Agenda item


Members to receive a report and presentation providing a summary of the CQC inspection process, along with details of areas of strength and improvement that have been identified.


Members received a report providing details of the Care Quality Commission (CQC) Inspection of Leicestershire Partnership NHS Trust(LPT).


Angela Hillery, Chief Executive, LPT gave a presentation providing details of the CQC Inspection, the three core services inspected, the CQC assessment of LPT and findings together with an overview of the improvements required and steps being taken to progress that.


It was noted that mental health dormitory accommodation continued to be a significant priority area to improve, and it was national policy to move the programme on and eliminate shared sleeping arrangements. LPT had a robust 3 year plan in place to eliminate shared sleeping arrangements, taking account of bed numbers and access to capital funding. Phase 1 had completed; Phase II was now underway, and Phase III would see the programme brought to completion.


Other key areas identified for improvements in the inspection included:

·         Issues of timeliness for repairs; storage and cleanliness – steps had been taken to act upon points raised and improve facilities management provided by UHL.

·         Call alarms and accessibility – this had been risk assessed in line with new national guidance since the inspection.

·         Personalised care plans - focus was on embedding this in practice.

·         Learning across teams -  there was focus on learning lessons and embedding that across services too.

·         Mandatory training – prior to Covid LPT were compliant but since they had to redeploy staff and stop face to face which impacted on ability to complete mandatory training. Staff were being supported to attend mandatory training as a priority now covid restrictions had eased.

·         Patient risk – a Quality Improvement programme was in place to address the findings and to monitor the embedding of these actions.

·         Access to psychologist roles/services – recruiting continues to these key roles.


Members noted that the service had continued to make improvements throughout the Covid-19 pandemic and the inspection report recognised that.


Members discussed the report which included the following comments:


In relation to the improvements outlined, most were covered off during January/February 2022 and the action plan showed some steps to complete by March. It was queried whether this meant there was confidence that by April 2022 the standard reached would therefore be good or still requiring improvement should there be an inspection?  It was advised the CQC retained a relationship with LPT, and met regularly to feedback on the findings and implementation of improvements. In terms of the action plan there was a series of actions up to end of April 2022, however the aim to complete mandatory training by end January was impacted by the rise in Omicron variant cases so the timetable was revised, however LPT had been very transparent with CQC over that.


Members were informed there was a shift in mindset, with regular governance and reporting twice a month on the CQC action plan. The action plan focused on quality transformation and any areas going off track were reported to the executive board on a regular basis. The action plan as at today had just six outstanding actions, these were around mandatory training and all due to complete by end February/beginning March 2022, there was confidence that would  be achieved despite the impact covid has had over past 2 years.


Members welcomed the improvements being taken forward noting that medicine management had also been improved. It was queried why the third core service inspected “wards for people with a learning disability or autism” remained static at Requires Improvement. Members were advised this was in part due to the mandatory training not being achieved and partly due to the challenge of algorithms used in the assessment, however this did not mean that the CQC did not find some improvement.


Members acknowledged the impact that the Covid-19 pandemic had and thanked staff for their work during the pandemic however, considering the damning report in 2018, Members expressed their concerns at the slowness and level of progress e.g., the dormitory accommodation programme, and it was suggested that the action plan and activities to be done before April 2022 seemed to be a tick box exercise rather than a culture change. Members queried the strategic approaches being taken to address the inspection findings and commented that it was not appropriate to accept drift.


In response it was asserted there had been some clear progress during the pandemic but accepted it was slow however following the report in 2018 it was indicated that the LPT were on a 3-5 year journey to make and embed changes. There was now a clear position and programme in place to deal with the dormitory accommodation with an implementation plan which was on track to deliver. The action plan following the latest inspection was there to satisfy the CQC on the evidence that they required, and it was difficult to demonstrate a focus on culture, but LPT were committed to deliver what it says is firmly there.


In terms of seeking a peer review to provide more assurance that LPT were improving, Members were informed that part of the work had been to seek an outside view from Northampton Trust as part of the process. There was also membership to accreditation schemes and Royal College networks that were used to check/inspect as part of the LPT journey of improvement. Assurance was given that the Board were committed to overseeing the changes and embedding improvements/culture change necessary and that was emphasised by the presence of Board members at this meeting.


A point was raised about regular checks and spot checks to ensure consistent and effective management of contraband items and how that was balanced with patient dignity. It was clarified that in terms of process, those searches were focused on storage of clothing and how to enter a patients space, with clearer processes for entering and leaving rather than searches of the person.


In relation to the findings around personal patient call alarms it was explained that there were alarms in place on all wards and there was no instance where a call alarm was not available for incidents. The issue was around those patients that declined wrist alarms however, the CQC would like to see more availability and usage of wrist alarms and LPT had reflected upon that in their guidance.


The Chair thanked LPT health partners for the report.



1.  That a report providing more detail of the Mental Health Dormitory Accommodation programme be provided to the 28th March 2022 meeting of the committee together with a brief update on progress with the Action Plan.


2.  That a further update on the LPT CQC inspection outcomes and a digest of peer review work be brought to the Autumn meeting in conjunction with the update on Step Up to Great Mental Health.

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