Quality Account
2010 / 2011
QUALITY ACCOUNT
TABLE OF CONTENTS:
Statement by Director of Mental Health Services
Introducing North East Lincolnshire Mental Health Services
Care Quality Commission
Visits by the Commission to inpatient units
Registration
Performance, data quality and assurance
Data quality
Crisis resolution services
7 day follow up
Home treatment
Acute inpatient user survey
Early intervention
Suicide
Quality across the service
Clean and safe environments
Assessing and managing risk
Learning from significant and untoward incidents
Training to support a quality service
Quality inpatient environments
Service users and carers contribute to quality services
Clinical research
Conclusions on 09 .10
Priorities for 2010 / 2011
Renewing accreditation for the adults inpatient unit by the Royal College of
Psychiatrists
Review services for the Black and ethnic minorities
Improve information for patients on medication
Make greater use of audits to learn form patient experience
Increase the use of outcome measures to gauge clinical improvement
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Introduction
Statement of Quality from the Director of Mental Health Services
I am proud to present the first quality account for the trust which illustrates the
importance of Quality within the organisation, and how we improve in the
coming year.
From 1st April 2010 it is a legal requirement to produce a „Quality Account‟ to focus on the
quality of services and treatment we provide. The NHS Next Stage Review; High Quality
Care for All (2008) provides the framework for including the content of a quality service.
Patient Safety – that the NHS does no harm to patients , the environment is safe
and clean and any avoidable harm is reduced.
Clinical Effectiveness – understanding if the treatment provided is effective and
leads to incurring mental health.
Patient Experience – do the patients who receive our services feel they were
treated with dignity and respect and that we invited them to tell us of their
experience so that we can improve services
Service users in North East Lincolnshire have clear views on what they expect from a
quality service which is:
Control over their own care
Real choice in meeting their individual and person needs
Services which are accessible, responsive and where necessary, intervene early.
There are some significant challenges in meeting the very individual and personal needs
of patients, for all patients, for all of the time. This Quality Account concentrates less on
figures, data and tables but rather gives an overall picture and sets the scene of the broad
work that contributes to quality across the Directorate that impact on the experience of
patients.
Staff across the Directorate through their hard work, commitment and the positive values
which underpin our work, believe that by working in partnership with patients, that recovery
is a real prospect with a positive message of moving towards to a life lived with purpose
and meaning.
Kevin Bond
Director of Mental Health
The Eleanor Centre
21 Eleanor Street
Grimsby
DN32 9EA
Email: Kevin.bond@nelctp.nhs.uk
Tel: 01472 625832
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Introducing North East Lincolnshire Mental Health Services
North East Lincolnshire includes the towns of Grimsby, Cleethorpes and Immingham and
immediate surrounding countryside with a total population of 165,000 people. The Mental
Health Service, which is the only service in North East Lincolnshire is one of the smallest
in the country, but with that has some significant advantages:
The Social Care and Health Staff are integrated into the one service – there are no
demarcation problems between the council and the health service.
The NEL Council and the Primary Health Care Trust cover exactly the same
geographical area, therefore joint work and collaboration is significantly greater than
other areas.
The local profile of the senior team in the mental health service means they are
more visible to patients and to local people and their representatives – because
they are based in Grimsby and respond to local needs and concerns.
The Council and the health community have recognised the importance of mental health
services to the wellbeing of everyone, and they have supported both politically and
financially the modernisation of local services, to include:
A purpose built inpatient unit for older people .
A purpose built inpatient unit for working adults (Harrison House)
A new building for open access to psychological therapies (Open Minds)
Alongside this, there are many features to our services which lead regional practice in the
delivery of services:
Our impatient services do not use seclusion rooms to manage challenging
behaviour.
Our Community Mental Health Teams are physically based in Primary Care Centres
to develop and enhance joint working with GPs
Our open access service for employment and training for vulnerable people
including those with mental health needs (Tukes) won a National Award in 2008
presented in London by the Secretary of State for Health.
Access to psychological therapies is the only direct public access service in the
region, with a town centre location.
We do not use standard NHS control and restraint techniques which can induce
pain and injury. We promote and sell across the country a different training with
greater emphasis on de-escalation and non-confrontation.
We try to get the service right each and every time we deliver services to patients. This
quality account gives some further information on how we are starting to deliver quality –
and keep those in our care safe.
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Transport
Services,
triage
and
medical advice provided remotely
Care Quality Commission
Our current registration status is
“registered without conditions” for health
care services however, we await final
notification of registration status on 1 st
October 2010.
The Care Quality Commission visited all
inpatient areas in 2009/10 and several
areas of good practice were noted
including the high standards of cleaning
and catering. Several deficiencies were
noticed in inpatient paperwork which has
been corrected. Nothing was noted that
was a concern to the safety of patients
In the coming year we will be working
towards registration of the Social Care
services were successfully for the
following registered activities:
During 2009/2010, the Care Quality
Commission has not taken enforcement
against us as provider of Mental Health
Services of the Care Trust Plus, implying
the systems, processes and outcomes we
have in place do recognise patient safety
and quality. This has been supported by
internal auditing and scrutiny in April 2010
by an independent body that stated
„significant assurance‟ was provided and
that the controls in place are sufficient
and consistently applied so as to
minimise risks to patients .
Treatment of disease, disorder or
injury
Diagnostic and Screening
Transport Services, triage and
medical advice provided remotely
.Performance
Assurance
,
data
quality
and
Accurate and timely data is paramount in
meeting the needs of our service users.
It enables delivery of effective, relevant
and timely health care, minimising clinical
risk and it gives confidence that the data
we monitor our service against is correct
Care Quality Commission Registration
On the 1st April 2010, our health services
were successfully registered with the
Care Quality Commission (CQC) under
the new regulatory framework for the
following registered activities:
The trust makes data submissions to the
Government Information Centre quarterly.
which contain case record level data
about the care of adults and older people
using secondary mental health services.
Accommodation for persons who
require treatment for substance
misuse
The data submissions are designed to
provide local clinicians and managers
with better quality information for clinical
audit, service planning and management.
At a local level it also monitors the
performance of individual teams and
healthcare professionals the outcomes of
care for patients, and at a national level,
to monitor the delivery of national service
framework priorities, facilitating feedback
to trusts and the setting of benchmarks.
Treatment of disease, disorder or
injury
Assessment of medical treatment for
persons detained under the Mental
Health Act
Diagnostic and Screening
In 2008/09 the trust had 98.95% data
completeness of the Minimum Dataset
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which includes the patient‟s NHS number,
Marital Status, GP Practice and
Postcode.
Reports were devised to
highlight missing fields within the trust‟s
Patient Administration System and we
expect the results for the same fields in
the 2009/10 assessment to be above
99.625%. Results have not yet been
published on the CQC website.
to the 7 day deadline. This has led to
improvements in the quality and
timeliness of the service which helps
guard against suicide risk.
The number of service users receiving
treatment and support in their own home
has also increased in line with the ethos
of the service which delivers care and
treatment in a familiar environment away
from the traditional hospital setting.
There were 363 home treatment episodes
in 2009/10 compared with 268 in
2008/09.
In 2009/10 our commitment to improving
performance was reflected in a number of
key measures used by the Care Quality
Commission (CQC) to monitor national
priorities.
The national priorities
assessment looks at performance against
priorities set during the Department of
Health's 2008-2011 planning round.
These include goals for the whole of the
NHS, such as reducing health inequalities
and improving the health of the
population.
Listening to and acting upon service
users‟ feedback has enabled the Trust to
realise excellent results in the 2009
service user inpatient survey carried out
by the Care Quality Commission where
North East Lincolnshire performed in the
top 20% across all mental health trusts
nationally for the majority of questions.
The survey of acute adult inpatient mental
health services involved all NHS trusts
providing
mental
health
inpatient
services. People were eligible for the
survey if they were aged 16-65, had
stayed on an acute ward or a psychiatric
intensive care unit (PICU) for at least 48
hours between 1 July 2008 and 31
December 2008 and were not current
inpatients at the time of the survey.
In 2009/10 performance improved on
Access to Crisis Resolution Services.
This measure examines whether our
crisis service functions properly as a
gateway to inpatient care and facilitates
early discharge of service users.
In
2008/09 89.96% of service users were
assessed by the crisis service prior to
inpatient admission.
This improved
significantly in 2009/10 to 95.6% after the
directorate re-examined local practice
particularly in relation to service users
admitted under the Mental Health Act.
Evidence from research indicates that the
earlier the identification of psychosis and
the commencement of treatments, the
better the long term outcomes for the
patient. Our team works with people from
14-35 years old whose behaviour or
presentation suggest that further
assessment of their needs is warranted.
Many will not require services but for
those who do, they are actively managed
to retain education, employment and
family relationships whist receiving
treatment. We significantly exceed our
regional target for new cases .
There is firm evidence that there are
higher than average risks associated with
patients who have been discharged from
an inpatient unit then other service users
.The national standard is that they are all
followed up with either a telephone or
face to face contact within 7 days of
discharge from inpatient care. Our
performance improved from 95.3% of
discharges followed up in 2008/09 to
99.4% in 2009/10. This is largely owing
to a weekly report which enables staff to
highlight any service users who have
been discharged and not yet visited prior
All inpatient areas are designed to
minimise the risk of suicide, for example
the use of ligature points. The curtain
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rails, the windows and all other potential
risk points are designed with the
minimisation of risks in mind. There
have been no suicides in our units for
more than the last decade.
team from the Care Trust Plus regularly
audit clinical practice. We use the
nationally recognised Infection Control
Nursing Audit as the tool to audit our
infection control standards in our inpatient
units, where the evidence supports that
we are fully compliant with the standards.
The Public Health Directorate completed
in September 2009 an audit of all suicides
as defined by the coroner in 2008. Of the
14 suicides, 10 were known to Primary
Care only and 4 were known to the
Mental Health Service. Each of these 4
were then subject to further intense and
specific review to determine whether
clinical and organisational practice should
be altered to take account of the findings.
Some of the findings include:
In 2009/10 there was no cases of
hospital acquired Methiallin Resistant
Staphylococcus Aureus (MRSA),
bacteraemia, nor Clostridium Difficle (C
Diff) on our inpatient units – except for
one case of the former which was present
on a patient transferred to us from
another hospital. The infection was
contained and it did not infect anyone
else.
Greater attention to be paid on
past history
Assessing and Managing Risk
Keeping people safe requires an
understanding of risk in the context of
their mental health and this Directorate
uses DICES as an evidence based
assessment and risk management
process .It is a methodological and
effective way of assessing and managing
risk which uses a series of checklists to
identify the key factors in judging each
type of risk.
The risk management tool DICES
was not always being used
appropriately.
The required changes to practice have
been made
Quality Across the Service
Providing a clean and safe environment is
very important to our patients, their carers
and to ourselves as service providers.
Brief DICES is carried out by the clinician
in the first instance if there are specific
concerns regarding violence, self-harm,
self-neglect, substance misuse, or
vulnerability to exploitation. Once a risk is
identified the clinician must develop a risk
management plan and share that plan
with other people in the care team.
In 2005, we changed our cleaning
contractors from a national company to
Tukes, who are an employment and
training enterprise for people with mental
health needs and part of the Mental
Health Directorate. The cleaning staff are
properly paid on national terms and
conditions, and the dimension they add is
their commitment because they have
used the service themselves, and hence
create an environment that they want for
themselves. The result has been a
significant increase in the quality of
cleanliness maintained continuously to a
high standard.
D-describe the risk
I- identify your options
C- Choose your preferred option
E-Explain your choice
S-Share with relevant colleagues.
Training in this approach takes place over
a 3 day period and clinicians have annual
updates, one face to face, one online and
one a review of five cases with the
supervisor.
Preventing the spread of infection is a key
priority to us and the infection control
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Eating Disorders
Deltoid Site Training (to give
injections)
Health & Safety and Risk Awareness
Appropriate Adults Training (to act
under the Criminal Justice Act)
Supervised Community Treatment
Update
Basis Life Support
Mental Health Law AMHP Refresher
Mental Health & Learning Disability
Update
BNF Chapter 4 Drugs Used In Mental
Health
Children & Mental Health Law
Refresher
Introduction to Deprivation of Liberty
Safeguards (DOLS)
AMHP Refresher, Nearest Relative
Safeguarding Children Level 1 – CTP
Dignity in Care of Older People Mental
Health
Emergency First Aid
Infection Control Training
Difficult and Disturbing Behaviour
The risk assessment tool DICES is used
quickly to identify risk both to staff, other
patients or to themselves or injury or self
harm. An audit compiled in 2009
considered the use of DICES as a
management tool and whether there
should be changes in practice. It was
found to be used to form a risk
management plan in 96% of the time and
used in Care Plans 100%. The area for
improvement was in its implementation
and use on the inpatient areas.
Learning from Significant Untoward
Incidents
When such incidents arise, the
Directorate is committed to reflecting on
the incident and how we could respond
differently should it arise again. Some of
the key points in 09/10 have been:
Insufficient attention to relevant
historical clinical risk information to
incorporate that into care plans.
Reminder to staff that the best use of
DICES is as a risk assessment and
management tool – aid. It does not
negate the need for clinical judgement
Managers should view as routine, a
random selection of case files on a
regular basis to ensure themselves of
the quality of recording and decision
making.
We need to audit both the files and
the assessment process to confirm
that these are both properly used,
completed and acted upon.
Quality Inpatient Environment
As regards respect and dignity the
national standard is that only members of
the same sex will share a room where
they sleep, and share same sex toilets
and bathroom.
In North East Lincolnshire, we exceed
that standard. Every inpatient bedroom is
a single en-suite room. No patient has to
share facilities with another patient.
The adult inpatient unit was operational
from February 2010 and it has a number
of features to improve the quality of the
experience received by adult inpatients
Training to Support a Quality service
To support a quality service, training in
professional practice on continuing
professional support is important and in
2009/10 the training provided to staff
involved:
The units are small with 2 x 10 beds ,
for general inpatient care and 5 beds
additional care unit ( with an
additionally secure room in addition )
which will help to manage behaviour
because as research indicates the
Rapid Tranquilisation
Risk Assessment & Management (the
DICES Program)
Suicide Prevention
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larger a group , the more problematic
group behaviour
All units are single story – no prospect
of injuries or incidents on stairs or
from upstairs windows
All bedrooms in the two 10 bed units
have individual fobs to secure the
door – so patients cannot walk
uninvited into other patients bedrooms
and should it be important to a
patients it can be set for example to
only allow female staff into female
bedrooms
The emphasis is on a non clinical
atmosphere therefore carpet
throughout ( no lino ) and nothing
purchased from the standard NHS
catalogue – all individual items from
local independent shops
All patients in the two general units
have their medicine stored in medicine
cabinets in their bedrooms – so
although they do not directly access it
themselves , there is not the classic
practice of queuing for the medicine
trolley
All patients have direct access to
make hot drinks at any time – they do
not have to ask , nor are their drink
rounds at predetermined times
Service Users and Carers Contribute to
Quality
We value and acknowledge the
contribution to improving the quality of our
services that those who have used the
service can bring. The North East
Lincolnshire Service User and Carer
Independent Forum have significant
influence by:
Having 6 Service Users and
Carers as members on the Mental
Health Board (with paid expenses)
to debate, help decide and
influence the decisions to be taken
on the future on services.
All staff appointments including
Consultants and the Medical
Director have a service user or
carer on the interview panel. They
undergo the same 2 day
recruitment and selection training
as the other panel members
All junior doctor induction
programmes (twice a year) have a
presentation by Forum Members
on their experience of receiving the
service – and what they expect
from medical staff
Our training programs are
enhanced by the involvement of
users and carers who comment
their experience to the topic. This
is particularly the case in training
on challenging behaviour where
service users who have been
restrained relate their experience.
As regards the older people service ,
there are two units of 5 beds each ,
again quite unusual because of the high
running costs of small units but again , a
quality environment is best delivered to
small numbers of people ,.They are
separated into functional and organic
units to enable specialist care but a
feature throughout is that every bedroom
has a kitchenette ( which helps
assessment of daily skills ) so that with
the appropriate risk assessment they can
make their own drinks and snacks . The
kitchenette is in a small lounge area
integral to each bedroom, which has a
sofa bed which allows carers and
spouses to stay with the patient
overnight. Again medicines are kept in a
cabinet in each bedroom
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Participation in Clinical Research
In 2009/10 we began working in
partnership with Professor Stephen
Curran and his team in Wakefield, looking
into setting up a research study into the
use of Transcranial Magnetic Stimulation
(TMS) for the treatment of moderate to
severe depression (in line with NICE
guidance 242) and in cooperation with
our local mental health independent user
and carer forum.
Currently in the UK there are other forms
of treatment for depression (NICE
Guidance 90) which include sleep
hygiene, psychosocial and psychological
interventions, Pharmacological
management and finally
Electroconvulsive Therapy (ECT). There
are potential adverse events with ECT,
notably cognitive impairment also risks
associated with a general anaesthetic
and whilst it can achieve significant
results there is a growing body of
evidence that in cases of moderate and
severe depression TMS is a safe non
invasive technique, free from serious side
effects however NICE guidance 242 does
not feel that there is sufficient evidence to
allow this as a main line treatment unless
within a research field.
Working with Professor Curran and his
team, we hope to be able to commence a
large scale research study to show that
this form of treatment for depression can
be as effective as ECT but with no
negative side effects and are awaiting
Ethics agreement for us to commence.
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Conclusions on 09.10
As this is the first quality account, it
concentrates on describing the many
aspects of work which contribute to a
quality service . No one aspect defines a
quality service -- and many would say
that quality can only really be assessed
by the person who uses that service . In
the complexity that is modern mental
health services, quality has many
dimensions. It is the overall combination
of experiences for patients and their
carers which culminate in their belief that
they have received a service which they
believe to be a quality one – or in some
instances , that they have been failed
In 2010/11 we will undertake more
specific audits which involve greater
engagement with people who use our
services.
We will review our services for people
from the BME community, in
particular, access to interpreter
services and to consider what
improvement could be made to help
them access our services, and our
response to their needs.
Patients want to make informed
decisions about their care and the
choices available to them. We will
review our approach particularly to
medication to ensure they have
written confirmation about both
diagnosis and also the medication
choice available.
This quality account tells readers some of
what we believe in – that seclusion and
standard control and restraint techniques
have no place in modern quality services,
and that users and carers can teach us a
great deal if we chose to listen
We will conduct a specific audit in
which those who have used our inpatient services are invited to
comment on their experience.
The quality account for 2010.11 will
contain a little more detail and more
action plans than this current introduction
has provided as we move forward
together with service users and their
carers to ensure they have the
experience they need – and that we want
to provide
In 2010/11 we will make greater use
of outcome measures to assess
whether the care and the treatment
we have provided has made
improvement in the mental health of
our service users. We use the Health
of the Nation Outcome Scales
(HONOS), the Hamilton Depression
Scale, and the GAD7 and PHQ 9,
access the service and develop a
wider program to use a greater variety
of evidence based tools to inform our
practice.
Priorities for 2010/11
The re-accreditations of the adult
inpatient service by the Royal College of
Psychiatrists.
This is an external, independent
assessment over 3 days to consider all
areas of practice against a Royal College
framework on best practice concentrating
upon:
General Standards ie staffing
Timely and purposeful admission
Safety
Environment and facilities
Therapies and activities
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