Project Brief

As an evolution of our 'Must and Should Do' project with NSFT, we supported them to embed continuous quality improvement within the Trust by delivering a programme of self-assessment and improvement across all teams within the trust (c.140 core teams in 11 service lines). For this, we used the CQC’s newly introduced Single Assessment Framework (SAF).

Working closely in partnership with the Quality Team and Clinical Leads, Baxendale supported a 20-week programme that sought to utilise the structure of CQC’s framework to empower staff to improve care delivery and safety across the 5 key questions – Safe, Effective, Caring, Responsive and Well Led. The project involved supporting all teams to understand the framework, and candidly self-assess, before identifying and delivering quality improvements capable of driving lasting change.

The coaching approach used in the previous Must Do project highlighted the importance of collaborating with frontline staff to ensure that change is sustainable and engages the entire team. A key aspect of the work was to enable cross-learning and collaborative change across the Trust.

The Solution

Our design of the programme, and its 20-week duration, included:

• Creating a structured and collaborative approach for 140 core teams to complete their self-assessments, using the Single Assessment Framework as a key tool.

• Designing the digital self-assessment tool in collaboration with the CNIO for staff to deliver, monitor and develop their self-assessments on a continuous basis.

• Facilitating weekly coaching sessions with a broad range of teams and services to empower staff, helping them recognise their expertise and build confidence in driving service improvements.

• Delivering training and drop-in sessions that addressed how to approach a self-assessment, navigating the newly designed digital platform, and the role of quality improvement and assurance in day-to-day practice.

• Designing learning material on the Single Assessment Framework, CQC assessment, improvement planning, and how to embed quality assurance within governance processes.

• Creating a learning pack that reflects the perspectives of service users, families, and carers, ensuring improvements were informed and championed in partnership with experts-by-experience.

• Managing key aspects of the project including actions and escalations.

• Designing and delivering regular reports, including a ratings rational executive report aligned with CQC methodology, highlighting the self-assessed scores of all 140 teams.

•  Designing and implementing a quality sampling methodology, engaging with subject matter experts to ensure specialist oversight and feedback for teams • Writing various forms of communications, including weekly comms, to ensure clear direction and strong engagement across the Trust • Planning and conducting various in-person events, including a ‘closing’ event that was attended by NHSE, CQC, Experts by Experience, and NSFT Staff.

The Results

Working closely with a broad range of staff during the 20-week programme highlighted how empowering individuals to take ownership of quality can inspire real change and drive meaningful improvements. While a push for change can be complex, this initiative sparked a transformative journey of learning, growth and improvement for NSFT, enabling cross learning across the organisation.

It helped them to identify gaps, recognise where they were delivering good care, and, ultimately, demonstrated the value of using quality frameworks to drive change and make lasting improvements. Bringing together 140 core teams within NSFT, the programme encouraged collaboration and a genuine commitment to quality improvement. The process empowered teams to take ownership of improvements that, fundamentally, have the ability to make positive impact for service users, their families, and carers while also sharing learning.