09b CQC Registration application by 7SN062C3


									                                                                        Agenda Item 9b


Report to:
                                Trust Board (in public)

Meeting Date:
                                27th January 2010

Lead :
                                Lisa Llewelyn, Head of the Centre for Service Excellence

Contact Point:
                                Lisa Llewelyn, Head of the Centre for Service Excellence

CQC Registration Application 2010

New CQC Registration system

From 1 April 2010, all NHS trusts (including primary care trusts as providers) that provide
regulated activities must be registered with the Care Quality Commission.

Each trust must make its application for registration from 4 January to 29 January 2010.

The Trust Board is asked to

    1. Note the contents of the NHS Confederation document attached, which has been
       produced as guidance for providers how the standards for better health link to the
       new registration regulations, updated December 2009.
    2. Note the contents of the up-dated action plan relating to CQC registration
    3. Note progress of plans being put in place to complete the registration process by the
       end of January 2010.
    4. Discuss and agree the content of this application and declaration of compliance for
       registration as a healthcare provider with the Care Quality Commission (Health and
       Social Care Act 2008 and associated regulations) .


        All staff working within Suffolk Mental Health Partnership NHS Trust.
        Service User and family carers
        Partner Organisations
        NHS Suffolk
        NHS East of England

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WHAT ARE THE STRATEGIC ISSUES TO CONSIDER(including contribution toward
TTBT, and Principal Objectives)?

Achieving compliance with the Essential standards of quality and safety is the minimum
standard required. The CQC Registration Process contributes to the achievement of the
Trust’s strategic objectives and achieving top ten status.

Our vision – what success will look like?

         To be one of the 10 best mental health Trusts in the UK

         Our business priorities – how we will thrive in the market

         Priority 1: to maintain our current customer base and income by giving quality to
         service users and value to customers
         Priority 2: to develop new services for existing customers
         Priority 3: to develop new customers
         Priority 4: to make public benefit contributions back to the communities we serve

         Our key strategies for the next 3-5 years – what we will do to deliver success

         1.   Continuously modernise all our services
         2.   Improve the measured quality of services year on year
         3.   Build & maintain strong financial and business management
         4.   Make the Trust a great place for great people to work
         5.   Give public benefit back to the communities we serve

WHAT ARE THE LEGAL ISSUES (including diversity and equality, employment law,
health and safety, and other statutory obligations)?

The Trust has a responsibility to provide services in line with key legislation, including;

        Health and Safety at Work Act 1974 & 2008
        The Corporate Manslaughter and Corporate Homicide Act 2007
        The Human Rights Act 2000
        Mental Health Act 1983 & 2007
        Health and Social Care Act 2008
        Care Quality Commission ( Registration) Regulations 2009


The outcome from the assessment of compliance against Registration should inform the
business planning process, with regards to priority investment.

Standards for Better Health are minimum standards required and although they have been
replaced by registration, the principles which underpin them will be important building blocks
towards achieving CQC Registration in April 2010.

The new registration system for health and adult social care will make sure that people can
expect services to meet essential standards of quality and safety that respect their dignity
and protect their rights. The new system is focused on outcomes rather than systems and
processes, and places the views and experiences of people who use services at its centre.

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Having an effective quality strategy and performance framework in place mitigates risk and
reduces harm to both staff and patients. Failure to provide effective quality and risk
management places the organisation at the risk of potential:

    1.       Financial risks through litigation
    2.       Loss of reputation
    3.       Loss of business
    4.       Risk of harm to staff and patients


Registration will underpin a locally led, patient centred and clinically driven NHS as set out in
the NHS Next Stage Review. Being registered demonstrates to our service users and the
Trust’s local community how our services, meet essential standards of quality and safety;
respect their dignity and protect their rights


        4th-29th January 2010- NHS Trusts to evidence as part of application for
        February-March 2010- CQC may wish to talk to trusts about their application and
         may ask them to supply more evidence to support their application.
        1st April 2010 The results of the NHS trust applications for registration will be made


Registration will have implications for policy development and implementation in SMHP.


Formal comments are not required for the application for Registration.


1. Health and Social Care Act 2008
2. Taking it on Trust (2009). A review of how boards of NHS trusts and foundation
   trusts get their assurance (Audit Commission 2009).
3. Criteria for assessing core standards in 2009/10-Mental Health and Learning Disability
   trusts (Care Quality Commission July 2009).
4. Health and Social Care Act 2008 Code of Practice for the Prevention and Control of
   HealthcareAssociated Infections
5. Registering with us: key phases of the new system (Care Quality Commission 2009).
6. SMHP final assessment of Standards for Better Health November 2009.
7. SMHP Workbooks for Team based self–assessment November 2009.
8. CQC Assessment Reports 2008/09 for C1b, C4d, C11b, C24.

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CQC Registration Application 2010

This report details what SMHPT needs to complete and submit electronically to the
Care Quality Commission (CQC)in order to apply for Registration from April 2010.


Applicant:                                  Mark Halladay
Service provider details                    Suffolk Mental Health Partnership NHS Trust
                                            St Clements Hospital
                                            Foxhall Road
                                            Suffolk IP3 8LS
Tel                                         01473 329603
Fax                                         01473 329019

Nominated Lead:                                           Robert Bolas
                                                          Mark Halladay
Invoice and financial contact                             Nick Gerrard



Suffolk Mental Health Partnership NHS Trust (SMHP) provides:

        Mental Health Services for adults and older people living in the county of
         Suffolk (the NHS Suffolk area) and the Thetford part of Norfolk.

        Mental Health Services for children and adolescents in the county of Suffolk
         (the NHS Suffolk area)

        Services for people with learning disabilities for the same population plus
         people living in the Waveney part of north Suffolk (the NHS Great Yarmouth
         and Waveney area).

        Substance Misuse Services (SMS) across Suffolk.

        Suffolk Support Services (SSS), a range of business support, financial,
         information management, estates and facilities services to the Suffolk and
         Great Yarmouth health economies.

Suffolk Mental Health Partnership Trust’s Strategic Direction is about

   Offering the best possible assessment of and help for any of the mental illnesses,
    developmental difficulties and behavioural challenges that can interfere with the
    direction of people’s lives.
   Giving people a clear understanding of the condition(s) that have caused their
    difficulties and what can be done to control and counter the effects.
   Being person-centred and recovery-focused in enabling people to live their lives
    to the full and be a part of their communities.

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   Encouraging an awareness of the importance of mental health and well-being in
    the communities and populations that we serve.
   Supporting staff and carers in their ability to help people in mental distress.
   Contributing to the quality of life in the community we serve and to public trust
    and confidence in the NHS.

Our mission or vision – consists of

Helping people make the most of their lives

Our values – what inspires us

We believe in:
   Valuing user and carer experience and expertise
   “Recovery”
   Professionalism
   Supporting and developing staff
   Providing early and effective services
   Working in valued partnership with colleague agencies

Regulated activity

Regulations set out the activities that trigger the need for the Trust to register. The
regulated activities are described in the Health and Social Care Act 2008 (Regulated
Activities) Regulations 2009. If any of these activities are carried out, the providers of
those activities must register with the Care Quality Commission.

Regulated activity, as defined by the CQC is carried on at the following locations:

                  Lothingland, Oulton, Lowestoft
                  Stourmead, Kedington, Haverhill
                  Walker Close, Ipswich
                  St Clements Hospital, Ipswich
                  Wedgwood House, Bury St Edmunds
                  Minsmere House, Heath Road, Ipswich


It is a legal requirement for the nominated lead to be able to produce the following items
of evidence to the CQC on request

                  Enhanced CRB check undertaken in the last year.
                  Evidence of proof of identity
                  Documentary evidence of relevant qualifications
                  A full employment history.

Completed CRBs were completed in December 2009 and responses are awaited.

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The application asks the following

How does the Trust ensure the views and experiences of people who use
services are listened to and acted upon when running the services?

How have the views        Service development is subject to consultation with users, carers and
and experiences of        communities. We liaise with groups such as Suffolk User Forum and PALS
people who use            regarding all aspects of modernisation and they have direct input into the
services, their carers    design of new facilities. User representation has been organised through core
and representatives       groups that look at the design and delivery of services. In specialist services
influenced your           we use IMPACT and Investors in Children to support engagement; a service
service priorities and    user as a co-opted Board member.
                          A multi-stakeholder initiative is developing CAMHS strategy and service
                          specifications with active involvement of users and carers. This has led to the
                          creation of a new service for looked-after young people.

                          Participation has covered planning of

                                Treatment Programmes
                                Security
                                Healthy Living
                                Services for Women
                                PICU
                                Equality and Diversity
                                Psychological Therapies
                                Physiotherapy/Gym/Complementary Therapies
                                Acute Care Pathways
                                S136 Policy Development
                                Dementia Assessment Treatment pathway
                                Triage/Crisis/Home Treatment Pathway
                                Administration

                          and continuing Service User and Carer involvement.

                          The core groups will continue work on the project during the build and
                          commissioning phases to ensure a seamless transition across from the
                          current to the new facilities.

                          New services such as IAPT are a response to local and national user surveys
                          and feedback on the accessibility of psychological therapies; this service links
                          directly with Job centre plus and a range of voluntary and community
                          organisations to meet individual service user needs

                          We facilitate involvement in business planning and strategic thinking
                          throughout the organisation by providing access, time, training and liaison.
                          The service user and carer forums provide a structured environment for
                          eliciting feedback and involvement. These consider feedback from the service
                          user survey and plan actions accordingly.

                          We collaborate with third sector organisations Joint advisory groups and
                          partnership forums with a special interest in mental health where people’s
                          feedback helps us re-design provision and care pathways.

                          Community meetings, independently chaired, and access to advocacy provide
                          additional routes for participation in planning and prioritisation.

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                          Many service areas have recently completed Equality Impact Assessments to
                          help us identify areas for improvement

How have their views      All aspects of service delivery reflect the influence of user views and
and experiences           experience. There are community meetings or user and carer forums for all
influenced how you        clinical services, supported by opportunities for 1:1 dialogue and advocacy.
deliver the services      These processes generate feedback on every aspect of our services from
(across the range of      layout, decoration and furnishings to nutrition and information.
regulated activities
applying to register?)    In LD, Users and carers have played a central role in changing how services
                          are delivered. Through Forums, the complaints process, and individual
                          representations – supported by independent advocacy – the service is
                          undergoing comprehensive change that we see the closure of hospital-based
                          care in 2010 and the transfer of residents to their own preference for

                          Examples of change resultant from user feedback include

                               contracts with suppliers re-negotiated to provide a wider range of meals
                                and greater flexibility in the availability of food.
                               Better facilities for female in-patients
                               A wider range of activities for people
                               improved furnishings
                               Better access to benefits advice
                               use of Independent living Funds
                               Invitations to users to participate in the provision of staff training
                               Developing a duty system within CMHTs to respond more appropriately
                                to service users and carers and offer immediate advice and input where
                               Reviewing individual and collective practice as a result of complaints and
                                compliments received
                               Collaboration in care planning and information giving using the Recovery
                                Model of Care and refocusing of CPA
                               CMHTs supporting user choice in housing through the choice based
                                lettings system
                               Furnishings and waiting room equipment renewed in CAMHS clinics
                               Walker Close hosting a dedicated citizen advocacy service for residents
                               Substance Misuse Services adopting a ‘Praise and Grumble’ scheme for
                                session-based feedback
                               CAMHS adopting a ‘Choice and Partnership’ approach
                               CORC feedback that enables Clinical supervisors are able to discuss
                                with staff how clients perceive individual therapists

                          Currently, the ‘Productive Ward’ Programme is designed to increase
                          significantly the time nurses spend in face to face contact with patients. Users
                          and staff are exploring together how to re-design layouts, improve
                          communications and information and use staff time more effectively.

What is the provider      People will continue to be fully involved in the planning commissioning and
doing to increase the     delivery of new facilities under the trust’s modernisation programme for the
influence people          Minsmere and St.Clement’s locations with full participation in the
have on planning or       modernisation programme Core groups In LD users and carers will continue
delivery of the           to participate fully in the commissioning of new accommodation and services,
services?                 and the development of new care pathways, initially through the Community
                          Estates Strategy, the DAAT partnership and CAMHS modernisation

                          SMS and CAMHS will develop a more comprehensive user network, based
                          around specific service lines. They will support the continuing reviews of
                          service specifications and strategy

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                          The Trust will consolidate the availability of independent chairs for community
                          groups and user participation in service visits to improve the mechanisms for
                          ensuring that patterns of concern are identified and responded to. The ‘praise
                          and grumble’ process will be extended across all services and there will be a
                          review of advocacy services and provision. Support will be offered to
                          encourage wider user participation in the Trust’s service user and carer forum

                          Patient-reported outcome measures begin to offer the opportunity to provide
                          measurable feedback on the quality of treatment. Teams will enhance the use
                          of CORC and TOPS outcome measures, exploring individual clinical practice
                          and benchmarking against other services. The Trust intends to extend
                          PROMs to all clinical areas in 2010-11.

                          Implementing the Dementia care strategy will involve systematic engagement
                          of users and carers in the re-design of care pathways.

                          The Older People’s Clinical Governance Forum will and Joint advisory Groups
                          will monitor all aspects of service delivery and performance to support teams
                          in learning from user views and experience.

                          Re-design of the Psychosis care pathway will actively engage service users
                          and carers

                          Users will be involved in evaluating the new ‘Gateway’ care pathway for
                          accessing specialist mental health services

                          Every clinical area will complete Equality Impact Assessment action plans;
                          enabling us to identify and respond constructively to marginalised
                          communities and to improve our sensitivity to cultural diversity


The application asks the following

How does the Trust ensure people's equality, diversity and human rights are actively
promoted in your services?

How do you ensure         We recognise that the need to access mental health services can be
that the promotion of     stigmatising. The plan to relocate many in-patient services contiguous with
equality, diversity       acute hospital services is designed to minimise stigma. Through WHALE, the
and human rights          community consultation project, we seek to raise awareness and better inform
influence your            our service planning agenda
service priorities and
plans?                    Through person centred planning users and carers are involved in all aspects
                          of service re-development, including the planning of care in a way that
                          respects gender and cultural differences, and makes provision for the needs of
                          different faiths and beliefs to be met. All new proposals are subject to Equality
                          Impact assessments and must thereby demonstrate how they promote the
                          EDHR agenda.

                          EIAs are undertaken for all service development, project planning, staff
                          training, individual clinical assessment and formulation of clinical intervention

                          The Board receives regular reports from the Equality and Diversity Manager.
                          The patient survey also provides information helpful to planning.

                          The Trust has adopted a common core agenda for all business and
                          governance meetings to help ensure that EDHR agenda is central to
                          discussion at team level.

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                          We use our website to share information and plans and seek feedback from all
                          communities across Suffolk.

                          St Clements also has access to the Trust’s EDHR reference group

How does the              EDHR has influenced both the information we seek about people, and the
promotion of              information we offer about services and treatments. The collection of
equality, diversity       demographic data and clinical assessment have both been modified to reflect
and human rights          EDHR concerns.
influence how you
deliver services          The introduction of a refocused CPA reflects FREDA principles; it is subject to
across the range of       systematic review and feedback from service users
regulated activities
you are applying to       Users and staff are able to identify and report any discrimination, abuse or
register?                 prejudicial behaviour. This is supported by a comprehensive policy framework
                          with a Single Equality Scheme covering equal opportunities, diversity, dignity
                          and respect, zero tolerance, bullying and complaints.

                          Our membership of Stonewall includes external and independent inspection of
                          our sensitivity to LGBT issues.

                          EIA action plans identify key issues and appropriate service responses, eg the
                          need for provision of hearing loops to aid communication.

                          Staff Induction and mandatory training courses for all staff facilitate a common,
                          basic, understanding of Equality, Diversity and the FREDA principles.

                          Design and delivery of CPA and risk assessment is built around EDHR. Our
                          offender patients are identified as vulnerable so we routinely invite legal
                          representatives to attend CPA, and that reports are drafted with explicit
                          reference to Winterwerp criteria

                          Information on Human Rights and anti-stigma posters are available to users
                          and carers and in all premises. We discuss ECHR issues regularly with
                          individual patients. We can evidence the discharge of patients related directly
                          to Convention compliant decisions

                          CMHTs support people’s access to general healthcare, encouraging GP
                          registration and access to health screening, dentistry etc.

                          Our “Centre for Forensic Studies” certificate and diploma programme has a
                          Human Rights component module, and a Women and Gender module. This
                          builds upon the in house training and induction in human rights and

What are you doing        We are re-evaluating the Terms of Reference of all Governance groups to
to increase the           ensure that membership and agenda setting recognises and responds to the
influence of equality,    EDHR agenda
diversity and human
rights issues on the      EDHR related training will focus on practice issues across teams; ; we will
planning and              explore how to broaden the cultural range of trainers
delivery of the
services?                 We will participate in inter-faith initiatives to ensure that spiritual needs of
                          people are understood and met. We will enhance our engagement with SIFRE
                          to inform our service modernisation processes.

                          We will support engagement within BME and LGBT groups through continued
                          liaison with Suffolk LINk. We will offer practical support to LINk and to Suffolk
                          Users Group to increase the diversity of their membership.

                          We will embed EDHR principles into all health and social care assessments
                          and care planning.

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                          We will complete Equality Impact assessments for all clinical and non-clinical
                          service areas, and develop and monitor action planning for issues that arise.

                          We shall complete Equality Impact Statements for all Trust policies and
                          strategies, ensuring that they are reviewed and revised where necessary. All
                          future policy initiatives will be subject to an EIA as part of the design and
                          implementation process.

                          We will work with partners to identify and respond to community and public
                          health issues related to mental health care, in particular considering equity of
                          access and the cultural responsiveness of our services. We shall use ethnicity
                          data to review access issues and explore ways in which PROMS can help us
                          ensure equity of access to all.

                          We shall further consider how governance tools such as clinical audit and
                          supervision can support the embedding of EDHR principles

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Regulated activities

Regulations set out the regulated activities that trigger the need to register. The
regulated activities are described in the Health and Social Care Act 2008 (Regulated
Activities) Regulations 2009. If any of these activities are carried out, the providers of
those activities must register with the Care Quality Commission.

The table below identifies the three regulated activities carrying on at the 6 locations
identified by the Trust in its pre - application process

Applicant:                                                        Daren Clark                         Sandra Cowie

                                                                                                        St Clements





Personal care
Accommodation for persons who                      √                 √            √        √            √             √
require nursing or personal care
Accommodation for persons who
require treatment for substance misuse
Accommodation and nursing in further
education sector
Treatment of disease, disorder or injury           √                 √            √        √            √             √
Assessment of medical treatment for                √                 √            √        √            √             √
persons detained under the MHAct
Surgical procedures
Diagnostic and screening procedures
Management of supply of blood and
blood derived products etc
Transport services, triage and medical
advice provided remotely
Maternity and midwifery services
Termination of pregnancies
Services in slimming clinics
Nursing care
Family planning services

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Service type

This section sets out the range of service type listings available and replicates the
service types in the guidance about compliance. See the Guidance about Compliance
for the full list.

The chart below identifies the types of service that best describes the service we provide
in each location. This should reflect those identified in the statement of purpose.

                                                                                                  St Clements





Acute services
Prison Healthcare Services                                                    √
Hospital services for people with                  √              √           √        √          √             √
mental health, learning difficulties and
problems with substance misuse
Hospice services
Rehabilitation services                                                                           √
Log term conditions services
Residential substance misuse                                                  √
treatment and/or rehab services
Hyperbaric chamber
Community healthcare services
Community based service for people                                                                √             √
with a mental health need
Community based service for people                 √              √           √
with a learning disability
Community based service for people                                            √
who misuse substances
Urgent care services

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Service user band

A service user band describe the needs of the people who use our service. For example we
offer a service for people with mental health needs, dementia, older people, children (under
the age of 18 years old) or people with learning or physical disability? These needs should
be the same as those listed in our statement of purpose.

                                                                                                  St Clements





Learning disabilities or autistic                  √              √           √
Older people                                       √              √           √        √          √             √
Younger adults                                     √                          √                   √             √
Children 0 – 3 years                               √                          √                                 √
Children 4 – 12 years                              √                          √                                 √
Children 13 -18 years                              √                          √                   √             √
Mental health                                                                          √          √             √
Physical disability
Sensory impairment
Dementia                                                                               √          √
People detained under the MHAct                    √              √           √        √          √             √
People who misuse drug and alcohol                                            √
People with an eating disorder                                                                    √
Whole population
None of the above

Regulated activity and compliance

The guidance about compliance for providers illustrates how each of the regulations may
be reliably met. Providers may decide on alternative approaches but should be prepared
to justify and evidence to the Care Quality Commission how the chosen approach is
equally or more effective in ensuring the regulations are met.

The Trust is asked to declare whether we are fully compliant or non compliant with the
Registration Regulations relevant to the regulated activities the Trust provides.

A Trust who will be compliant with the registration regulations will meet the outcomes for
people who use services as set out in the guidance about compliance. Evidence to
support the declaration must be available on request.

 A Trust who is non-compliant has not met elements of the registration regulations as
described by the outcome statements in the guidance about compliance.

A declaration of compliance must be completed for each location in which regulated
activities are carried out.

 For each regulation where non compliance is identified the Trust needs to state
- Why we are non compliant
- The action to be taken to become compliant

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- When will we become compliant?
- How will we sustain a level of compliance?

At the mid year declaration, submitted to the CQC in December 2007, SMHP declared
itself non-compliant with the following standards

        C1b Patient safety alerts
         Healthcare organisations protect patients through systems that ensure that
         patient safety notices, alerts and other communications concerning patient
         safety which require action areacted upon within required time-scales.

        C4d Medicines management
         Healthcare organisations keep patients, staff and visitors safe by having
         systems to ensure that medicines are handled safely and securely

        C5d Clinical audit
         Healthcare organisations ensure that clinicians participate in regular clinical
         audits and review of clinical services.

        C20b safe, secure environment
         Healthcare services are provided in environments which promote effective
         care and optimise health outcomes by being supportive of patient privacy and

        C21 clean, well designed environments
         Healthcare services are provided in environments which promote effective
         care and optimise health outcomes by being well designed and well
         maintained with cleanliness levels in clinical and non-clinical areas that meet
         with national specification for clean NHS premises.

    Proposed declaration of compliance

    A CQC Registration action plan is now in place to ensure that improvements in
    practice are implemented and processes are improved to ensure the Trust will
    achieve compliance with Section 20 of the Health and Social Care Act 2008.

    At the time of applying for registration, there is insufficient assurance that SMHPT
    is fully compliant with the all the necessary Regulations. The table below
    proposes that

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                                                                                                    St Clements





Regulation 9: Care and welfare of                    √              √           √        √          √             √
service users
Regulation 10: Assessing and                         X              X           X        X          X             X
monitoring quality of service provision
Regulation 11: Safeguarding service                  √              √           √        √          √             √
users from abuse
Regulation 12: Cleanliness and infection             √              √           √        √          √             √
Regulation 13: Management of                         X              X           X        X          X             X
Regulation 14: Meeting nutritional needs             √              √           √        √          √             √
Regulation 15: Safety and suitability of             X              X           X        X          X             √
Regulation 16: Safety, availability and              √              √           √        √          √             √
suitability of equipment
Regulation 17: Respecting and involving              √              √           √        √          √             √
service users
Regulation 18: Consent to care and                   √              √           √        √          √             √
Regulation 19: Complaints                            √              √           √        √          √             √
Regulation 20: Records                               √              √           √        √          √             √
Regulation 21: Requirements relating to              √              √           √        √          √             √
Regulation 22: Staffing                              √              √           √        √          √             √
Regulation 23: Supporting workers                    √              √           √        √          √             √
Regulation 24: Cooperating with                      √              √           √        √          √             √
√        Compliant with regulation
X        Not compliant with regulation

In conclusion:

        SMHPT is non complaint across all locations with
             Regulation 10: Assessing and monitoring quality of service provision
             Regulation 13: Management of medicines

        SMHPT is non compliant across all locations EXCEPT Wedgwood House on
             Regulation 15: Safety and suitability of premises

        SMHPT is compliant with all other regulations across the 6 locations

Lisa Llewelyn.
Head of the Centre for Service Excellence
January 2010

C:\Docstoc\Working\pdf\652ff29a-5c78-4e81-8c7f-a2810269a62e.doc                                                   15

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