Community of Communities Project Lead Pack 2017-2018 Developmental Members
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Artwork: ‘Seeds’, by Kate from the Brenchley Unit. Community of Communities Project Lead Pack 2017-2018 Developmental Members
Contents
Welcome to the Community of Communities 2017-2018 cycle ......................................................................... 1
Who is our Project Lead?............................................................................................................................. 1
What is the Self-Review? ............................................................................................................................. 1
The Standards ...................................................................................................................................................... 2
The Core Standards and Core Values .......................................................................................................... 2
The Core Values ........................................................................................................................................... 2
Section 1: Key tasks for the Project Lead ............................................................................................................ 4
Project Lead Preparation Checklist.............................................................................................................. 5
Section 2: Self-Review Workbook Guide ............................................................................................................. 6
Completing the self-review ......................................................................................................................... 6
Community Information Tab ....................................................................................................................... 7
Glossary and Principles ................................................................................................................................ 7
Action Plan from 2016-2017........................................................................................................................ 7
Workbook .................................................................................................................................................... 8
Importance of Evidence............................................................................................................................. 10
Frequently Asked Questions.............................................................................................................................. 11
Appendix I – Standards Glossary of Terms ........................................................................................................ 12Welcome to the Community of Communities 2017-2018 cycle
This pack has been created in order to assist you and your TC with completing your self-review
and preparing for your peer-review visit. If you have any questions about the process please
contact the Community of Communities project team.
This pack is for the use of the person within your service who will take a lead in organising the
completion of your self-review and preparing for your peer-review. This person is called a Project
Lead.
Who is our Project Lead?
Member services must nominate an individual within their service to be their CofC project lead;
this person will liaise with CofC and be the project lead within the community. The project lead
can delegate the key tasks within the organisation. Their main priority is to be the main channel
for communicating all information about their community to the CofC project team, and vice
versa, through e-mail, telephone or regularly checking the CofC website. It is recommended that
the project lead is an active member of the community who accesses their e-mails frequently and
who will be involved in completing the review process.
What is the Self-Review?
The self-review element of membership is the foundation of the quality improvement process.
The self-review process provides a framework for the whole community to holistically assess the
quality of their service, and to identify its strengths and weaknesses.
Members are asked to review their service against the Service Standards for Therapeutic
Communities (9th edition). The Service Standards contain a total of 127 Elements, broken down
into 30 Standards and 97 supporting criteria. Each standard has typically three or four criterion
statements. Criteria are not comprehensive, but are generally given as examples of good practice
to demonstrate meeting the standard.
As the basis for quality improvement, members are encouraged to think about the self-review
from the start of the cycle, ensuring as many views and opinions are included to complete all
sections. During the self-review, communities are asked to review their community against
criteria, commenting on how they meet them and giving them a score. Communities are also
required to highlight specific areas of achievement against the standards and also areas for
development. Additionally, the community will be asked to provide an update on any standards
which were highlighted as areas for improvement in the previous cycle.
1The Standards
The 9th Edition of Service Standards has been developed in conjunction with our members and on
best available evidence and expert consensus. The standards provide a tool to assess a service
as a Therapeutic Community. This process provides an opportunity for quality improvement by
identifying areas of achievement and areas for improvement against the standards.
The Service Standards contain a total of 127 Elements, broken down into 30 Standards and 97
supporting Criteria. Each Standard has typically three or four criterion statements, which define
what we would expect to see in a service that meets the overarching standard. The criteria are
not an exhaustive list, and communities are able to identify additional ways they meet the
standard during the self and peer-review process. It is important to note that each criterion is
accompanied by a number, 1, 2 or 3. These number represent the “typing” of associated with the
accreditation process. They are however, relevant to the peer-review process in that they identify
those criterion that are:
Type 1: Essential
Type 2: Expected in a good Therapeutic Community
Type 3: Recognised as best practice
To be deemed as meeting the overarching Standard, the TC must meet both Type 1 and Type 2
criterion.
The Core Standards and Core Values
Therapeutic Community practice is underpinned by a set of Core Values and specific theoretical
and philosophical position regarding treatment and care. The Core Values allow us to make sense
of the Core Standards and their primary importance for TC practice and approach. The Core
Standards operationalise the Values and have been agreed by all members to essentially define
a Therapeutic Community with the other 20 standards and sections identifying the necessary
infrastructure and operational factors to support and maintain the culture.
The Core Values
The Core Values, below, allow for a more in depth understanding of the meaning and purpose of
the Core Standards and it is important to hold them in mind when thinking about your service
and whether and how you meet the Core Standards.
Table 1:
Core Values
Healthy attachment is a developmental requirement for all human beings, and
CV 1
should be seen as a basic human right
A safe and supportive environment is required for an individual to develop, to grow,
CV 2
or to change
People need to feel respected and valued by others to be healthy. Everybody is
CV 3
unique and nobody should be defined or described by their problems alone
All behaviour has meaning and represents communication which deserves
CV 4
understanding
2Personal well-being arises from one’s ability to develop relationships which
CV 5
recognise mutual need
Understanding how you relate to others and how others relate to you leads to
CV 6
better intimate, family, social and working relationships
Ability to influence one’s environment and relationships is necessary for personal
CV 7 well-being. Being involved in decision-making is required for shared participation,
responsibility, and ownership
There is not always a right answer and it is often useful for individuals, groups and
CV 8
larger organisations to reflect rather than act immediately
Positive and negative experiences are necessary for healthy development of
CV 9
individuals, groups and the community
Each individual has responsibility to the group, and the group in turn has collective
CV 10
responsibility to all individuals in it
Table 2:
Core Standards
There is a clear Therapeutic Community model of practice that is consistently
CS1
applied across the service
CS2 Community Members are aware of the expectations of Community Membership
Community Members are encouraged to form a relationship with the Community
CS3
and with each other as a significant part of Community life
Community Members work together to review, set and maintain Community rules
CS4
and boundaries
There is a structured timetable of activities that reflects the needs of Community
CS5
Members
All behaviour and emotional expression is open to discussion within the
CS6
Community
CS7 Community Members take part in the day to day running of the community
CS8 Everything that happens in the Community is treated as a learning opportunity
Community Members share responsibility for the emotional and physical safety of
CS9
each other
CS10 Community Members are active in the personal development of each other
3Section 1: Key tasks for the Project Lead
As the project lead there are a number of tasks for you to complete throughout the cycle. These
include:
Task Commentary Completed
The Project Lead is the point of contact between the project
Disseminating
and the TC. The Project Lead needs to be available to be
information from contacted by the project team and to respond to relevant
CofC to your
requests. Examples of information that is sent to Project
community
Leads include: documentation to be completed; details
regarding peer-review visits; information about events and
learning opportunities.
The Project Lead must ensure that all members of the TC
Collating feedback
are involved or given the opportunity to be involved in the
and information to
completion of the self-review workbook. Deadlines must be
complete your self-
abided by to ensure the smooth running of a peer-review
review on time
and positive experience for all.
1. Community Information
Complete all sections 2. Action plan from the previous year
in your self-review 3. Score and comment against each criteria
Workbook including: 4. Summarise areas of achievement and areas for
development
5. Report on any progress made following your previous
review
6. Create a timetable
Submit your self- Based on the deadline set by the CofC Team, ensure the
review workbook self-review workbook is completed and submitted on time.
Submit a copy of the
At a Trust/ Organisational level and at a local level
most recent
regulatory reports
Prepare an evidence Evidence can include electronic copies of welcome booklets,
portfolio to send to supervision agendas and anonymised notes, therapeutic
the CofC team activity timetables.
CofC provides a draft report of the self-review findings
Draft report within 4 weeks of the date of your self-review submission.
consultation The lead contact should organise members of the
community to read this draft and return any comments or
questions within two weeks. The report will be finalised
after the two week consultation period.
The report will outline areas of achievement and areas for
development. These areas for development should be fed
Action planning
back to the community so that meaningful action planning
following completion takes place after the review. Communities are encouraged
of your self-review
to action plan against all criteria which are not being fully
met. The final report will contain an action planning
template which the community should complete and submit
to CofC two months after their review date.
4Project Lead Preparation Checklist
Use the below simplified checklist to complete the self-review workbook with your community to
ensure your service gets the best of out the experience of quality improvement:
Lead Contact Tasks Completed
Invite all community members to contribute to the self-review
Submit your completed self-review workbook to CofC
Provide evidence portfolio to demonstrate Core Standards to CofC
Complete an action plan with the community and submit to CofC
5Section 2: Self-Review Workbook Guide
Completing the self-review
When completing the self-review workbook you should aim to provide clear examples which
demonstrate how you meet or partly meet the criteria. Where you partly meet or don’t meet a
criterion, think about what changes you could implement to include this in your working practice.
CofC will disseminate the self-review workbooks to all project leads. The project lead should plan
meetings for completion of their self-review including all community members.
Top Tips to complete your self-review
All scores and comments recorded in the workbook should be representative of
staff and service user views
Complete the self-review with input from the whole community
Start completing the workbook as soon as you receive a copy
Identify areas of achievement and areas for development
Think of creative ways to engage all community members in the process
There are five sections within the self-review workbook:
Community Information
Glossary and Principles
Action Plan from 2016-2017
Review Checklist
Workbook
Click on each of the labelled tabs at the bottom of the screen to navigate between the different
sections.
6Community Information Tab
This tab collects important information about your community, the service user population and
staffing figures for the past 12 months. It is really important that you provide accurate data in
this section as it is collected to measure changes in the TC landscape over time.
When completing the figures for service users and staff please round averages up to whole
numbers.
Please also make sure every box is completed for consistent data collection.
Glossary and Principles
This provides you with some core definitions, terms and principles for you to refer to whilst
completing your self-review workbook with your community members.
Action Plan from 2016-2017
Action planning is a critical aspect of quality improvement. Members are expected to prepare an
action plan to develop and progress for standards which have been scored as partly met or not
met in your previous self-review and peer-review.
The action plan provides you with a space to reflect on the developments you have made over
the past 12 months. Listing the planned action gives an insight into what has worked and what
might not have worked so well.
Example 1:
Please also include any improvements and developments which have been made against
standards which have been scored as met.
7Workbook
There is a space in the self-review workbook entitled “Our Story‟ where you can provide some
contextual information. This description should cover the background and recent history of your
organisation. Ensure you use as much detail when describing your community in the ‘Our Story’
section.
The workbook tab contains five sections of standards and criteria:
Core Standards
Joining and Leaving
Staff
Therapeutic Framework
External Relations and Performance
Each section of the workbook contains a series of standards with supporting criteria statements.
This cycle there is more focus around the overarching standards when reviewing each criteria.
Example 2: This is where you can score the overall
standard. The standard should only be
marked met or not met.
This is the Standard
– you do not self-
review against this
statement directly
These are the
criterion. You need
to provide a score
and a validating
comment or an
example against all
of the criteria.
Add more information
here relating to how you
are able to meet the
standard as a whole.
Scoring the criteria and the standard
To complete the self-review, communities should think about the way they work and review this
against the criteria statements within each section. The review should result in each criterion
having a score: 2 = Met, 1 = Partly Met, 0 = Not Met, 9 = Not Applicable. Each standard
should then be scored “Met” or “Not Met”
8Validating criterion scores
Each criterion should have a validating comment, an example or description which justifies the
score you have provided. The Core Standards are informed by the TC Core Values (see page 2)
and it is always useful to go back to these when reflecting on why something is important in a
TC, why a particular Standard is important. Most commonly this information is gathered from
special community meetings where the criterion statements are discussed.
It is critical that the self-review provides accurate reflections of the community, if your community
does not meet a criterion statement then please note this down. You are able to report on other
ways you are able to meet the standard using the box directly under each set of criterion. During
the self-review you are able to continue scoring each criteria individually and whether the
overarching standard should be considered met or not met. Remember, that when scoring each
criteria you should go back to the overarching Standard which will provide context and will inform
the meaning.
You will need to judge whether each standard is met by considering whether the majority of
component criteria are met and to what degree. As a general rule of thumb, all type 1 and type
2 criterions within a standard (see page 6) should be fully met to determine if the overarching
standard should be deemed met or not met. This will then be fed into your report following
submission to the Community of Communities Project Team.
Where possible, provide brief examples to describe the extent to which you meet a criterion
You must complete every criteria statement, even if you do not feel you meet the
requirements. In this instance, score the criteria as ‘0’ and provide a validating comment.
This is not an inspection. Communities should not feel they need to meet every criterion. The
aim of the self-review is to enable reflection on current practice using the standards as a
framework.
9Importance of Evidence
The CCQI require members provide regulatory reports and outcomes to the project teams. This
includes reports at a Trust/ Organisational level and local level, e.g. Ofsted Care, Ofsted
Education, CQC. These reports should be submitted with the self-review workbook.
Evidence Triangulation
As part of the self-review process, communities are asked to collate evidence to support how they
are meeting the criteria and standards.
The quality improvement process looks for evidence in each of the categories, combining what
can be seen, what can be heard and what can be read.
The review day includes formal meetings, informal time together and a review of key documents.
When considering evidencing standard communities should think about where they might be
asked to back up a comment with documentary evidence, e.g. 1.2.1 – The therapeutic community
provides information to new staff and service users that describes the expectations of
membership. Communities should prepare a portfolio of evidence to submit with their self-review
which supports the comments against the criteria in the Core Standards section of the workbook.
Some examples of the types of evidence are: documents, photographs, videos or feedback.
Possible criterion which can be evidenced
Criterion Suggested evidence
The evidence you provide is not
1.2.1 Welcome book prescribed by CofC. However, it is
important that you consider the
1.5.2 Timetable of activities criteria which the evidence supports.
This should be clearly marked on the
3.1.1 Service user assessment forms documents to enable the peer-
review team to link the documents
3.2.1 Staff information pack with their scores and comments on
the review day.
4.2.4 Written records of groups
10Frequently Asked Questions
Q. How do I get community members involved in the self-review?
A. Members can get involved by forming working groups to look at sections of standards. We
encourage communities to be as creative as possible when gathering their evidence for self-
review; this could include making posters and taking photos to evidence the criteria.
Q. How long does it take to fill out the self-review workbook?
A. We would recommend starting the self-review workbook as soon as possible as it can take a
while to gather information together from the whole community.
Q. What happens if I don’t meet all of the standards in the workbook?
A. Don’t worry if you do not feel you meet all of the standards. CofC is a quality improvement
network and the review will support you in reflecting on the areas you do well in and those you
might find more challenging and can help to provide suggestions that could improve your
performance in the next cycle.
Q. Do we need to visit another community?
A. Yes, as part of your membership you can send three community members to attend peer-
reviews.
Q. Can I learn more about the peer-reviewer role?
A. Yes, there is information on our website about the peer-reviewer role. Additionally, we run
training sessions throughout the year to train peer-reviewers from member services. The training
is free to attend and we expect every member service to send a selection of staff to attend peer-
reviewer training.
Q. What happens to the report after it’s finalised?
A. The report is a confidential document for your community to use. It will not be published by
CofC and will only be shared with the peer-review team during the consultation period.
Q. When can I apply to upgrade to accreditation membership?
A. Communities need to be a full member of the network for a minimum of one full cycle.
Members can apply for accreditation membership and will be asked to complete an application
form which outlines the minimum requirements. Additionally, we would recommend that
members read through their last report to see which areas might require additional work to meet
the accreditation requirements. If you would like more information about accreditation
membership please download the Accreditation Handbook from the website.
11Appendix I – Standards Glossary of Terms
Age Appropriateness It is recognised that for some standards and criteria there
will be a difference in interpretation depending on age in
services for Children and Young People. This should be
discussed at reviews.
Appropriate Qualification This includes a professional qualification and/or experience
relevant to the nature of role and responsibility.
Community Member Refers to anyone within the organisation who has or should
have significant involvement in the life of the community.
This includes all staff (e.g. includes administrative staff and
cleaners etc.), service users/children and young people/
residents/clients/prisoners.
External Refers to someone not employed by the organisation.
Leadership Refers to anyone with direct authority to make
clinical/financial/strategic decisions that affect the
functioning of the community and/or service users or staff.
Minimum Annually A minimum annual timeframe is given, due to the high
numbers of turnover of members in some services, to
ensure all staff and service users are involved.
Service Refers to the specific environment being reviewed - it does
not refer to a whole organisation of which the Therapeutic
Community may be part e.g. The NHS, HMP Prisons.
Service User Is used as a term in the standards to describe all children
and young people, residents, offenders etc. The self-review
workbooks will be adapted to use the appropriate
terminology for the service.
Therapeutic Community Each service should have a clear and cohesive description of
Model of Practice why their service is a “Therapeutic Community”. The
model/approach may differ across the membership of the
Community of Communities but it is expected that there is
a definition which supports day to day practice and informs
staff training. The definition of a Therapeutic Community
provided by the Community of Communities (give reference)
is a guide.
12Project Contact Details
Sarah Paget
Programme Manager
Sarah.Paget@rcpsych.ac.uk
spaget@rcpsych.ac.uk
0203 701 2675
Josie
AnnaThorne
Cook
Deputy Programme Manager
Anna.Cook@rcpsych.ac.uk
jthorne@rcpsych.ac.uk
0203 701 2679
2674
Arun Das
Arun Das
Project Worker
Project Worker
adas@rcpsych.ac.uk
Arun. Das@rcpsych.ac.uk
0203 701
0203 701 2676
2676
Laura Simmons
Project
Katie Worker
Plummer
lsimmons@rcpsych.ac.uk
Project Worker
0203 701 2678
Katherine.Plummer@rcpsych.ac.uk
0203 701 2654
Community of Communities
Royal College
Community of Psychiatrists'
of Communities
Centre for Quality
Royal College Improvement
of Psychiatrists'
21 Prescot
Centre for Street
Quality Improvement
London
21 Prescot Street
E1 8BB
London
E1 8BB
www.communityofcommunities.org.uk
www.communityofcommunities.org.uk
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