Care Quality Commission Report

It is a legal requirement that any organisation that provides health and social care activities in England must be registered with the Care Quality Commission (CQC). 

Our Trust is fully compliant with the registration requirements of the CQC under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We were last inspected by the CQC in November 2022, with the report published in February 2023 Norfolk and Suffolk NHS Foundation Trust - Overview - Care Quality Commission.

CQC inspectors noted that we had moved at pace since April 2022 and that significant improvements could be seen at all levels of the Trust. In total, 60% of individual services rated were ‘good’.

The inspection helped us to identify key areas for improvement work as the report specifies actions the Trust must take (‘must dos’) to comply with our legal obligations and also actions we should take (‘should dos’).

There were 30 ‘must do’ and 23 ‘should do’ actions in the report.

Improvement work related to the ‘must’ and ‘should dos’ was progressed and monitored through an evidence assurance process within our Improving Care programme. Evidence for each ‘must’ and ‘should do’ was prepared by individual teams and included direct and corroborative evidence pieces for check, challenge and scrutiny, to determine if we could robustly evidence sustained and embedded improvement.

The many improvements include, but are not limited to:

• Waiting times for people accessing our services
• Contacting people on waiting lists
• Improving our assessments and care planning
• Ensuring bedrooms for service users are safe environments
• Using data to understand service delivery, safety and service user experience
• Safer staffing levels
• Training, supervision and appraisal rates for our staff

We have completed all of our ’must dos’ but know that we must continue to monitor our progress and sustain the improvements we have made which we are doing by implementing the Single Assessment Framework 

The Single Assessment Framework (SAF) is a method for assessing health and care delivery which enables us to have a clear view of care, quality and safety standards and areas where we need to focus on to make improvements​ to provide safer, kinder and better care.

The framework focuses on what really matters to people, covering five domains to ensure we deliver high quality care:

• safe
• effective
• caring
• responsive to people's needs
• well-led. 

SAF has been introduced by the Care Quality Commission (CQC) to make sure that quality of care assessments are formed from a variety of evidence sources. These sources include people's experiences, feedback from staff, partners and leaders, observations and processes.

To ensure we capture a variety of viewpoints, each domain has a set of quality areas and statements to describe what high-quality care looks like in practice:

• ‘We…’ statements reflect how NSFT delivers high-quality, person centred care
• ‘I…’ statements reflect what service users experience in terms of their quality of care

To date our clinical teams have worked together to complete their SAF and have improvement actions they are working through. They will update their assessments regularly when information such as feedback, reports and data are reviewed by the team