13 October 2022 – Mental Health Network webinar

14 October 2022

This week, we were joined by Ian Trenholm, Chief Executive, CQC. He spoke of the concerning recent Panorama episode and noted it begs the question of the degree to which visiting inspection-based methodology can get to the bottom of dreadful behaviour from small numbers of people.

Ian spoke of not wanting to tar everyone with the same brush. He noted the CQC is looking at the detail of how they operate, including lessons learned from autism services and ensuring consistency. He also spoke of reviewing their position on cameras and undercover activity, which the CQC have the power to put in place but which they have never done, as there is usually a better method of inspection. Many have strong opinions regarding undercover operators and cameras. Ian also spoke of liaising with the department about sentencing guidelines and spoke of an example whereby many staff were arrested however only a few were charged and with low level offences.

A participant introduced themselves as senior management in the CQC and spoke of their background as a mental health nurse.

Someone highlighted the importance of human factors, including understanding human behaviours and how this relates to culture.

"There is a disconnect between skills in a trust and how they are activated. I spent years trying to change the cultural approach at Mersey Care so that people feel able to speak out safely and with support."

"There is danger in thinking ‘it won’t happen here’."

Someone else spoke of working alongside a mental health provider and doing supportive visits with the trust, during which the true picture of the trust is not always seen. They mentioned doing a triangulation of data and agreed this is a cultural issue.

"In the Panorama episode, the culture was not hidden. How can ICBs test the culture and methodology to ensure people speak out? ICSs are not the enemy and working alongside them will allow for shared learning, opportunities and partnership working."

"The importance of culture can’t be overestimated."

A participant spoke of an instance where the necessary processes were in place, however a safeguarding issue only became apparent because someone spoke up.

"The model of service and the knowledge that services that are congregated and/or segregated are a breeding ground for bad behaviours. We ought to challenge the model of service apparent in the Panorama episode - we know that services that are geographically isolated don’t work well."

Regarding the human factors point, Ian noted the new single assessment framework will allow the CQC to alter current key lines of enquiry into quality statements.

"We must look to build relationships with academic partners regarding capturing the right questions to codify culture. A new, more flexible technology programme will also mean questions can be rotated, allowing for more dynamism in methodology, although there is a need to balance this with consistency. I am slightly concerned with overthinking and people worrying about processes as opposed to the outcome."

"There is a need for rebalanced thinking and training to ensure front line workers have the tools required for difficult conversations with managers."

"We need efficient merge and acquisition processes and the disadvantages of closed recruitment process. With regards to the model of care point, the CQC can require that new services are not in isolated locations, however for existing services, they can only close them down."

My experience in the acute sector, there are benefits in rotating staff. However, this is not always ideal, logistically. The hierarchical nature in health, including training, can make it difficult for learners to not assimilate attitudes that may prevail. There are new ways of actively listening to staff to enable them to speak up, whereby clinical leaders put themselves into challenging situations where staff can relay concerns."

Ian suggested holding an event to allow for further, more structured discussion regarding the topics raised at this meeting. The CQC would be happy to convene this. Details will be confirmed.

Many welcomed more substantial time on how to address this.

Some participants felt CQC levers are more apparent in the well led component. They feel the programme was reproducing what has previously been seen in LD environments and noted the reporter’s observation that senior management was never present.

"What are the processes in place, for example for student nurse debriefs at the end of a placement?"

"We might thing of using a mystery shopper approach for a minor issue and the possibility of using this again around waiting lists. I feels trusts could do more on this, however thought needs to be given as to how."

"It's about conducting investigations and getting an early indication as to whether something is good or problematic."

"I feel trusts struggle to do rigor with compassion – some help on what this looks like would be appreciated. An illness model is applied and people are trained in this, whereas the predominate model in mental health is a relational care model."

Somone spoke of a lack of psychological support for those working with struggling, potentially violent patients, resulting in a hostile environment where the absence of management is profoundly felt.

"I want to emphasise the importance of the true voice of service users and feeding this back to the board."

Ian spoke of spending time in staff focus groups to understand what is happening ‘on the ground’. He mentioned the balance between competence and compassion.

"We need to recognise the impact of CQC action on an entire trust and workforce when there is heavy criticism and understand how this impacts on service users... Balance appropriate system regulation with appropriate regulation of the people in the system."

"Trusts should however not be relying on the regulator to find out things. I feel this is fundamentally about leadership, as leaders drive culture, along with investment and how staff are selected to work in inpatient services."

Some highlighted the importance of selecting and supporting the right leaders.

"When it comes to patient safety, everyone is a leader and it is important to promote this."

The group briefly discussed the impact of CQC reports, as a provider of last resort support and issued a plea that the context and an understanding of this is incorporated into reports.

To conclude, Ian noted the system point and implicit context. He is excited about the ability to play out the contextual point in a more structured way, and left the meeting saying: "Leadership post covid is very different and there is a need to think about first line leadership being able to intervene with individuals. Selecting and training people for these roles has to take into account the flexible workforce."

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