion and seclusion rooms (on track)
  • Staff supervision (on track)
  • Green room policy (completed and CSPI checked)
Long stay/rehabilitation mental health wards for adults of working age
  • Blanket restrictions (on track)
  • Infection control (completed and CSPI checked)
  • Governance/Quality assurance (Governance is completed – Quality assurance is completed and CSPI checked)
  • Staff Supervision (completed)
  • Staffing levels (completed)
  • Mandatory training (on track)
  • Safeguarding (completed and CSPI checked)
  • Medicines management (completed)
  • Activities (completed)
  • Food Safety (completed)
  • Incidents and Complaints (on track)
  • Understanding Mental Health Act (on track)
Forensic in-patient wards
  • Mandatory Training (on track)
  • Restrictive practices and blanket restrictions (on track)
  • Seclusion room and practices (on track – practices completed)
  • Ligature risk assessment and ligatures (ligature risk assessment completed, ligatures on track)
  • Multi-faith facilities (on track)
  • Staffing levels (on track)
  • Privacy around medication (on track)
  • Activities (completed)
  • Waiting times from referral to assessment (completed)
  • Collaborative care planning (on track)
Wards for older people with mental health problems
  • Ensuring single-sex accommodation is provided (on track)
  • Seclusion room (on track)
  • Mandatory training (on track)
Wards for people with learning disabilities or autism
  • Mental Capacity Act recording including advocacy (on track – advocacy completed)
  • Storage of medication (on track)
  • RESPECT, Autism and Dementia training (RESPECT completed and CSPI checked, Autism and Dementia training on track)
  • Incident sign off (on track)
Community based mental health services for adults of working age
  • Mandatory training (on track)
  • Safeguarding (completed)
  • Lone Working (completed)
  • Collaborative care planning (on track)
  • Physical health needs (completed)
  • Performance and waiting lists and risk (Performance and waiting lists completed, risk on track)
  • Mental Capacity Act (on track)
Community based mental health services for older people
  • Mandatory training (on track)
  • Alarms and keys (Memory Service) (completed and CSPI checked)
  • Clinic room stock (completed and CSPI checked)
  • Collaborative care planning (completed and CSPI checked)
Mental health crisis services and health based places of safety
  • Risk assessing (completed and CSPI checked)
  • Physical health (completed and CSPI checked)
  • Documentation quality (completed and CSPI checked)
  • Ligature risk (completed and CSPI checked)
  • Learning from incidents and feedback (completed)
  • Governance (completed)
  • Training (on track)
  • Staff supervision (on track)
  • Waiting times (on track)
  • Facilities for assessment (on track)
  • Communication/accessibility (completed and CSPI checked)
  • 24 hour service provision (on track)
Community mental health services for people with a learning disability or autism
  • Mental Capacity Act- assessments of capacity, knowledge and training (completed)
  • Crisis/advance planning (completed)
Substance Misuse Services
  • Infection control (on track)
  • Risk assessing (on track)
  • Mandatory Training (on track)
  • Collaborative care planning (on track)
  • Audit of care records (on track)
  • Performance oversight (completed)
  • Telephone system and volume of calls (on track)
  • Equipment (completed)
  • Waste disposal (completed)
Provider report
  • Mandatory training (on track)
  • Governance systems (on track)
  • Single sex accommodation (on track)
  • Medicines processes (on track)

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

Easy Read Report for Learning Disabilities Services

Easy read report – Care Quality Commission Inspection 2016