Posted on: 25 February 2020


Update on CNWL's Falls QI Programme


In September 2019, CNWL launched a QI Programme on ten inpatient wards to reduce the number of falls. The ten project teams are supported by training in QI methodology from the Institute of Healthcare Improvement (IHI) and CNWL QI coaches.

On 27 January QI teams and stakeholders on the falls programme met for a workshop to share ideas and progress on their projects. The workshop was headed by Goodall Division Medical Director Dr Paul Hopper, Falls Programme Manager Peter Smith and Diggory Division QI Lead Michele Dowling. Chief Nurse Maria O’Brian, the Executive Sponsor of the falls programme was present at the workshop as well. All QI teams present had shared a diverse range of change ideas to help reduce falls on their wards. 

The Older Persons Assessment Service discussed innovative change ideas aimed at making staff instantly aware of a patient’s risk of falling in order to prevent an injury. These were:

  • Introducing an information sheet that was placed next to the Personal Emergency Evacuation Plan (PEEP) in the patient’s bedroom. Rather than stating the level of risk the sheets were colour coded to respect the patient’s privacy. 
  • Having a falls section on the hand over sheet, it detailed if the patient was at risk of falling so appropriate measures could be put in place to protect the patient. 
  • Strengthening and balancing exercise classes for patients and using colour coded frames to show which patients are more at risk at falling.

The Windsor Intermediate Care Unit (WICU) shared their progress on their QI project which was focussing on completing patients Multifactorial Risk Assessment, which outlines their risk of falling. Previously these assessments were taking a considerable amount of time to complete. Using QI practices the team were able to complete the assessment within 48 hours and surpassed their goal of 95 per cent completed in 48 hours to 100 per cent. 

A third of people over 65, and half of people over 80, fall at least once a year. Falls cost the NHS over £2bn a year and over 4 million bed days. Goodall Division Medical Director, Dr Paul Hopper has said, “The reducing falls QI programme ensures the Trust provides better care for patients and improves their safety whilst on our wards as well as addressing the impact falls have on CNWL healthcare services. Reducing falls is a quality priority for the organisation and it is good to hear from teams about the improvements they have made to date”.

CNWL staff can find more information about the work of the teams and their ideas for change on Life QI.

Falls Programme Manager, Peter Smith can be contacted for any questions regarding the programme at this address

Brent Friends and Family Survey QI Project

Brent Older Adult Community Mental Health Team has taken part in a Quality improvement project to increase the number of Friends and Family surveys completed by patients.  The team have successfully increased the number of friends and family tests received from 4 per month in August 2019 to 22 per month in October 2019. 

Gloria Achiekwelu, Clinical Lead and Project Lead said “we want the service to offer the best experience possible for our patients. In order to achieve this, Friends and Family Surveys are vital as they determine what areas need improvement, so it was important to start a QI project increasing the amount of surveys we receive”.

The team established these change ideas which were then put into place.

  • Staff were made aware of the importance of gathering regular feedback and trained on how to encourage patients to complete the survey. 
  • Patients were asked to take part in a session where they had a chance to discuss questions and ideas about the Friends and Family Surveys.   
  • A friendly competition was started to encourage members of staff to increase the amount of surveys they give out. A progress board was displayed where staff could track how many surveys they gave out. 

Sarah Johnson, Lead Clinical Psychologist said,“It was fantastic to see staff support each other to achieve the aim. Undertaking this QI Project has brought the team together.”

Gloria Achiekwelu, Clinical Lead and Project Lead said, “Anyone looking to start a QI project, should just do it. Not only has this project enabled us to reach and maintain our aim, it has also made the team stronger.  My advice is the little steps matter a lot, don’t discount them, and raise awareness of the great work you’re doing and the journey you’re going through within your service or clinic”.

CNWL staff can learn more about this project on Life QI.

If you have any questions about this QI project, Gloria Achiekwelu, Project Lead can be contacted at this address

New Milton Keynes QI Forum

Involved in a QI project or interested in QI and in the Milton Keynes Area? If it’s a yes, then our Milton Keynes QI Forum is open you. 

Our first meeting took place in September 2019 and we have dates in the diary for every month in 2020. 

At our most recent session we focused on process mapping and will follow this up with an interactive session on PDSA cycles in early March.

The MK QI Forum aims to provide an informal place where we can share learning, explore QI tools and gain confidence in using QI methods.  It is also a great way to develop your informal QI network! 

We look forward to welcoming many more in the coming months.
Please email Michele Dowling, Diggory QI lead at if you’re interested in joining.

Brent QI Forum


Brent Metal Health services have set up a Brent QI Forum which takes place every month. The forum allows Senior Leadership to track the progress and find out more about QI projects in CNWL services across the borough of Brent.

This month we have talked to Clinical Director for Brent Mental Health Services, Bill Tiplady about Brent’s QI Forum.

What is the purpose of the meeting?

The main purpose of the Brent Forum is to provide shared learning and support to QI projects by discussing their project’s aims, their driver diagrams and their change ideas. It is a chance for QI teams to receive endorsements and sponsorships from Senior Leadership for their project.
When a QI project is complete the Forum discusses whether the changes are fully embedded within the service and if the results are being maintained. It is also a place to enquire if the completed project is something which can be replicated in other services across Brent who might benefit from the project as well.

What is the benefit of a project sponsor?

Linking a QI project with a senior sponsor has helped teams receive support for their project at a senior level. Senior project sponsors can help to unblock obstacles the team might encounter and be an extra support system for the team.

What have you found useful about the meeting?

As Directors and Senior Managers we have really valued having the chance to hear more about some of the fantastic QI work going on in Brent.  Hearing about new projects helps to try and link different projects together, and hearing about successful projects as they come to an end helps us think about how learning can be spread and how the results can be sustained.

Feedback from people presenting to us has been positive too and staff have said they valued having a chance to hear direct feedback and knowing their hard work is visible to the Senior Leadership Team.

For more information on the Brent QI Forum you can contact Divisional QI Lead for Jameson, Lorianne Martin at

Meet CNWL’s New Goodall Clinical QI Lead


Congratulations to Peter Smith who will become Goodall Clinical QI Lead in March of this year. 

Peter joined CNWL as a Business Manager for Offender Care in 2006, since then he has excelled in multiple roles within the Trust including Service Redesign and Transformation, a position he held for 3 years, before moving onto the Trust’s QI team two years ago as a Program Manager for the Improvement Support Service. 

Prior to joining the Trust Peter had experience in Service management, overseeing Acute Hospitals, Rehabilitation and Radio Therapy units.

Peter is trained as a PRINCE2 Practitioner, a Lean Practitioner and as a QI Coach.
Since July 2019 Peter has been Programme Manager for the Trust wide Falls Reduction Programme. 

Peter said “I’m really excited to undertake this role at time when QI is starting to show results within the division and I’m keen to build on the successes we’ve had so far”.

Congratulations to Harrow Child and Adolescent Mental Health Service


Big congratulations to the team at Harrow Child and Adolescent Mental Health Service who undertook a QI project and now  seeing 100 per cent of patients within 18 weeks from referral to treatment.