Project Brief

In Summer 2023, we worked with Norfolk and Suffolk NHS Foundation Trust to develop and support the effective implementation of a comprehensive quality improvement plan, addressing the ‘Must’ and ‘Should Do’ actions identified in their most recent CQC inspection published in February 2023. The CQC report outlined 30 critical actions (Must Dos) and 23 recommended actions (Should Dos) for the Trust to address. These actions were identified at Trust level, as well as across multiple service lines including Adult Community, Crisis Teams, Inpatient Services, Older People's services and CAMHS.

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.

In response to the actions, NSFT formed a committee called the Evidence Assurance Group (EAG), a forum chaired by the Medical Director of the Integrated Care Board (ICB) and attended by other system partners to ensure transparency and objective scrutiny. The forum provided a platform for services and teams to present evidence and improvements to demonstrate that they had addressed and sustained progress against their Must and Should Dos.

The Solution

Baxendale worked closely with NSFT to establish a structure, timeline and documentation for presenting evidence at the EAG meetings. By implementing a structured project management framework, we ensured deadlines could be achieved and that communication channels and escalation routes to the Executive team were clear. The scale and operational complexity of NSFT provided a challenge with the need to work with approximately 50 individual teams, across a variety of services and roles within the organisation. Our coaching approach was delivered through a series of regular check-ins where we facilitated teams in delivering and developing solutions to the Must and Should Dos - building understanding and commitment to the process.

Working collaboratively with clinical leaders, we supported them to collate comprehensive pieces of evidence to provide the required assurance, including data insights, service user experiences, and staff evidence. Alongside this, we supported the Quality Team to ensure evidence met the quality standards set by the EAG. With over 250 individual templates to present, Baxendale managed the overall programme, ensuring clear communication with key stakeholders, and identifying potential risks along the way and escalating them when required. 

The Results

The final EAG meeting took place in July 2024, during which evidence for the remaining Must and Should Dos were presented. While this marked the conclusion of the EAG meetings, it also represented a significant collaborative effort across the entire organisation. The project contributed to a cultural shift within many teams and services by fostering collaboration within each of the services and accountability at team level. In all, the key goal was to help develop and present improvements that were embedded and that would be sustainable in the longer term. NSFT are now in a stronger place for future CQC inspections, and Baxendale continues to work with NSFT to drive further improvements to quality and safety, and ensure teams are well-prepared for future CQC assessment.