The CQUIN payment framework is a national framework for agreeing local quality improvement schemes, making a proportion of our total potential income from CCGs conditional on the achievement of ambitious quality improvement goals, and innovations agreed between commissioner and provider with active clinical engagement. The CQUIN framework is intended to reward genuine ambition and stretch trusts, encouraging a culture of continuous quality improvement.

CQUINS are currently suspended for 2020/21 in line with national guidance. The table below details the Trust’s level of achievement in 2019/20.



Level of Achievement 

Actions / Mitigation 

2: Staff Flu Vaccinations 

Achieving an 80% uptake of flu vaccinations by frontline clinical staff. 

Fully achieved 


3: Alcohol and Tobacco  

In a given quarter, 80% of eligible inpatients are screened for both smoking and alcohol use. 








Partially achieved 

  • Posters with flowcharts of the assessment and intervention procedure were developed and distributed to all ward areas. 

3b: Alcohol and Tobacco – Tobacco brief advice 

In a given quarter, 90% of eligible inpatients identified as smokers are given brief advice. 

  • Staff were provided with further training on the use of Nicotine Replacement Therapy. 

3c: Alcohol and Tobacco – Alcohol brief advice 

In a given quarter, 90% of eligible inpatients identified as drinking above safe levels are given brief advice or offered a specialist referral. 

  • The Dual Diagnosis lead continues to work with wards to encourage the effective use of assessment tools and to offer suitable interventions. 

4: 72 Hour Follow-Up Post Discharge 

Over the applicable time period, 80% of adult mental health inpatients receive a follow up within 72 hours of discharge from CCG commissioned services. 

Fully achieved 


5a: Mental Health Data Quality – MHSDS Data Quality Maturity Index Score 

Over the applicable time period, achieve a Data Quality Maturity Index Score of 95%. 

Fully achieved 


5b: Mental Health Data Quality – Intervention Coding 

Over the applicable time period, 70% of eligible patients with two attended contacts have at least one intervention procedure code recorded. 

Fully achieved 


6: Use of Anxiety Disorder Specific Measures in IAPT 

Over the applicable time period, 65% of eligible patients have paired scores recorded on the specific Anxiety Disorder Specific Measure. 

Fully achieved 


N.B. Due to the COVID-19 pandemic, an assessment of performance was made based on available data at the time of Quarter 4 reporting in accordance with national guidelines. 

Clinical Audit

Clinical audit is a quality improvement process that seeks to improve patient care and outcomes via:

  • The critical examination of patient care in order to identify the gap between best practice and actual practice.
  • The introduction of change to reduce this gap.
  • Subsequent re-audit to determine if the intended improvements have occurred and whether further change is necessary.

The Trust’s Clinical Audit Programme is developed on a yearly basis, reflecting national and local priorities. The current programme can be downloaded below. Please note that this is a dynamic and responsive programme and as such is subject to change.