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Meeting the requirements of our external regulatorsDuring 2015, we received an independent external assessment of the quality of our services under theCQC’s comprehensive inspection national programme. SEPT’s services were rated GOOD overall andGOOD for being effective, caring, responsive and well-led - a tremendous achievement. However, we werenot complacent and the inspection reports indicated areas where we could improve further.Since then, we have driven forward all the actions required to address the CQC’s findings and undertook adetailed assessment of our progress in September 2016. As a result, the Board agreed that all actions withthe exception of one had been implemented successfully. It was felt that whilst it was evident that action hadbeen taken to improve access to psychology provision, further work was required. A thorough review of ourservice has been carried out and recommendations are being implemented. Further details are included insection 2.4.5 of this report. Our programme of internal inspections has continued to ensure that we havefocused consistently and firmly on maintaining high standards in our services and making furtherimprovements going forward.Until the end of quarter 2 of 2016/17, we were fully compliant with the “Monitor” targets set by our externalregulator. From 1 October 2016, NHS Improvement (which replaced Monitor as our external regulator from 1April 2016) introduced new stretching targets for NHS organisations and the Trust has struggled to achievesome of these. Most are within our gift to achieve and I am determined that we will improve our position in2017/18.Looking to the futureThere is always opportunity for improvement. This is an exciting time for the Trust with the launch of our newEssex Partnership University NHS Foundation Trust from 1 April 2017. A significant amount of work wasundertaken with NEP throughout 2016/17 to prepare for this merger and to ensure that the quality of servicesis maintained and continues to go from strength to strength. Section 2.2 of this report sets out the qualitypriorities we have agreed for the new organisation, based on the specific priorities within each of thepredecessor organisations.This merger brings significant opportunities to design and deliver new models of service. There will be noimmediate changes to services. It will be “business as usual” for service users and carers for the foreseeablefuture. Clinicians from both Trusts are working together with commissioners and people with lived experienceto develop a proposed new clinical model for Essex-wide mental health services. Any changes to currentservices proposed by this model are likely to be subject to formal consultation.Funding challenges may mean sometimes standards of service delivery have to be redefined to beaffordable. Our continuous focus on the quality of service provision, regardless of the complexity of theexternal environment, means that we, our commissioners and regulators can be confident about the qualityof our existing service provision.To support our development work, the Quality Academy established in SEPT will continue to act as a catalystto improve quality across the organisation. We will do this by providing an opportunity to capture and sustainthe commitment and enthusiasm of staff, supporting them and enabling them to drive forward changes whichmake a difference to the care we provide.Our staff are our greatest assetOur staff take pride in everything they do and provide consistently professional and high quality services.They work very hard to provide the highest quality care for our patients and I am immensely proud of them.Without each and every one of them, SEPT would not have been able to deliver the excellent services weand our patients expect.We have a Staff Recognition Scheme and each month staff were nominated for In Tune Awards for theirexcellent customer service. On 1 February 2017 we held our annual SEPT Star Awards where more than 40staff were recognised for their innovations and achievements with 26 proud winners taking home a trophy.Additionally, more than 400 staff were recognised for their excellent service throughout the year at ourmonthly Board Meetings.Page 5 of 77

After reading this Quality Report, I hope you will understand how seriously we all take quality and how hardwe work to ensure that we continue to deliver services in a caring, dignified and respectful way. We believethat our patients, service users, carers, staff, volunteers and other stakeholders are the best people to tell uswhat constitutes the highest quality of service. We will continue to strive to meet their expectations andprovide the highest standards of care by listening carefully to them and taking action promptly wherenecessary.Statement of AccuracyI confirm that to the best of my knowledge, the information in this document is accurate.Sally MorrisSEPT Chief Executive 2016/17Chief Executive of the Interim Board of Directors, EPUT from 1 April 2017Page 6 of 77

PART 2OUR QUALITY PRIORITIES FOR IMPROVEMENT DURING 2017/18 ANDSTATEMENTS OF ASSURANCE FROM THE BOARD FOR 2016/17Progress against the quality priorities for improvement for 2016/17, as set out in SEPT’s 2015/16Quality Report, is set out in Part 3 of this document.What services did SEPT provide in 2016/17?During 2016-2017, SEPT provided hospital and community-based mental health and learning disabilityservices across South Essex as well as a small number of specialist mental health and learning disabilitysecure services in Bedfordshire and Luton. SEPT also provided community health services in Bedfordshire,South East Essex and West Essex.How have we prepared this Quality Report?This Quality Report has been prepared in accordance with the national legislation / guidance relating to thepreparation of Quality Reports and Quality Accounts in the NHS. From 1st April 2017, SEPT merged withNorth Essex Partnership University NHS Foundation Trust (NEP) to form Essex Partnership University NHSFoundation Trust (EPUT) and from this date responsibility for the finalisation of this Quality Reporttransferred to EPUT. The legislation / national guidance on Quality Reports and Accounts specifiesmandatory information that must be reported within the Report and local information that the Trust canchoose to include; as well as the process that Trusts must follow in terms of seeking comments from partnerorganisations (Clinical Commissioning Groups, Healthwatch organisations and Local Authority HealthOverview and Scrutiny Committees) and the Council of Governors on their draft Quality Report andindependent assurance from an external auditor.This Quality Report has been collated from various sources and contains all the mandated information that isrequired nationally, as well as a significant amount of additional local information. It has been set out in threesections in accordance with the national legislation / guidance. The report was considered in draft form bythe EPUT Quality Committee and the Board of Directors. The draft report was also sent to ClinicalCommissioning Groups, Healthwatch organisations and Local Authority Health Overview and ScrutinyCommittees in draft form and they were given 30 days in which to consider the draft and provide comment / astatement for publication in the final Quality Report. Clinical Commissioning Groups are required to provide astatement whereas the other partners are given the opportunity to provide a statement for inclusion shouldthey wish to do so. The resulting statements are included at Annex A of this Quality Report {to be inserted infinal version prior to publication}. The draft report was also sent to Local Authority Health and WellbeingBoards for consideration and comment should they wish. The Lead Governor for SEPT also provided astatement, on behalf of the SEPT Council of Governors, which is included in Annexe A.The report was sent in draft form to the Trust’s external auditors in April 2017, in order to provideindependent external assurance in accordance with national guidance. This process has been completedand the external auditor’s report is included at Annexe C of this Quality Report. {To be inserted in finalversion prior to publication}.The EPUT Board of Directors approved the final version of this Quality Report 2016/17 and their statement ofresponsibilities in this respect is included at Annexe B of this report. {To be inserted in final version prior topublication}.2.1 Key actions to maintain and / or improve the quality of services delivered in 2017/18How have we developed our priorities for the coming year?As part of the preparation for the merger, SEPT and NEP established a joint planning process that led to thedevelopment of aligned strategic priorities and action to be taken to achieve these. Two joint stakeholderplanning events for EPUT were held in December 2016. Those in attendance included commissioners,representatives from statutory and voluntary partners, staff, governors and service users and carers.Page 7 of 77

EPUT’s vision commencing on 1st April 2017 is “working to improve lives”. The priorities for quality for ournew organisation have been produced with input from the Board, the Trust’s Leadership Team, healtheconomy partners and the Council of Governors. In addition, a number of economy wide discussions havebeen held with partners at Board and Executive level on the delivery of the Five Year Forward View andsystem wide Sustainability and Transformational Plans (STPs).A safe transition from two organisations to one is clearly the key priority. A detailed “Post-TransactionImplementation Plan” (PTIP) was developed and scrutinised by NHS Improvement and by external auditors.A Quality Merger Workstream was put in place during 2016/17 and sub-workstreams established to overseethe review and harmonisation of systems, processes and policies associated with the management of qualityin EPUT. Clear plans were put in place to establish harmonised processes required on day 1 of the neworganisation (ie those most critical processes, for example adverse and serious incident reporting; complaintshandling etc) and to understand those processes that could run in parallel until full harmonisation has takenplace in a managed and safe way during the first 12 months post transaction.In support of the above, harmonised written policies / procedures were developed for the critical processesfor implementation on Day 1; and a prioritised plan is in place to harmonise remaining policies over thecoming 12 month period.EPUTs approach to quality will be firmly aligned to the quality governance framework principles.The Interim Board, put in place in November 2016 to prepare for the merger, identified that achieving thehighest quality standards would be one of the key benefits of merger. EPUT’s ambitions in respect of qualityare to achieve a “good” CQC rating in the first comprehensive inspection post-merger; to achieve maximumautonomy in NHS Improvement segmentation ratings and to achieve top quartile ranking in the nationaltransparency index.Delivering quality services is one of the new Trust’s four key strategic priorities, demonstrating that quality willdrive the trust’s strategy. The following overarching quality priorities have been identified as a result of theplanning process put in place to develop the 2017/18 annual plans and articulate the key actions that willdeliver EPUT’s strategic vision for quality. These quality priorities have been identified as corporateobjectives to ensure that they are integral to the delivery of the Trust’s strategic and operational plans andare as follows:Implementation of a new mental health clinical model: the implementation of a new clinical model will be oneof the key drivers and contributors to the strategic vision of the Trust in 2017/18. We aim to develop theproposed model and consult with stakeholders on it, with a view to implementation starting in 2018/19.Page 8 of 77

Continued reduction in harm: both NEP and SEPT have taken action under the “Sign up to Safety” campaignto reduce harm. EPUT will align systems and processes and continue to reduce harm in the following areas: Pressure ulcers Avoidable falls Unexpected deaths Medication omission Physical health of mental health patients and early warning systems for deteriorating patients Restrictive practiceRecord Keeping and Care Planning: both trusts experience on-going challenges associated with ensuringthat high quality care records are maintained and that care plans are complete and personalised. Action willbe taken to agree revised standards for record keeping and personalised care planning based on bestpractice and putting in place trust-wide training and practice development programmes to support excellence.Mortality Review Processes: The CQC published the outcome of a comprehensive review of mortality reviewprocesses in December 2016. Both organisations have taken action in 2016 to establish local mortalityreview processes in response to the Southern Health report findings but these require review in light of CQCfindings and recommendations (and the National Guidance on Learning from Deaths subsequently publishedby the National Quality Board in March 2017) and embedding in organisational systems and culture goingforward.Using Technology: utilisation of new electronic systems and tools and maximising the use of those in placealready will be required as part of changing culture and creating efficiencies required to deliver the agreedfinancial plan.Standardisation and reducing variation: there are some excellent examples of leading practice and highquality services in both predecessor Trusts but neither could demonstrate consistently high standards acrosstheir entire portfolio. The new Trust will utilise the obvious internal opportunity to strengthen the use ofbenchmarking to identify clinical variation within mental health services provided in north and south Essexand action will be taken to agree a standardised approach to recording outcomes and the metrics in place tomonitor them.Creating a culture of quality improvement will be a high priority for EPUT. The Trust will develop and roll out aunique systematic approach to quality, building on the Quality Academy that was in place in SEPT and theStar Quality initiative in NEP. The EPUT approach to quality will support delivery of the agreed qualitystrategy; providing staff with the tools and training to support improvement activities and recognising andrewarding quality improvement as it takes place and makes a real difference to patient care.The organisational development plan put in place to support merger identifies strong clinical leadership asintegral to the trusts’ aims. Within the workforce plan, a commitment has been made to develop a talentmanagement programme to grow effective clinical leaders and managers within the organisation to supportsustainable improvement.2.2 Quality priorities for 2017/18In setting the specific Quality Report / Account priorities for 2017/18, the EPUT Interim Board of Directorsconsidered the strategic context, their knowledge of the predecessor Trusts and feedback from staff andstakeholders during the planning cycle. The Interim Board of Directors believe that the quality prioritiesoutlined below will continue to deliver the improvements most often identified by our stakeholders and willlead to improved health outcomes for our patients and service users.It is EPUTs intention to be ambitious with quality improvement and to set stretching targets. However, as anew organisation, it is the intention to undertake benchmarking and assessment of current position acrossthe entirety of the new organisation in quarter 1 before setting appropriately ambitious and measurableimprovement targets to be achieved through the remainder of the year. The priorities outlined below aretherefore articulated to reflect this approach.Page 9 of 77

PRIORITY 1 - PATIENT SAFETY – Continued reduction in harmNEP and SEPT have taken action under the “Sign up to Safety” campaign to reduce harm. EPUT will alignsystems and processes and continue to reduce harm.Target: To continue to reduce harm across the organisation in the following key areas: Pressure ulcers Avoidable falls Unexpected deaths Medication omissions Physical health of mental health patients and early warning systems for deteriorating patients Restrictive practiceTo achieve this, the Trust will deliver the following actions during 2017/18:1) Pressure ulcers, avoidable falls, medication omissions and restrictive practice During Q1, the Trust will establish a baseline for the new organisation for each of the above areasand standardise processes and reporting where differences exist.At the end of Q1 when the baseline across EPUT has been established, the Trust will establishappropriate reduction targets for the remainder of the year.The Trust will monitor performance in each of the above categories during Q2 – Q4 and will haveachieved an appropriate reduction against the new organisational baseline established in Q1 for:o The number of avoidable grade 3 and 4 pressure ulcers acquired in our careo The number of avoidable falls that result in moderate or severe harmo The number of omitted doses within serviceso The number of prone restraintsThe Trust will achieve above 95% harm free care from the “Safety Thermometer” every monththroughout the year.2) Unexpected deaths During Q1 the Trust will review the different suicide prevention training packages in place across theTrust and establish the organisational baseline for staff having completed suicide prevention training.At the end of Q1, the Trust will agree the training approach going forward and appropriate trajectoriesfor completion of agreed suicide prevention training across the Trust.The Trust will monitor training completion during Q2 – Q4 and will have achieved the agreedcompletion rate by the end of Q4.3) Physical health of mental health patients and early warning systems for deteriorating patients During Q1 the Trust will review the physical health monitoring tools in place across the Trust,standardise and deliver training on the agreed tool. During Q2, the Trust will undertake an audit of physical health and early warning systems fordeteriorating patients and agree appropriate outcome measures to achieve by the end of Q4. At the end of Q4, the Trust will review performance against the agreed outcome measures. The Trust will consistently achieve the following targets in terms of patients with psychosis receiving a

Part 2 secondly reports the required statements of assurance from SEPT as well as performance against nationally mandated indicators for 2016/17. Section 2.4. sets out the mandated statements of assurance from the Board appertaining to SEPT for 2016/17 . 13 . Section 2.5 . reports SEPT's performance against the national mandated quality .