The actions detailed for all inspections referred to above are for those time tabled for completion by August 2017.

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1 Foundation Trust Board of Directors 28 September 2017 NHFT CQC, HMP Whitemoor and Rainsbrook STC action plans: assurance report to 31 August 2017 F Situation Following the Care Quality Commission (CQC) inspection in January 2017, the Trust developed action plans in relation to the requirement notices, and the must and should do s. This report provides details of progress against the specific actions associated with the requirement notices within the Trust CQC action plan created in response to that inspection. It also provides an update in respect to the CQC requirement notices and subsequent actions plans created, following the HMP and CQC March 2017 inspection of Whitemoor Prison and the joint CQC and OFSTED inspection of Rainsbrook Secure Training Centre in June The actions detailed for all inspections referred to above are for those time tabled for completion by August Background The CQC, following their comprehensive inspection of the Trust in January 2017, rated the Trust as good overall with the following rates for each domain: Safe - Requires improvement Caring - Outstanding Effective - Good Responsive - Good Well led - Good As a result of the judgements made by the CQC at their inspection the Trust has set actions that the CQC require the Trust to complete. A comprehensive action plan was developed and is being managed and tracked via Datix. The final inspection report on the joint inspection of HMP Whitemoor during the week commencing 20 March 2017 has now been published and the Trust has now formally been issued with requirement notices, which set out the areas for improvement and the action the Trust must take to improve. The Trust has provided a written report to the CQC of the actions we have and are going to take to achieve compliance. A comprehensive action plan was developed and is being managed. In addition, a joint inspection by CQC and OFSTED of Rainsbrook Secure Training Centre took place on the 19 th June The Trust received a requirement notice. The Trust has provided a written report to the CQC of the actions we have and are going to take to achieve compliance. A comprehensive action plan was developed and is being managed.

2 Assessment NHFT CQC update The Trust action plan identified 34 requirement actions (previously shared with Trust Board), of which 18 were planned for completion by the end of August Seventeen of these REQUIREMENT actions were due completed, one is still in progress. Plans are in place for the outstanding action, as shown below. The requirement action that is still in progress is: REQUIREMENT NOTICE: The Trust did not ensure staff received the training, supervision and appraisals necessary for them to carry out their roles and responsibilities. o Supervision is now recorded on OLM to enable central monitoring and this is being reviewed weekly by exec. o Appraisals are now recorded on OLM to enable central monitoring and this is being reviewed weekly by exec. o Role specific training project is underway to re-define audiences and enable improved accuracy of recording and monitoring. A steering group has been formed and is meeting in October to ensure traction. o RAG rated training compliance reports are being issued and monitored monthly. o Central monitoring has been hampered by technical and ESR infrastructure issues. o Plans are in place and issues are being actively managed. To ensure that actions taken are fully embedded into business as usual (BAU), the Executive Directors will be assuring themselves of the action taken and the sustainability of the improvements/changes for the requirement notices. Each director has been assigned specific service areas to focus on as per the original allocation for the Beyond Good programme. This will take place in Oct/Nov 2017 as all requirement notices should have been addressed by the end of October. HMP Whitemoor update The formal paper work has been received, completed and returned to the CQQ in relation to the requirement notices. This action plan identified 2 requirement actions (previously shared with Trust Board), which were broken down into 9 discrete actions rather than individual requirement notices as previously reported, 6 of which were due for completion by the end of July of the 6 discrete actions were completed and reported in June. The 1 action is due for completion in July is still in progress, this relates to an ultimate deadline for delivery of the action plan for that specific requirement notice given to the CQC of the 1st of November. Plans are in place for the outstanding action. The requirement action that is still in progress is: REQUIREMENT NOTICE. The Trust should ensure Medicines are managed safely in relation to their administration and monitoring. o There has been a reduction in night time medication. o D wing have gone live with Dossette boxes, the amount of night medications administered has reduced as a consequence. o A review of the rest of the prison is also currently underway with the pharmacist and GP working together to reduce numbers. Rainsbrook Secure Training Centre update The Rainsbrook Secure Training Centre inspection identified one (see appendix 3) requirement notice that has been completed.

3 Recommendations The Trust Board is asked to: i. Approve this report; as assurance that requirement actions are complete and fulfil the CQC requirement notices, with the exception of the highlighted outstanding actions. Governance table Paper sponsored by: Julie Shepherd, Director of Nursing, AHP s and Quality. Paper authored by: Caroline Marshall, Interim Senior Manager Date submitted: 19 th September 2017 State which Board Committee or other forum within the Trust s governance structure, if Quality Forum and Quality & Governance Committee have received similar reports although, last one up to 31 st July. any, have previously considered the report/this issue and the date of the relevant meeting(s): State whether this is a one off report or, if An update will be provided to the next Trust Board. not, when an update report will be provided for the purposes of corporate Agenda planning If considered elsewhere, state the level of n/a assurance gained by the Board Committee or other forum i.e. assured/ partially assured / not assured: DIGB Q strategic alignment*: Develop x Innovate Grow Build Quality X Organisational Risk Register Considerations: 2384 Regulatory non-compliance with CQC/Ofsted jeopardises the Trust s ability to deliver its strategy,2385 The Trust is unable to maintain the right workforce capability and capacity to deliver its strategic plan, 2386 The Trust fails to safeguard children and adults appropriately, 2387 The Trust fails to identify and act on poor practice, 3195 Health based place of safety fails to meet regulatory requirements for safety and privacy and dignity, 3196, Failure to demonstrate systems and processes that deliver safe practices in community health services, 3351 Medication Management failure to ensure safe care and treatment FOMI considerations: N/A Equality considerations: N/A

4 Extract of CQC Action plan showing Requirement actions in progress with completion dates up until 31 st August 2017 Appendix 1 ID (Risk ) 3370 /748 CQC Report Title Quality CQC Regulations Regulation 18 HSCA (RA) Regulations 2014 Staffing Regulated Activity(ies) Assessment or medical treatment for persons detained under MHA 1983, Treatment of disease, disorder and injury Description of risk REQUIREMENT NOTICE The trust did not ensure staff received the training, supervision and appraisals necessary for them to carry out their roles and responsibilities. Synopsis Managers will ensure that staff mandatory training, supervision and appraisal is completed in line with trust policies by:- Records will be kept of all mandatory training, supervision and appraisals to demonstrate compliance, which will be reported as part of the quality and performance data (regulation 17 actions above). Reports will be generated (until the new system is rolled out) and sent to all managers outlining their team compliance with mandatory training. The Trust supervision template will be reviewed to ensure it includes a section on mandatory training and appraisal any updates will be communicated across the organisation via the established routes. Communications to all staff in relation to their role and responsibility in ensuring that an appraisal and supervision is undertaken will be developed and communicated. The supervision policy on a page will be re-circulated, so that this can be clearly displayed within the team environment. Supervision training provision will be reviewed. ESR training to be provided where appropriate. Action CQC Compliance In progress Records are kept of all mandatory training, supervision and appraisals. Compliance levels are reported as part of the quality and performance data. Managers are receiving reports outlining their team compliance with mandatory training. The Trust supervision template has been reviewed to ensure it includes a section on mandatory training and appraisal. The recording of supervision on the OLM system has been communicated across the trust and support is being provided to embed this. Communications to all staff in relation to their role and responsibility in ensuring that an appraisal and supervision is undertaken has occurred through MK2K and e-bulletin and via myesr updates. The supervision policy on a page has been re-circulated. Supervision training provision has been reviewed and is being updated. ESR training is being provided where appropriate and guidance has been produced and circulated.

5 Appendix 2 Healthcare, HMP Whitemoor Extract of CQC/HMIP Inspection Action plan for actions due for completion by 31 st August 2017 CQC Regulations Regulated Activity(ies) Description of risk Response / Action Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 REQUIREMENT NOTICE The Trust did not ensure that care and treatment was being provided in a safe way for service users. Night medication needs reviewing for times administered In progress Assessment or medical treatment for persons detained under the Mental Health Act 1983, Nursing Care, Treatment of disease, disorder, or injury, Diagnostic and screening and Surgical procedures. Dossette boxes are now in place for D wing prisoners. Review of medication is on-going with an evident reduction in numbers receiving night medication. The rest of the prison is also currently under review with the pharmacist and GP working together to reduce numbers. This remains an on-going project, but there has been a reduction of night time medication throughout the prison.

6 Appendix 3 CQC HSCA Compliance Citygate Gallowgate Newcastle upon Tyne NE1 4PA Telephone: Fax: Our reference: INS Angela Hillery Nominated Individual Northamptonshire Healthcare NHS Foundation Trust St Mary s Hospital 77 London Road Kettering Northamptonshire NN15 7PW Care Quality Commission Health and Social Care Act August 2017 Northamptonshire Healthcare NHS Foundation Trust Registered location: Rainsbrook Secure Training Centre Location ID: RP1Y6 Regulated activities: Treatment of disease, disorder, or injury, Diagnostic and screening procedures. Dear Ms Hillery, Joint inspection of Rainsbrook STC in week commencing 19 June The final inspection report on the joint inspection of Rainsbrook STC during the week commencing 19 June 2017 has now been published. We are therefore able to formally issue requirement notices, which set out the areas for improvement and the action the trust must take to improve. You were notified of these notices in our letter of 7 July Any further recommendations for improvement are included in the joint inspection report. Under Regulation 10(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, you must send us a written report of the action you are going to take to achieve compliance with the Health and Social Care Act 2008, associated regulations and any other legislation we have identified you are in breach of within 14 days of the date of this letter. Rainsbrook STC Outcome of Inspection Letter 1

7 If you have any questions about this letter, you can contact our National Customer Service Centre using the details below. Please include our reference number INS in any communication in relation to this letter as it may cause a delay if you do not: Telephone: health-and-justice-inspection-team@cqc.org.uk Write to: CQC Health & justice Inspections Citygate Gallowgate Newcastle upon Tyne NE1 4PA Yours sincerely Jan Fooks-Bale Health and Justice Manager Rainsbrook STC Outcome of Inspection Letter 2

8 Requirement Notices Provider: Northamptonshire Healthcare NHS Foundation Trust Location: Rainsbrook Secure Training Centre. Location ID: RP1Y6 Regulated activities: Treatment of disease, disorder, or injury, Diagnostic and screening procedures. Action we have told the provider to take The table below shows the regulations that were not being met. The provider must send CQC a report that says what action it is going to take to meet these regulations. Regulation 18 Staffing How the regulation was not being met: (2) (a) Persons employed by the service provider in the provision of a regulated activity must receive such appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform. At the time of the inspection staff were not in receipt of regular formal clinical supervision and appraisals, and cited feeling unsupported and deskilled. Mandatory training had not been completed by all staff and some did not have up to date fire safety, infection control and safeguarding training. Rainsbrook STC Outcome of Inspection Letter 3

9 Report on actions you plan to take to meet CQC fundamental standards Please see the covering letter for the date by which you must send your report to us and where to send it. Failure to send a report may lead to enforcement action. Account number Our reference RP1Y6 INS Regulated Regulation activity(ies) Assessment or medical treatment for persons detained under the Mental Health Act 1983, Nursing Care, Treatment of disease, disorder, or injury, Diagnostic and screening and Surgical procedures. Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations How the regulation was not being met: At the time of the inspection staff were not in receipt of regular formal clinical supervision and appraisals, and cited feeling unsupported and deskilled. Mandatory training had not been completed by all staff and some did not have up to date fire safety, infection control and safeguarding training. Please describe clearly the action you are going to take to meet the regulation and what you intend to achieve

10 All staff have received an appraisal in the last 12 months, many of these are due to be appraised again in September and all staff have a date of when this will take place booked with their line manager. A process to ensure that clinical supervision is occurring in line with NHFT policy has been implemented and all staff have been communicated with to ensure they are aware of who their clinical supervisor is and dates for supervision have been arranged. A clinical supervision structure is in place and has been shared with all staff and displayed on the notice board in the staff room. The Band 8a Brenda Wilson will ensure through her supervision with the healthcare manager Molly Saitch that all staff are compliant with the supervision policy. All staff are using ESR to record their supervision and appraisal sessions and to complete on line training. Mandatory training sessions for Safeguarding have been arranged for all staff who require it, fire prevention and infection control is online training via the ESR, all staff not in date will have completed this training by the 31st August. Individual training plans are being developed to encompass training outside of mandatory requirements in order to ensure competency for role delivery. The Healthcare Manager is reviewing appraisal, supervision and mandatory training through regular reports and dashboards and is identifying any staff out of date with these requirements. These staff are being contacted immediately and told to complete either on line or face to face training as soon as possible. To prevent staff feeling de-skilled and unsupported the Healthcare Manager and Head of Healthcare are identifying the training requirements to maintain skills used within the role of a nurse working within a community model and will be ensuring staff are utilising this training. Through supervision and team meetings, the Healthcare Manager and Head of Healthcare will ensure staff feel more supported. Who is responsible for the action? Molly Saitch, Healthcare Manager How are you going to ensure that the improvements have been made and are sustainable? What measures are going to put in place to check this? The healthcare manager is reviewing, through reports and dashboards, the percentage of staff and the status of their appraisals, supervision and mandatory training. Staff who are not compliant with the appraisal, supervision or mandatory training requirements will be are communicated with and told to arrange for these to be completed immediately. ESR will be used to continually monitor this. Supervision, appraisal and mandatory training compliance will be a standing item for discussion on the team meeting agenda. All mandatory training will be checked on the ESR system before supervision and appraisal sessions and will be a standing item at these discussions. NHFT have appointed an additional Band 7 Occupational Therapist who will be working across Rye Hill and Rainsbrook STC, part of this role will be to appraise and supervise the mental health team in Rainsbrook STC. Who is responsible? Brenda Wilson, Head of Healthcare

11 What resources (if any) are needed to implement the change(s) and are these resources available? None external to NHFT. Date actions will be completed: 31 st August 2017 How will people who use the service(s) be affected by you not meeting this regulation until this date? There are minimal risks to service users as all staff have had an appraisal, supervision is in place and a training plan to identify outstanding gaps in mandatory training has been developed. Completed by: (please print name(s) in full) Position(s): Brenda Wilson Molly Saitch Head of Healthcare Healthcare Manager Date: 17/08/17