Quality account
2009/2010
Safety
Service user experience
Effectiveness
1
Contents Part 1
1.1
Statement on quality from the Chief Executive
6
1.2
Statement
8
1.3
Quality highlights and challenges in 2009/2010
9
1.3.1
Effectiveness
1.3.1(i)
1.3.1 (ii)
1.3.1 (iii)
1.3.1 (iv)
1.3.1 (v)
1.3.1 (vi)
1.3.1 (vii)
Therapeutic approaches
Clinical audit and evaluation
The National Institute for Health and Clinical Excellence
Communication and information
Pathways
Effective financial controls
Staff
9
9
9
10
10
10
11
12
1.3.2
Experience
14
1.3.2(i)
1.3.2 (ii)
1.3.2(iii)
1.3.2 (iv)
1.3.2(v)
1.3.2 (vi)
1.3.2 (vii)
1.3.2 (viii)
Care Planning Approach
Effective partnerships
Mutual respect project
Physical healthcare
Service user surveys
Environment
Innovation
Supporting employment
14
14
15
15
15
15
15
16
1.3.3
Safety
17
1.3.3(i)
1.3.3(ii)
1.3.3(iii)
1.3.3 (iv)
1.3.3 (v)
1.3.3 (vi)
1.3.3 (vii)
NHS Litigation Authority risk management standards
Infection prevention and control
Safeguarding
Information governance
Managing and learning from serious untoward incidents
Managing aggression and violence
Medicines management
17
17
18
18
19
19
20
1.3.4
Regulators
21
1.3.4(i)
1.3.4(ii)
1.3.4(iii)
Care Quality Commission
Mental Health Act and Mental Capacity Act
Monitor
21
21
22
2
Part 2
2.1
Priorities for improvement
24
2.1.1
Identification of priorities
Table 1
Table 2
Priorities for improvement
Our quality priorities for improvement and why we decided on them
24
24
25
2.1.2
How progress against identified priorities will be monitored and measured
26
2.1.3
How progress to achieve the priorities will be reported
26
2.2
Review of services
27
2.2.1
Service review
27
2.2.2
Participation in clinical audit
Table 3
Table 4
Table 5
Table 6
Table 7
National clinical audits
National clinical audits data collection 2009/2010
National clinical audit – action
Local clinical audit - action
Local clinical audit – reports not yet completed
28
28
29
30
33
35
2.2.3
Participation in research
36
2.2.4
Goals agreed with commissioners
2.2.4(i)
Table 8
Table 9
2.2.4(ii)
Table 10
Table 11
Table 12
Commissioning for Quality and Innovation (CQUIN)
Regional CQUIN 2009/2010
Medium secure services CQUIN 2009/2010
CQUIN scheme 2010/2011
Regional CQUIN indicators 2010/2011
Local CQUIN indicators 2010/2011
Medium and low secure CQUIN indicators 2010/2011
37
37
38
40
42
43
45
46
2.2.5
What others say about the Trust
2.2.5(i)
Table 13
Table 14
Table 15
Table 16
Table 17
Care Quality Commission (CQC)
CQC annual health check quality of services 2008/2009
CQC quality of services review 2009/10
CQC acute inpatient service user survey 2009
CQC acute inpatient service user survey - overall ratings
CQC acute inpatient service user survey - highest/lowest scoring questions
47
47
47
47
49
49
49
2.2.5(ii)
Table 18
Monitor
National targets 2008/2009 and 2009/2010
49
50
2.2.6
Data quality
2.2.6(i)
2.2.6(ii)
2.2.6(iii)
NHS number and medical practice code validity
Information governance toolkit attainment levels
Payment by Results
51
51
51
51
3
Part 3
3.1
Review of quality performance
Table 19
Local quality indicators and quality domains
53
54
3.1.2
Priority area - mutual respect between service users and teams/individuals
55
3.1.3
Priority area – personalised care
56
3.1.4
Priority area - improving practice and positive outcomes for service users
57
3.1.5
Priority area - environment and hotel services
58
3.1.6
Priority area - suicide prevention and risk management
59
3.1.7
Quality indicators which were reported in the 08/09 quality report
60
3.2
Statements from Local Involvement Networks, Overview and Scrutiny
Committees and Primary Care Trusts
61
3.3
Your comments
63
4
Part 1 5
1.1 Statement on quality from the Chief Executive
Quality accounts are annual reports to the public from providers of NHS healthcare services
about the quality of the services we provide. The audience for this report is wide ranging and
includes people who use our services and their carers, staff, commissioners, regulators and
academics. It is for anyone who wants to know more about the quality of our services and how
we aim to maintain and improve this.
This report provides an overview of our quality achievements and challenges throughout
2009/2010, showing how we are meeting our regulatory requirements as well as trying to meet
the expectations of all our stakeholders. The report also outlines our quality priorities for
2010/2011, outlining how we will continue developing high quality care for all.
Our Trust is committed to ensuring our services are not only safe and effective but also fully
focussed on the individual, to help them to make choices about their care and to move on from
our services as soon as they are able. Our commitment to quality is embodied in our mission,
vision, values and goals; we want to support people to enjoy productive and independent lives
and to have confidence that their care is of consistent high quality.
Our Trust provides specialist mental health and learning disability services to the people of
Calderdale, Kirklees and Wakefield, and over 98% of the care we provide is in the local
community, working with people in their own homes. The Trust also provides some medium
secure (forensic) services to the whole of Yorkshire and the Humber.
About 900,000 people live in Calderdale, Kirklees and Wakefield across urban and rural
communities from a range of diverse backgrounds. During 2009/2010 we had direct contact with
approximately 26,000 people, about 10,000 of whom were using our services for the first time.
We always aim to match the community’s needs with locally sensitive and efficient services and
we are proud to have been recognised for good practice in the field of equality and diversity by
being successfully appointed as an equality and diversity partner supported by NHS Employers
for 2010/2011. Having achieved partner status the Trust will be at the forefront of developing
equality, diversity and human rights good practice both within the NHS and across the wider
public sector, driving up the quality of our own services.
Throughout 2009/2010 we have engaged with our stakeholders to identify meaningful quality
priorities which are reflected in this report. This work has involved service users, carers, staff,
our Members’ Council, our commissioners and other partners. It reflects our position as a
Foundation Trust, continually working in partnership to drive up quality and gain perspective on
our efforts to do so.
Public accountability is key to meeting the challenges of the future. This report has been
developed with our stakeholders, not just for them, and by publishing this information we are
strengthening our commitment to quality and inviting our stakeholders to hold us to account.
Throughout the year we have worked hard to deliver improvement against the priorities identified
in our 2008/2009 quality report. We have also defined clearer quality measures to reflect our
performance against the quality priorities identified by our stakeholders. This enables the Trust
to respond positively to the expectations of our local communities, to partners and to national
directives, including:
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• Healthy Ambitions, The Quality, Innovation, Productivity and Prevention (QIPP)
agenda, and local quality targets set by commissioners
• developing continuous quality improvement
• delivering key Trust strategies and innovation
• ensuring standard setting and consistency of implementation
• embedding learning across the organisation
• defining and developing skills and competencies and developing coaching processes
• developing a culture of empowerment, person centred care and leading edge thinking
• developing, with partners, a whole systems approach to personalised care
• developing Microsystems approaches.
The above initiatives combine to enable the Trust to deliver the right services, of the right quality
at the right time to support recovery and wellbeing.
During 2009/10 we have looked at some specific services in terms of quality, productivity and
efficiency. For example:
• Psychological therapies. The Trust reviewed performance against the 18 week waiting
target for psychological services so we could ascertain the demand for, and capacity of
the services in Calderdale, Kirklees and Wakefield. The review demonstrated that service
capacity could not meet the demand. Constructive discussion with all three
commissioning primary care trusts led to additional investment in Kirklees and Wakefield
during 2009/2010. However we recognise that demand continues to outpace capacity
and this will be an area of focus for the Trust throughout 2010/2011.
• Prison services. The primary care trust in Wakefield has put out to tender for a newly
developed model of mental health in-reach services to HMP Newhall and HMP
Wakefield. The Trust currently provides some in-reach services to both prisons and so
the outcome of this tender will have an impact on our priorities for 2010/2011.
• Improving Access to Psychological Therapies (IAPT). During 2009/10 the Trust began to
deliver an IAPT service in the Kirklees area. This new service delivers the psychological
approach of cognitive behavioural therapy within primary care surgeries. The service was
formally launched in June 2009 and there are specified national targets which the team
has worked hard to try and meet in 2009/2010. The team will continue to drive up quality
to improve performance against these targets in 2010/11.
These are just a few examples of our quality challenges for the future. Our quality principles are
based on continuous service improvement and working in innovative ways to meet local
priorities, whilst ensuring compliance with national standards and external regulation.
Our approach is based on best practice internationally and other shared learning opportunities to
help us to use quality to deliver best value. In 2010/11 we will be implementing a Quality
Academy initiative to align services and resources in a way that enables us to make the best
quality offer to people who use our services and their carers.
I hope you find this report both informative and interesting. We are committed to achieving the
best possible service outcomes and improvements for people who use our services and our
plans will continue to evolve in the coming year. We will continue to work in partnership with our
staff, people who use services, their families and carers, our partners and our members in
continuing to drive up the quality of our services.
Steven Michael
Chief Executive
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1.2 Statement As Chief Executive of South West Yorkshire Partnership NHS Foundation Trust,
I can confirm that, to the best of my knowledge, all information in this document
is correct.
Steven Michael
Chief Executive
South West Yorkshire Partnership NHS Foundation Trust
8
1.3 Quality highlights and challenges in 2009/2010
Information presented in this part of the account relate to our overall review of quality
performance which is more formally reported against in part 3 (page 53).
1.3.1 Effectiveness
1.3.1(i) Therapeutic approaches
Some examples of innovative therapeutic approaches implemented by the Trust include:
• Staff working in a disabled children’s team devised a 13 week anger management
programme for young people with learning disabilities. The programme not only helps young
people understand their own feelings of anger and give them skills to cope but also develops
their confidence and self-esteem.
• A Psychosocial Intervention (PSI) strategy has been introduced in the medium secure
service. PSI ensures that individuals are involved and empowered in decisions relating to
their care. Every member of staff on one ward has been trained and the ward is fully focused
on the concept of recovery - not containment or even maintenance. Therapeutic
relationships have been enhanced, aiding risk assessments and ensuring an approach that
focuses on the whole person.
• As a response to local need, community mental health teams for older people in one area
have developed a number of therapeutic and social groups for people who have severe and
enduring mental health problems.
• Dance movement psychotherapy takes place in day centres for people with memory
problems as well as in hospital settings. It promotes health, supports mobility, improves
interaction skills and helps maintain abilities already present. The service has been listed by
the Department of Health demonstrating the Trust’s commitment to innovative care practices
and meeting national requirements in dementia care.
1.3.1(ii) Clinical audit and evaluation
Clinical audit and evaluation involves reviewing the delivery of healthcare to ensure that best
practice is being carried out. Effective clinical audit and practice evaluation is critical to the
development and maintenance of high quality person-centred services.
During 2009/2010 the Trust has continued to deliver a range of projects which help strengthen
learning and change. This includes the annual undetermined deaths audit (where it is unclear if
a death resulted from self-inflicted harm, an accident or another cause) and a new Trust-wide
Care Programme Approach (CPA) audit (this will ensure that CPA is properly implemented in the
Trust). More detail is provided in section 2 of this report.
The Trust wants to ensure that audit and evaluation continues to be used effectively alongside
other processes to embed clinical quality at all levels in the organisation. As such, a new audit
and evaluation policy will be implemented by the Trust in 2010/2011.
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1.3.1(iii) The National Institute for Health and Clinical Excellence (NICE)
The National Institute for Health and Clinical Excellence (NICE) is the independent organisation
responsible for providing national guidance on the promotion of good health and the prevention
and treatment of ill health.
The Trust identifies and responds to NICE guidance as part of our annual planning processes,
as well as at all levels within the Trust in terms of how we deliver care and provide treatment.
Relevant published NICE guidance is used to inform practice development and is taken into
account for new service developments. As at 31st March 2010 there were approximately 40
guidelines applicable to the Trust, but during 2009/2010 we never had a red or amber risk rating
against these, in terms of compliance or action planning. This means we were meeting all the
NICE guidance applicable to our Trust. However the review of the Schizophrenia guidance
highlighted shortcomings in the provision of Cognitive Behaviour Therapy (CBT) for people with
psychosis. The Trust is therefore implementing a clear action plan to address this.
1.3.1(iv) Communication and information
Effective communication and the provision of high quality information is central to supporting the
therapeutic and care processes and is seen as the responsibility of all Trust staff. Examples of
how we have tried to improve communications include:
• A group of staff from a range of professions (eg nursing, therapy, involvement etc) worked
on a special project designed to improve the information provided to people who use adult
inpatient services across the Trust, as well as their carers. The group worked to ensure
services had a consistent approach to providing detailed and accurate information that
supports dignity in care. Service users and carers were involved in giving feedback on the
project and shaping the information. A hotel style directory of information for each service
user was produced with locally tailored information as well as Trust-wide service users’
leaflets and carers’ booklets.
• During the closure of a social services centre, staff at a special care unit completed person
centered communication passports for all service users undergoing change as a result of the
closure. These passports enabled the new staff team to access all relevant information
relating to an individual’s care. Feedback from carers and staff at the new respite service
identified that the passports were excellent and extremely useful in enabling them to get to
know service users. The team’s person centered planning work has continued to enable staff
working in conjunction with carers and service users to provide comprehensive transition
plans for all individuals in regard to a new day service.
• Calderdale compact toolkit was produced by collaborative working between statutory and
voluntary sectors and offers a guide to future collaborations. All partners recognise that
community leadership is a shared responsibility and the toolkit is about setting high
standards for everyone to conduct their business together.
• The Trust’s corporate communications team has continued to support the recruitment of
Trust members, as well as their continued learning needs. This has been through a range of
innovative materials that represent best practice in communications. This approach has
encouraged education on mental health issues, promoting good mental wellbeing and antistigma messages. The Trust was also the first in the country to use social networking site
Facebook to reach out to potential members and it is now successfully using the social
media phenomenon, Twitter. The Trust’s members’ magazine ‘Like Minds’ has also been
very well received amongst the Trust’s 14,000 members.
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1.3.1(v) Pathways
The Trust has played a prominent role in the development of the care pathways and packages
which promotes consistently high quality practice and provides useful, reliable data about the
needs of people who use mental health services. It supports clinical decision making as well as
helping managers make the right decisions when planning and developing services.
During 2009/2010 the integrated care packages team has worked with clinicians and
practitioners to revise and update the Care Delivery System Template (CDST), describing in
detail what a service offers within evidence-based care packages and pathways. This way of
working also supports the developing national models for Payment by Results (PbR) for mental
health. PbR is a transparent, rules-based financial system which rewards Trust’s efficiency and
supports patient choice.
With our local authority partners the Trust has also been developing a learning disabilities
pathway. This will help simplify the way that a person with learning disabilities is referred into
specialist health and social care services and makes the services they are offered more
focussed on their individual needs. Implementation of the pathway will start to change the way
services work from April 2010.
1.3.1(vi) Effective financial controls
In the recent tough economic climate, the Government put out a number of economic directives
to the NHS, and the Trust has played its part in responding to these. For example, organisations
were asked to make sure that local suppliers are paid within 10 days, and the Trust has currently
managed this in 95% of all cases.
Another example of using effective financial controls is when, in March 2009, external auditors
highlighted the cost of using agency staff and made particular reference to the controls in place
when using temporary staff. With this in mind, the Trust has tried to source all our temporary
agency staff only from suppliers that have a formal contract with the NHS. Since taking this
action, over the last 12 months, figures have shown that since 2005-06 (when agency spend hit
a peak) the level of agency expenditure has not only halved but the spend against contract is
now nearly 100%. Whilst the latest figures are extremely encouraging the challenge ahead is to
reduce the level of expenditure further and to keep agency spend to a minimum.
We work hard to ensure the Trust has effective financial controls in place to meet standards for
financial governance and demonstrate value for money. The Trust has shown year on year
improvement since the ‘Use of resources – Auditors Local Evaluation’ assessment was
introduced in 2005/2006. The Trust gained an overall score of ‘3 – Good’ for the first time in the
2008/2009 assessment, showing our commitment to improving quality in this area.
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1.3.1(vii) Staff
We are only able to continue to provide high quality care and best practice if we have well
trained, competent and motivated staff. We work hard to try and ensure that our staff can always
provide a high standard of care. Here are some examples of work in the Trust to support this:
• The Trust achieved Investors in People (IiP) accreditation in June 2009. Within the
conclusion and recommendation section of the IiP report it says, “It is very evident that the
Trust has come a long way. The history of the organisation is complex, and the organisation
itself is relatively large, diverse and geographically challenging. However, the stories that
people tell about working in the Trust are generally quite straightforward – their focus is on
the users of the services, their needs and their care”.
Elsewhere in the report it says, “The Chief Executive asked for feedback on how engaged
staff are in the change process. The answer is that they are very proactive and positive
about making changes which will ultimately result in better services for the service users and
patients.”
It also says, “On a local basis, staff feel valued for the work they do – they receive positive
feedback and recognition from their patients, service users, their families, colleagues, peers
and their immediate manager. Some comments included:
- ‘I’ve done this job for a long time and I have good days and bad days but overall, I know I
make a difference to people and that is why I do it….’
- ‘I try and provide the support that people need so they can do their job and help our
patients. It makes a real difference that they appreciate what I do and respect me for what I
bring to the team….’”
• The Trust demonstrated the value we place on our staff during a celebration of positive
practice at our first annual ‘Excellence’ event held at the Galpharm Stadium in Huddersfield
in October 2009. There were over 120 entries into the awards scheme from across all
services and geographical localities. Judges included service users and carers, Trust staff
(from clinical and non-clinical services), Members’ Council representatives, non-executive
directors and external partners from our local health economy.
• Effective leadership is vital in promoting good quality care and the Trust is committed to
ongoing investment in leadership training and development. Excellence 2009 offered an
opportunity to recognise some outstanding leadership achievements. These included a
general manager seen to be instrumental in the continued development and improvement of
older people’s services in Wakefield. An older people’s services team leader in South
Kirklees was also praised for developing an effective model of supervision (recognised
through Practice Development Unit accreditation as a potential national pilot).
• The Trust was challenged by some of the results of the 2008/2009 national staff survey
which gave a lower than the national average rating for staff saying they had personal
development plans or received a well structured appraisal in the last 12 months. We have
continued to promote good practice by reviewing our supervision policy and redesigning
documentation. Further training is also planned to take place throughout 2010. Positively,
monthly internal monitoring of supervision and appraisal activity now demonstrates an
uptake of over 80%.
• Staff surveys consistently highlight how our staff value investment in their training and
development and to help deliver this there are purpose built training facilities in Wakefield
with bespoke training also delivered across the Trust. As well as internal training provision
we tender for best practice external training programmes such as Sainsbury Risk
Management and we also support specialised training programmes developed by clinical
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teams. An example of this is a learning disability team who provide a course in intensive
interaction, a valuable person-centered communication technique. The course enables those
caring for people with learning disabilities and/or autism to build relationships with the people
they care for, enriching their quality of life and reducing distressed behaviour. The course
shows staff and carers how to use the approach effectively and change their and the
individual’s experiences as a result. A further mark of our commitment to excellence in
training provision is our 2009/2010 positive external assessment for our City and Guilds and
Institute of Leadership and Management programmes.
• The Trust knows that staff wellbeing is crucial in relation to staff motivation and ability to
provide a quality service. In November 2009 the Secretary of State formally responded to the
NHS Health and Wellbeing review led by Dr Steve Boorman. The key factors used in the
Boorman review which indicated staff health and wellbeing were work related stress, work
related injury, job satisfaction and intention to leave. The local analysis report demonstrated
that the Trust is above average performance against all mental health trusts and in
comparison with the NHS overall. In 2009 the Trust further strengthened this commitment to
staff wellbeing in a unique project with Bradford District Care Trust called the Wellbeing at
Work Partnership. This project supports and supplements a number of broader agendas
across the NHS, including the Boorman review and the Trust will continue to develop this
work throughout 2010/2011.
• We are fully committed to supporting and promoting diversity and equality both in the way we
provide services and as an employer and we have been running the Positive Action Training
scheme in North Kirklees for two years, as a way of ensuring our workforce is representative
of the population it serves. The scheme gives local people from South Asian backgrounds
living in North Kirklees the opportunity to gain work based training and qualifications.
Traineeships aim to give participants the qualifications and workplace experience required to
secure employment within the organisation and successfully resulted in appointments within
the Trust. One of the trainees won an award at our Excellence event in 2009 and was
described as “fully demonstrating the values and the goals of the Trust on a practical day to
day basis.”
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1.3.2 Experience
1.3.2(i) Care Planning Approach (CPA)
Effective care planning is central to the promotion and co-ordination of an individual’s care and
support. Getting CPA right isn’t just about giving people a copy of their care plan. It is about the
entire process, ensuring that people who use our services, and their carers, are involved,
consulted and engaged in the entire care planning process. This is fundamental to improving
people’s experience of using our services and we recognise that we don’t always get this right.
CPA was identified as a priority for 2009/2010 within the previous year’s quality report. Since
then there has been considerable investment in the development and implementation of new
CPA policy and processes. This was developed in partnership with local authorities to meet
national guidance that was published in 2008.
The Trust invested in a member of staff to lead CPA and recently extended this secondment for
a further year to enable continued improvements across all areas of CPA. It is of ongoing
concern to the Trust that service user surveys (such as the Care Quality Commission 2008/2009
national service user survey) continue to reflect that individuals don’t know who their care
coordinator is nor do they receive a copy of their care plan. During 2009/2010 the Trust has
been able to demonstrate improvement in staff recording that individuals are offered a care plan
(currently over 80%). However this is not matched by service user perspectives on the quality of
care planning. Personalised care and care planning therefore continues to be an identified
priority for the Trust in 2010/2011.
1.3.2(ii) Effective partnerships
Close partnership working is essential to ensure that people who use our services experience an
integrated approach to care that is not complicated by different organisational or professional
boundaries. Some examples of successful partnership working include:
• Pathways day services is an integrated mental health service run by the Trust and Kirklees
Council. It offers a range of meaningful activities that help people build confidence, learn new
skills and increase and develop strengths. Pathways encourages the use of local amenities
and supports individuals to access other community services working with sympathetic
organisations such as the Gearstones Charity Trust. Gearstones owns a lodge in North
Yorkshire and over the last 8 years Pathways service users have helped restore and
renovate this large building on working holidays supported by staff. Pathways also works
with the Electronic Village Hall which runs courses and qualifications in IT, literacy and
maths. Over 60 service users have gained qualifications in the last 2 years.
• The Wakefield discharge liaison team was established when it became clear that older
people with dementia were not being discharged from acute hospitals in a timely or
appropriate manner due to perceptions of risk or lack of knowledge regarding their illness.
The team enables people with dementia to continue living in the community for extended
periods. In the first 6 months there was a measurable effect on average lengths of stay
within the acute trust and our commissioners have noted a positive impact on numbers of
people requiring specialist intermediate care placements.
• Nabcroft outreach team enable the older person with mental health needs to be cared for in
their own home. The team, where possible, offer an alternative to hospital admission and the
capacity to offer care flexibly and intensively over a seven day period.
14
1.3.2(iii) Mutual respect project
During 2009/2010 the new low secure Bretton Centre based in Wakefield successfully
completed a mutual respect project. This involved service users, clinicians and managers
considering four key areas: culture and environment, patient experience, ways of working and
performance management. The project results were very positive in regard to service users’
experience of care planning, dining and general wellbeing. A specially designed survey gave
some interesting and useful comments about the culture and environment of the service and a
feedback event was held to allow staff and service users to make suggestions to overcome
problems and meet challenges to improve quality. This work will be progressed by a further two
units where similar mutual respect projects will be completed in 2010/2011.
1.3.2(iv) Physical healthcare
The Trust works hard to promote good physical healthcare. People with mental health problems
have a higher risk of physical illness but certain physical health problems are preventable by
making simple lifestyle changes. An example of where our services can make a difference in this
area is a winner in the 2009 Excellence awards; a community mental health team which has
established a health screening clinic. This helps identify and analyse basic physical healthcare
needs and ensures individuals get the advice and care they need.
1.3.2(v) Service user surveys
In the Care Quality Commission’s 2008/2009 acute inpatient national service user survey we
were pleased to receive positive feedback relating to individuals’ stays on our wards (single sex
accommodation, feeling safe on the wards, food and cleanliness). Yet there were other areas
where improvement is needed, this is in common with nearly all organisations involved in the
survey.
The Trust did least well on the section related to the provision of activities on the ward but is
trying to address this. There are various initiatives aimed at improving activity provision including
the activities programme on a ward in Dewsbury which sees a number of partnerships with
voluntary organisations. This includes sessions by a complimentary therapies practitioner as well
as Zak, a Pets As Therapy (PAT) dog who regularly visits the ward. Star Wards, a scheme that
aims to enhance inpatient daily experiences, was also implemented on a ward in Wakefield. It is
supporting people to be more active participants in their care planning and making life on the
ward more active, interesting and boredom free.
The Trust’s acute care forum owns and monitors the action plan for all areas of improvement
identified from the national survey, including the provision of activities.
1.3.2(vi) Environment
In line with the national programme towards eliminating mixed sex accommodation the Trust
completed a self assessment audit in respect of privacy and dignity. The Trust complies with
mixed sex accommodation requirements in all wards and 94% of total beds (including those in
community units) are single rooms. The one area where action was required was appropriate
labelling of bathroom facilities within community units, this was completed by the end of March
2010.
1.3.2(vii) Innovation
The Trust has continued to encourage and support innovative approaches to engaging with
service users which facilitate mental health improvement. Some examples include:
• The Good Mood Football League is made up of 9 teams of people who have all used mental
health services. Each team trains on a weekly basis but league events take place quarterly.
The league has been remarkably successful in its first year and with the help of The Zone at
15
Huddersfield it has secured funding from The New Football Pools allowing affiliation with the
Football Association. Service users are involved in the planning of league events and often
come up with new ideas like entering mainstream lunchtime league tournaments. Of 56
service users surveyed 92% agreed that their physical and mental health had improved, 94%
said it had helped prevent readmission to hospital, 75% felt more optimistic about their future
and 85% said it had helped develop their confidence.
• ‘Portrait of a Life’ is a multi-media toolkit for life story work that has been developed by a
project team within the Trust. The project has been funded by the Mental Health Foundation
(MHF) as part of their ‘Home Improvements’ scheme and was one of four successful teams
selected from over 350 applications. Although intended initially for use in care homes, the
MHF have supported the wider application of the toolkit into other care settings such as
community, ward and memory services. The work which is due to be launched in the
summer has seen interest from across the UK and Europe as well as in Australia where the
team are presenting at a conference in June 2010. The team now also deliver life story
training and, in February 2010, a member of the team co-ordinated the first national life story
conference for which the Trust was a sponsoring organisation.
• The Trust makes a significant contribution in engaging with people with a learning disability
and their carers via a number of routes. These include the learning disability partnership
boards, major events such as “It’s my health day”, a mutual respect project where service
users are involved in secret shopper questionnaires and focus groups, work around the
essence of care standards and communication which links into and complements the mutual
respect project. Significant work around developing accessible information in learning
disability services has also been progressed in 2009/2010.
1.3.2(viii) Supporting employment
The Trust works hard to support people who use our services to gain employment, should they
wish to. Examples of initiatives that support this include:
• North Kirklees learning disability services introduced a unique initiative called ‘job carving’,
which not only promotes employment for people in the wider community but also addresses
how to include people with a learning disability in staff teams. This was done by looking at
roles within a service and identifying tasks that could be undertaken by an individual with a
learning disability. Jobs were then restructured to create these roles and there are now two
team members with a learning disability. Having people with a learning disability
represented in Trust staff teams not only sends a positive message to service users but it
also promotes a positive image for people with a learning disability and the Trust.
• The Kirklees vocational team helps adults identify and take part in vocational activities, often
working with individuals who are still in the early stages of their recovery. The team provides
a service which is evidence based in clinical application and modern in approach, as directed
by national government guidance. In its first year of operation the team successfully
supported 22 clients into paid employment, seven into work placements, five into voluntary
work and 10 into education/training.
• All Trust services are encouraged to support service users and offer them work experience
placements if possible, to support return to work. The finance department have supported
service user placements in partnership with an organisation called ‘Back in Touch’. From the
last three work placements two of the service users involved have so far moved back into
employment.
16
1.3.3 Safety
1.3.3(i) NHS Litigation Authority risk management standards
The NHS Litigation Authority (NHSLA) works to improve risk management standards in the NHS.
The standards involve minimising any threats to safe effective services and care. It also requires
the management of any remaining risks in a sensible and carefully considered way
There is a set of risk management standards for each type of healthcare organisation. The
mental health and learning disability risk management standards provide our Trust with a
structured framework to make sure we manage risk well. This then helps us to improve the
quality of the care and services we provide.
Trusts are regularly assessed against the NHSLA risk management standards which include
organisational, clinical, and health and safety risks. In November 2008 the Trust had a level 1
assessment against the standards and successfully achieved a 100% pass rate. The Trust has
continued to implement its strategy in this area and will be reassessed for level 1 in 2010/11 with
a level 2 assessment the following year.
1.3.3(ii) Infection prevention and control
People using Trust services expect cleanliness and safety and rightly assume that we will aim to
prevent infections while they are in our care. In 2009, a new system to improve infection control
nationally was introduced and it became a legal requirement for our Trust to be registered with
the Care Quality Commission (CQC). To be registered, Trusts had to ensure they take steps to
protect patients, workers and others from getting a healthcare-associated infection (HCAI). The
Trust applied for, and achieved, unconditional registration with the CQC. This is thanks to the
measures put in place to effectively manage infection control issues in our services.
Since achieving HCAI registration the Trust has had to continue to meet the Hygiene Code
standards in order to maintain this registration. The Hygiene Code lists the actions that each
NHS trust must take to ensure a clean environment, in which the risk of infection is kept as low
as possible. These actions cover all aspects of infection control, not only cleanliness.
Throughout 2009/2010 the Trust has been able to comply with all standards within the Hygiene
Code. This has been achieved by ensuring we have a robust infection prevention and control
assurance framework as well as regular checks against this work (audit).
To comply with the Hygiene Code the Trust is required to report MRSA bacteraemia (blood
stream infection) and Clostridium difficile infections to the Strategic Health Authority.
The Trust had one case of a reportable infection in 2009/2010. This was a single case of
Clostridium difficile, a spore forming bacterium which is present as one of the 'normal' bacteria in
the gut of up to 3% of healthy adults; however it can cause illness when certain antibiotics
disturb the balance of 'normal' bacteria in the gut. This infection was very well managed by our
medical and nursing staff. This prevented its spread or further infections.
17
1.3.3(iii) Safeguarding
Vulnerable people deserve the best protection we can give them. We are fully committed to
ensuring we do everything we can to ensure this always happens, it remains a top priority for our
Trust.
Children and young people
In 2009 a safeguarding review report was published by the Care Quality Commission (CQC).
The NHS Chief Executive then told all trusts to assess their own position against the review
findings. All Trust Boards had to make sure that, as a minimum: the Trust meets the statutory
CRB (Criminal Records Bureau) requirements, policies and training are up to date, designated
and named professionals are clear about their role and there is a Board level executive lead for
safeguarding.
During 2009/10 the Trust has worked hard to ensure we complied with all the above areas. In
particular there has been a focus on all staff being trained via classroom training, e-learning or
team discussion based on the document ‘What to do if you are worried a child is being abused’.
All staff in the organisation have had access to this document and, as at quarter 3, over 72% of
staff had taken part in face to face or e-learning training.
Within the year the Trust also contributed to an Ofsted safeguarding inspection in Calderdale –
the part of this inspection that focussed on health was rated as ‘good’, which is defined as ‘A
service that exceeds minimum requirements’.
Vulnerable adults
In response to the Government’s consultation on strengthening protection for vulnerable adults,
new legislation is being introduced so that every local area will have a Safeguarding Adults
Board – a body made up of the local social services authority, the police, the NHS and working
with all other groups involved in protecting vulnerable adults. The board will ensure that
vulnerable adults who suffer abuse will have quick and easy access to the people who can help
them best. The Government, working with stakeholders, is now mapping out a programme of
work to lead and support all agencies involved in safeguarding adults.
Within the Trust, staff training on protecting vulnerable adults is available via a full day basic
awareness course with a 2 hour refresher course every three years. In 2009/2010 a workbook
used at induction sessions was developed into an e-learning tool which was successfully
introduced in the Trust in January 2010.
1.3.3(iv) Information governance
The Trust needs high quality, accurate and reliable information to help us provide excellent care
as well as plan future services, monitor performance and manage resources. So, it is very
important that we make sure information is efficiently managed and stored. We also need to
protect the information we have against theft, malicious damage or accidental damage. This is
all known as information governance.
The NHS Operating Framework for 2009/2010 requires organisations to achieve level 2
performance against all key requirements identified in the information governance toolkit - this
toolkit helps us check that we have policies and procedures in place to look after information.
The toolkit relates to 25 standards that form the Information Governance Statement of
Compliance (IGSoC). Our Trust, like all NHS organisations, must sign the IGSoC to confirm that
we are meeting all the key requirements, and we must demonstrate we have strong,
comprehensive plans in place to improve where we need to against any other requirements.
18
The Trust always ensures that any information governance incidents are reviewed with training
and support provided for staff to ensure ongoing vigilance.
Data quality is also very important to the Trust. This is about making sure that clinical information
is accurately and consistently recorded. By doing this we can not only help improve patient care
but also reduce clinical risk and show how we are meeting national standards.
1.3.3(v) Managing and learning from Serious Untoward Incidents (SUIs)
Over 15,000 local people use our services each year and the vast majority receive very high
standards of care. However, incidents do occur, and it is important they are reported and
managed effectively. The Trust has very strict processes for the management of all incidents to
ensure that they are always thoroughly investigated, analysed and monitored.
The main type of incidents reported during the year are suspected suicides of people who use
Trust services, but all types of incidents are analysed and actions put in place to try and prevent
similar incidents happening again, including sharing the learning from incidents.
The Trust will always learn as much as possible from both internal and external incident review
processes. In 2009/2010, following a coroner inquest into the death of a gentleman on one of
our older people’s wards in August 2008, a Rule 43 letter was issued to the Trust. A Rule 43
letter is sent by a coroner when evidence at an inquest raises concerns that circumstances
creating a risk of other deaths may occur or continue to exist. The Trust had to respond within 56
days and provided full details of actions already taken to address the concerns. The Trust
thoroughly reviewed all the points raised and showed where action had been taken, as well as
outlining how continued improvements will help safeguard against future incidents of this type.
As part of this process a jointly planned awareness day with Age Concern is planned for June
2010. We have also continued to work on revision to our slips, trips and falls policy.
We will continue to not only try and prevent all types of incident from occurring, but when they do
we will learn from them to help further improve the quality of our services.
1.3.3(vi) Managing Aggression and Violence (MAV)
Effectively managing aggressive or potentially violent episodes in mental health and learning
disability settings is extremely important.
All NHS organisations must apply full and consistent measures to reduce the risks of aggression
and violence, in line with national guidance. Within the Trust there are systems to not only
support best practice, but also promote it. The Trust uses a public health model advocated by
the World Health Organisation as a framework to underpin our strategy. The way the Trust
manages aggression and violence is not only about physical interventions once an incident has
occurred, but also about how to minimise the risk of incidents happening in the first place. This is
heavily based on the principles of mutual respect.
Throughout 2009/2010 the number of reported incidents has generally remained below a level
that is set by the Trust Board, based on previous year’s figures. However there can be
differences each month if an individual in our care is responsible for multiple incidents - in these
cases, specialist care planning advice is provided. The Trust carefully monitors changes in
number, type and severity of incidents.
19
To continue to ensure the highest levels of safe and effective care, the Trust raises awareness
of techniques that either minimise the risk of violence and aggression or help staff know how to
best handle it, as part of our 3 year MAV training plan. Training is given by the Trust’s specialist
MAV team and is line with the NHS Security Management Service’s national syllabus which
emphasises the non-physical aspects of aggression management.
Every effort is made to sensitively manage any violent incident, but there are occasions when,
for safety, a planned physical intervention has to be made by trained and skilled members of
staff. This is to prevent individuals from harming themselves, endangering others or seriously
compromising the therapeutic environment. Following a serious untoward incident in 2008/2009
where restraint had been used and a serious injury to a service user occurred, the Health and
Safety Executive (HSE) visited the Trust in July 2009 to review the incident and we are
anticipating receipt of the HSE report very shortly.
Various actions have also been taken to ensure any issues are identified and addressed. A
restraint monitoring form has been devised, which allows staff to record where they were
positioned when the incident occurred and good practice prompts have been added to make
sure service user and staff wellbeing is recorded. This also helps ensure that a review takes
place after any incident with staff and service users, so that we can learn from the incident.
The 2008/2009 national staff survey results showed that we were higher than average compared
to similar organisations for the numbers of staff who said they had experienced violence and
aggression. However, our results were comparable to trusts that also provide medium secures
services, like we do. The Trust will continue to be proactive in its approach to violence and
aggression management and a number of new appointments strengthen this. The Trust has also
invested in training staff in personal safety, our latest figures showed we had trained 54% of staff
compared to 41% in other trusts.
As a provider of specialist learning disability services we also aim to comply with the latest
guidance in this area. The British Institute of Learning Disabilities (BILD) has developed
accredited training for staff working with people with learning disabilities, and this is supported by
the Department of Health. Our Trust mainly supports individuals who have complex learning
disabilities and we also provide consultancy advice to a range of partners. As such, we are
aiming to develop our own BILD accredited trainers and have a strategy in place to help us
achieve this aim.
1.3.3(vii) Medicines management
The management of medicines is a vital part of providing safe, effective high quality care for
people who need to use our services. The Trust’s chief pharmacist has recently been awarded
the status of Fellow of the College of Mental Health Pharmacists, this is awarded retrospectively
to professionals who have demonstrated outstanding commitment in the practice of mental
health pharmacy.
Further testament to our excellence in this field is the ‘Medicines with respect’ project that has
been developed by the Trust in conjunction with NHS Trusts and higher institutions within the
Yorkshire and Humber region. It aims to support practitioners in achieving safe and effective
practice in relation to medicines management. It is primarily an assessment tool that can be
used to measure performance and identify development issues. It can be used to identify
developmental needs and helps staff check that their own medicines management practice is
safe and effective.
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1.3.4 Regulators
Because we are a foundation trust we are accountable to local people and to an independent
regulator, called Monitor. We are also regulated by the Care Quality Commission.
1.3.4(i) Care Quality Commission (CQC)
The CQC are the independent watchdog of health and adult social care services across
England. To be registered with the CQC our Trust Board had to formally declare that we are
meeting all the new CQC registration regulations. We are pleased that the CQC has confirmed
that the Trust was registered from April 2010 without any compliance conditions.
However, the Trust was disappointed to see its overall rating for ‘quality of services’ from the
CQC reduce from ‘excellent’ to ‘good’ in the 2008/2009 Annual Health Check result. We were
amongst 45.6% of mental health trusts to score ‘good’, whilst 24.6% scored either ‘weak’ or
‘poor’. The score is a combination of scores for performance against the Government’s national
priorities, existing commitments, and how well we can prove we meet core standards.
The specific reason the Trust did not achieve an overall ‘excellent’ rating was our selfassessment against something called the ‘Green light toolkit’ - a national priority that looks at
how good mental health services are for people with a learning disability. For this we had assess
ourselves against 12 specific criteria in collaboration with each of the 3 primary care trusts
(PCTs) in our area. There were two criteria that we rated red (we were not meeting them),
relating to culturally specific services and mental health promotion. Joint work has been
undertaken with the PCTs and local authorities (our commissioners) in 2009/10 to ensure
improvement. This includes clarification in respect of access to services within Trust policies
such as the new care planning approach (CPA) policy. We have also confirmed the pathway in
all three geographical areas to women only services not directly provided by ourselves.
1.3.4(ii) Mental Health Act (MHA) and Mental Capacity Act
As well as monitoring our overall performance, the CQC are also now responsible for Mental
Health Act visits and reports. During the period 1st April 2009 – November 2009 the CQC (MHA
commissioners) visited Trust inpatient facilities on 10 separate occasions and interviewed 26
patients who were subject to the Mental Health Act at the time of the visits. The Trust received
the CQC annual report in January 2010 within which the CQC made 6 recommendations. An
action plan has since been agreed and all actions will be completed by the end of June 2010.
In 2009/2010 the Trust has continued with the implementation of the amendments to the Mental
Health Act 1983 and the implementation of the Mental Capacity Act 2005. To comply with the
amendments a number of new administration procedures have been implemented such as
requests for second opinions and Mental Capacity Act Deprivation of Liberty Referrals.
In April 2009 we saw the introduction of the Deprivation of Liberty safeguards under the Mental
Capacity Act 2005. Information and training for staff has been implemented and the programme
will be ongoing throughout the Trust. Also in April 2009 the role of the Independent Mental
Health Advocate (IMHA) came into effect. Amendments to the policy relating to patients rights
have been made to ensure that staff inform all patients subject to the MHA of their right to have
support (from an IMHA). The policy also covers staff responsibilities in referring patients who
lack capacity to the IMHA. Information leaflets have been made available to all services and this
in information has also been incorporated into the internal MHA training programme which is
ongoing throughout the Trust.
In April 2010 the amendment in regard to age appropriate accommodation for patients who are
detained under the Act came into effect. In 2010/2011 we intend to implement and roll out the
MHA module on our clinical information system (RIO).
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1.3.4(iii) Monitor
Monitor is the independent organisation who regulates all foundation trusts, including ours,
making sure we comply with the terms of our authorisation. There are a set of detailed
requirements covering how foundation trusts must operate – in summary they include:
•
•
•
the general requirement to operate effectively, efficiently and economically;
requirements to meet healthcare targets and national standards; and
the requirement to cooperate with other NHS organisations.
The Trust’s board has to submit an annual plan and regular reports to Monitor who then check
how well we are doing against these plans and identify where problems might arise.
Throughout 2009/2010 the Trust has continued to prove that we are complying with all the terms
of our authorisation. We had to say how much at risk we were of our governance failing - which
means whether the measures put in place in order to ensure smooth functioning and control of
the Trust work. We submitted governance risk ratings of green throughout 2009/2010, which
means we think we are meeting all the terms and there are no risks around this.
22
Part 2 23
2.1 Priorities for improvement
2.1.1 Identification of priorities
Throughout 2009/2010 the Trust undertook a number of processes to engage with our
stakeholders (people who take an interest in what we do). This was to help us identify
meaningful quality priorities. The engagement processes included:
• The Trust Board identified future priorities (as described in the 2008/2009 Quality Report)
based on a range of listening and visioning events with staff, service users and carers in
Autumn 2008. These were then reflected in what is known as the Trust’s ‘assurance
statement’. These priorities were:
ƒ mutual respect between service users and teams/individuals
ƒ effective care plans and care planning.
ƒ positive outcomes for service users
ƒ equality and human rights
ƒ working with partner organisations and Trust members to address stigma, social
inclusion and community cohesion
• Specific staff engagement processes regarding quality issues, concerns and priorities for
improvement have been conducted with:
ƒ
Service delivery groups
ƒ
Community team leader network (including early intervention services, community
mental health teams, improving access to psychological therapies, assertive
outreach and crisis and home treatment teams)
ƒ
Ward manager network
ƒ
Practice effectiveness trust action group
•
Specific service user and carer engagement processes have been facilitated via a service
user and carer re-engineering group and service user dialogue groups. There are currently
10 dialogue groups established across the Trust which allow people who currently use our
services, and their carers, to have open and honest two-way discussions with our staff.
•
Trust Members’ Council representatives were involved in reviewing and helping determine the
quality account content and format. The Trust has a total of 39 representatives on the
Members’ Council, They consist of 20 public, elected representatives, 7 elected staff
representatives and 12 appointed representatives from partner organisations. Together they
represent the views of the Trust’s 14,000 members.
• The full range of identified quality priorities have been reviewed by the Trust Board and
executive management team in order to specify five clear priorities for 2010/11. These are:
Table 1: Priorities for improvement
Priority
Mutual respect between service
users and teams/ individuals
Personalised care
Improving practice and positive
outcomes for service users
Environment and hotel services
Improvement initiative areas
Focus on service user experience
Better care planning processes and greater service user and carer
involvement
Continued compliance with national standards such as NICE;
innovative practice development such as continued development of
care packages and pathways; workforce development
Ensuring safe, accessible surroundings that promote service user
wellbeing
Clinical risk management; key focus on safeguarding
Suicide prevention and risk
management
See table 2 on the following page for the reasons why these were chosen as priorities.
24
Table 2: Our quality priorities for improvement and why we decided on them
Patient experience
1. Mutual respect between service users and teams/ individuals
In 2008/2009 we said that for any organisation to be successful its workforce needs to reflect its values.
Mutual respect is central to the Trust’s value base. Staff attitudes and behaviour consistently feature as
one of the most important aspects of care in feedback from service users and carers. Mutual respect is
also a common theme identified by staff. Within the Trust assurance framework there is a principal
objective to, ‘Maintain performance against a range of indicators demonstrating a culture of mutual
respect’. If we fail to deliver this objective, the identified principal risk is, ‘Failure to organise services that
are responsive to the needs and lives of service users and carers’.
2. Personalised care and effective care planning
Patient experience
Safety
Effectiveness
Effective care plans and care planning was a high priority identified in 2008/2009 via listening and visioning
workshops. It also features significantly again in stakeholder feedback in 2009/2010; care planning and
care plans based on really listening to service users is seen as vital. People who use our services also say
they want to be fully involved in the planning and delivery of their care and want to be offered copies of
their care plans. Nationally, personalised care is a critical component of the new Care Quality Commission
registration requirements. This is outlined in regulation 17: Respecting and involving service users –
ensuring personalised care, treatment and support through involvement.
3. Improving practice and positive outcomes for service users
Patient experience
Safety
Effectiveness
In 2008/2009 we said that we would work with our partner organisations to provide activities that promote
wellbeing and enable people to live full lives. We also said we wanted to promote innovative practice. In
the stakeholder feedback in 2009/2010 improving practice and outcomes was identified as a critical quality
objective. This included implementing national guidance, such as NICE, as well as more specific issues
such as physical health checks and screening. There is a clear desire for the provision and availability of
meaningful and structured activities on inpatient units, and a need to be confident that clinicians are
adequately trained, skilled and supervised was also identified. A principle objective in the Trust’s
assurance framework is to continue to develop a performance improvement culture – this will be linked to
positive outcomes for service users and the new model mental health contract. We also identify the need
to build on and further develop the pathways and packages methodology for organising care across
working aged adults and older people’s services. A further objective is to work with commissioners to
develop innovative services which improve outcomes, whilst also increasing efficiency and productivity.
4. Environment and hotel services
Patient experience
We recognise that a constant theme throughout the 2009/2010 stakeholder feedback relates to the
environment and facilities. There is concern about mixing people of opposite sexes on wards, appropriate
measures to ensure cleanliness and the provision of good quality and nutritious food. These concerns are
why we want to include things that can measure how well we are performing in these areas in our quality
account.
5. Suicide prevention and risk management
Safety
Effectiveness
In 2008/2009 we said that we would work to meet all external standards for risk management and clinical
safety. The 2009/2010 stakeholder feedback also identifies several factors relating to suicide prevention
and risk management. This includes confidence around the critical 7 days after someone has been
discharged (post-discharge period) as well as clinical risk assessment and management. Safeguarding
(children and adults) is both a national and local priority. Regulators, commissioners, public and service
users all need to be assured that the Trust is implementing effective safeguarding measures.
25
The identified priorities will provide an outline for our quality account reporting for 2010/2011.
They are also reflected through the local indicators reported against in this quality account.
Whilst our five priorities combine all our previously identified quality areas, all these areas,
identified by engagement, will provide a basis for continued stakeholder debate in 2010/2011.
The information we gained through talking with our stakeholders is also being used to inform key
organisational processes such as how we decide our 2010/2011 prioritised clinical audit and
evaluation programme.
As well as the stakeholder engagement described above, we have also worked with our
commissioning PCTs to determine regional and local Commissioning for Quality and Innovation
(CQUIN) targets for 2010/11. Read more about this on page 37 under 2.1.4 ‘Goals agreed with
commissioners’.
2.1.2 How progress against identified priorities will be monitored and measured
ƒ Identified indicators related to each priority area will be monitored throughout the year.
ƒ The priorities will underpin specific reviews throughout 2010/2011 under the three quality
headings of ‘safety’, ‘service user experience’ and ‘effectiveness’.
ƒ The priorities will be reflected in Trust audit and evaluation processes. For example,
questions that relate to these priorities will be included in local service user surveys.
ƒ The priorities will be reviewed and debated within ongoing stakeholder engagement
processes throughout 2010/11.
ƒ Performance against the regional and local CQUIN (Commissioning for Quality and
Innovation) targets will be measured.
2.1.3 How progress to achieve the priorities will be reported
ƒ Identified indicators will be reported within Trust Board reporting schedules and processes
ƒ Throughout 2010/2011 specific review reports will be given to the Trust Board under the
three quality headings of ‘safety’, ‘service user experience’ and ‘effectiveness’.
ƒ The Trust’s prioritised audit and evaluation programme will be monitored throughout the
year. This will enable issues relating to the quality priorities to be identified and reported.
ƒ Stakeholder engagement processes throughout 2010/11 will be reported to the Trust Board
ƒ The regional and local CQUIN (Commissioning for Quality and Innovation) targets will be
monitored, reviewed and reported. This will be within contractual monitoring and quality
review processes with PCT commissioners.
26
2.2 Review of services
2.2.1 Service review
During 2009/10 South West Yorkshire Partnership NHS Foundation Trust provided and/or sub
contracted 62 NHS services. The Trust has reviewed the data available to them on the quality of
care in all of these services. The income generated by the NHS services reviewed in 2009/2010
represents 100% of the total income generated from the provision of NHS services run by the
Trust for 2009/2010.
The Trust has continuously reviewed quality across all of its services in 2009/2010 so that we
can identify and implement effective processes for change. There were quarterly service reviews
for each care group (adult, older people, learning disability and forensic) as well as specific
quality reviews related to each of the three quality headings of ‘safety’, ‘service user experience’
and ‘effectiveness’.
The following actions are intended in 2010/11:
ƒ We will use the quality review results to produce a quality plan that relates to what we are
contracted to provide (contractual commissioning requirements) in the first quarter of the year.
ƒ Quarterly reporting against the plan will reflect performance against local indicators and quality
improvement measures agreed with commissioners. These will look at performance against
regional and local CQUIN (Commissioning for Quality and Innovation) targets.
ƒ Specific quality reviews conducted during the year against each of the three quality headings of
‘safety’, ‘service user experience’ and ‘effectiveness’.
ƒ Business Development Units (BDUs) will conduct quality reviews as part of their quarterly
performance review processes.
Data that will support the assessment of our quality performance will cover the quality headings
of ‘safety’, ‘service user experience’ and ‘effectiveness’. When the amount of data available for
review has delayed the ability to meet an objective, this will be clearly indicated.
There will be ongoing analysis and review of the quality of the data. There will also be some
specific data quality review processes that will involve clinicians and other stakeholders. This will
help allow some challenge and peer review (a system where reviewers are professional equals).
An essential part of our data quality review process is the specific CQUIN (Commissioning for
Quality and Innovation) reporting. This is part of the contract review processes with the PCTs
who commission our services. The following actions will support this in 2010/11:
ƒ Continuing stakeholder engagement processes.
ƒ Continued involvement of our Members’ Council who will review the quality account.
ƒ CQUIN monitoring and review with the PCTs who commission our services.
Quality improvement measures have been built into the organisational structures of the Trust. In
2009/2010 quality indicators were reported monthly or quarterly (as appropriate) to the Trust
Board as part of the Trust’s performance dashboard (this describes a set of data that shows the
latest information on how an organisation is performing, similar to a car dashboard). The
following actions will support organisational quality accountability in 2010/11:
ƒ Local quality indicators and CQUIN targets reported as part of the Trust dashboard and in
performance and compliance reporting to the Trust Board.
ƒ Business Delivery Unit (BDU) quality indicators monitored and reported against.
ƒ Prioritised audits and evaluations (including service user surveys) reacting to the identified
quality priorities will be conducted.
27
2.2.2 Participation in clinical audit
Clinical audit and evaluation involves reviewing the delivery of healthcare to ensure that best
practice is being carried out. Effective clinical audit and practice evaluation is critical to the
development and maintenance of high quality person-centred services.
National audits
During 2009/2010 ten national clinical audits and one national confidential enquiry covered NHS
services that South West Yorkshire Partnership NHS Foundation Trust provides. During that
period South West Yorkshire Partnership NHS Foundation Trust participated in eight (80%)
national clinical audits and one (100%) national confidential enquiry of the national audits and
national confidential enquiries, which it was eligible to participate in.
The national clinical audits and national confidential enquiries that South West Yorkshire
Partnership NHS Foundation Trust was eligible to participate in during 2009/2010 are shown as
table 3.
Table 3: National clinical audits
The national clinical audits and national confidential enquiries that the
Trust was eligible to participate in during 2009/2010 are as follows:
Trust
participation
2009/2010
National Audit of Psychological Therapies for Anxiety and Depression
(NAPTAD): anxiety and depression
National falls and bone health audit
Prescribing
Observatory
for Mental
Health
(POMH):
prescribing
topics in
mental health
services
Topic 1d:
Topic 6b:
Prescribing high dose and combination
antipsychotics on adult acute and intensive care
wards
Screening for metabolic side effects of
antipsychotic drugs in patients treated by assertive
outreach teams
Prescribing of high dose and combination
antipsychotics on adult mental health and
psychiatric intensive care wards: Time series
benchmarking
Assessment of side effects of depot antipsychotics
Topic 7a:
Monitoring of patients prescribed lithium
Topic 8a:
Medicines reconciliation
Topic 9a:
Use of antipsychotic medication in people with
learning disability
Topic 2d:
Topic 5b:
;
;
;
;
;
;
;
;
Royal College of Physicians (RCP) continence care audit
National confidential inquiry into suicide and homicide by people with mental
illness
;
28
The national clinical audits and national confidential enquiries that South West Yorkshire
Partnership Foundation Trust participated in during 2009/2010 and for which data collection was
completed during 2009/10 are listed below (as Table 4) alongside the number of cases
submitted to each audit or enquiry.
The percentage of the number of registered cases required by the terms of that audit or that
enquiry is not specified. The Prescribing Observatory for Mental Health (POMH) audits do not
specify a minimum number in their sampling framework criteria.
Table 4: National clinical audits data collection 2009/2010
Audit
POMH (Prescribing Observatory for
Mental Health) topic 2d
Data
collection
period
April 2009
POMH topic 5b
April 2009 –
March 2010
POMH topic 6b
October 2009
POMH topic 9a
June 2009
National confidential inquiry into suicide
and homicide by people with mental
illness
April 09
March 10
Number of cases submitted
N=121 (no minimum sample
identified: included all patients
prescribed an antipsychotic on
assertive outreach team caseloads)
Numbers variable for each month of
submission
N=151 (no minimum sample
identified: 11 teams collected a
minimum10 cases)
N=153 (no minimum sample
identified: consultant caseloads
sampled)
32 questionnaires received from the
NCI. 121 returns to date
1
Only 21 returned to date because of delayed data collection processes by NCI – 15 questionnaires sent by NCI in
the last 3 weeks of March 2010. All outstanding questionnaires are currently being completed
29
Table 5: National clinical audit – action
The reports of eight national clinical audits were reviewed by South West Yorkshire Partnership
Foundation Trust in 2009/2010 and South West Yorkshire Partnership Foundation Trust intends to
take the following actions to improve the quality of healthcare provided.
Audit and data
collection
period (number
submitted)
National falls and
bone health
2008
organisational
audit
POMH
(Prescribing
Observatory for
Mental Health)
Topic 1d
February 2009
(N=99 census
day)
POMH
Topic 2d
April 2009
(N=166)
POMH
Topic 5b
April 2009 to
March 2010
Summary results
46 of 58 eligible mental health
trusts and mental health
services submitted data for the
organisational audit.
Domain 2: Case finding and
referral score 83
Domain 5: service settings
score 88
Domain 6: Training and audit
score 89
Overall Trust score 87
54% antipsychotic prescribing
within BNF/SPC limits. 45%
received only one antipsychotic
at a time. 52% first and second
generation antipsychotics are
not prescribed concurrently.
For patients prescribed an
antipsychotic medication the
following annual measurements
completed:
56% blood pressure;
45% BMI or other measure of
obesity;
62% blood glucose or HbA1c;
lipids 27% (27% all four
aspects).
16% did not smoke;
52% offered help with smoking
cessation;
32% smokers not offered help
Data collection completed in
March 2010.
Report will be available in
June 2010.
Actions
An older people service local audit was
undertaken in regard to use of the falls risk
assessment tool (FRAT) for new admissions.
Inpatient areas were audited by a questionnaire
to clinical staff and a structured interview to the
ward managers. Reasons/barriers to the use of
FRAT were explored. A trust wide falls strategy
incorporating FRAT awareness and training is
being implemented. The Trust is also exploring
the use of assistive technology in its inpatient
areas in an attempt to reduce the frequency and
number of falls.
A large number of the combination and high
dose antipsychotics were due to prescribing as
required in the event of a rapid tranquilisation
episode. As a result the Trust is updating rapid
tranquilisation guidance and producing a new
prescription and administration chart.
Results to be taken to the drugs and
therapeutics Trust action group and an action
plan to be agreed together with the assertive
outreach team, physical health monitoring group
and drugs and therapeutics representatives.
POMH re-audit took place in March 2010.
A large number of the combination and high
dose antipsychotic were due to prescribing as
required in the event of a rapid tranquilisation
episode. As a result the Trust is updating rapid
tranquilisation guidance and producing a new
prescription and administration chart.
30
Audit and data
collection
period (number
submitted)
POMH
Topic 6b
October 2009
POMH
Topic 7b
October 2008
(N=131 nurse
led clinics)
POMH
Topic 8a
February 2009
(N=50 inpatients
6 adult wards
4 older people
wards)
POMH
Topic 9a
June 2009
Summary results
Actions
Report only received in March
2010
Results to be taken to the drugs and
therapeutics Trust action group and an action
plan to be agreed together with the assertive
outreach team, physical health monitoring group
and drugs and therapeutics representatives.
Before initiating treatment:
89% renal function tests
recorded;
89% thyroid function tests;
67% weight or BMI or waist
circumference.
Maintenance therapy:
56% serum lithium levels 3
monthly;
79% renal function tests 6
monthly;
73% thyroid function tests 6
monthly;
56% weight or BMI or waist
circumference annually
The Trust has an approved
policy which states: who is
responsible; time frame to take
place; where to document the
details of medicines
reconciliation.
16% - identified discrepancies
with the medication regimen;
26% - fewer than two sources of
information were checked.
96% of cases recorded
indication for treatment with
antipsychotic medication, 60%
had annual reviews to assess
side effects of antipsychotics.
Screening documented:
37% assessment for EPS;
35% obesity;
21% hypertension;
35% diabetes;
40% dyslipidaemia
The Trust’s Lithium safety group are to:
o Review the National Patient Safety Agency
(NPSA) Lithium safety alert
recommendations
o Revise the shared care guidelines
o Review the procedures with the acute Trust
laboratory departments to ensure
communication of blood results
o Adopt the use of the NPSA patient
information leaflets, lithium alert card and
record books for tracking blood tests
o In the interim, promote the Trust patient
safety cards
POMH re-audit April 2010
A business case has been produced for
improved medicines reconciliation in line with
NICE/NPSA guidance which will be taken to the
executive management team with the medicines
management strategy.
POMH re-audit November 2010
The learning disabilities medicines management
sub-group are:
o Developing a proforma to capture the side
effect monitoring
o A review of equipment is required for
weights and blood pressure recording
POMH re-audit Jan 2011
31
Local audits
The Trust undertakes a significant programme of clinical audit.
Clinical audit and evaluation involves reviewing the delivery of healthcare to ensure that best
practice is being carried out. Effective clinical audit and practice evaluation is critical to the
development and maintenance of high quality person-centred services.
Prioritised Trust-wide clinical audits are included in this section of the quality account. In addition
to the Trust wide audits a number of audits which are not shown in this report have also been
completed for individual teams, localities and care groups which include documentation and
local drug audits.
As part of the prioritised audit programme in 2010/11 the Trust will include any required audit to
support regional and local CQUIN (Commissioning for Quality and Innovation) reporting
requirements.
The reports of seven local (trust-wide) clinical audits were reviewed by South West Yorkshire
Partnership Foundation Trust in 2009/2010 and South West Yorkshire Partnership Foundation
Trust intends to take the following actions to improve the quality of healthcare provided (see
table 6 on the following page).
32
Table 6: local clinical audit - action
Local audit and data
collection period
(sample numbers)
Recovery standards –
re-audit July 2009
(50 service users
across 5 adult wards)
Summary results
Significant overall improvement in
6 out of 8 standards, slight
improvement in one standard and
a decrease in one standard.
Overall the Trust achieved 80% for
the care planning standards
Annual undetermined
deaths audit
Report produced July
2009
(35 deaths)
Annual ECT audit
(NICE) 2009/2010
Audit of clinical
management plans
(Non-medical
prescribing)
2009
(24 clinical
management plans)
Annual pressure
sores audit
Data period (01/11/08
– 31/10/09)
ƒMost common methods of suicide
were hanging and poisoning.
ƒMain diagnostic category was
depressive illness.
ƒNo service user died on an
inpatient unit but two people were
on home leave at the time of their
death. Four people died within a
week of discharge.
ƒDemonstrable continued action to
maintain good practice in line with
suicide prevention toolkit
standards
Annual audit demonstrates
compliance with NICE guidance.
ƒ 100% demographic information
recorded
ƒ100% prescribers contact details
recorded
ƒ100% relevant information on the
medication recorded
ƒ88% clinical plans recorded
formal service user agreement
There were a total of 6 service
users who were admitted with or
developed a pressure ulcer after
admission.
ƒ5
Collected January
2010
out of the 6 service users were
admitted with a pressure ulcer
ƒ1
(27 wards)
out of the above 5 service users
had 3 pressure ulcers when
admitted
ƒ1
out of the 6 service users
developed a pressure ulcer
Actions
Actions implemented by each ward
include:
ƒ Instigation of advanced directives
ƒ Reinforcement of patient information
leaflets
ƒ Re-launch of various activity groups
ƒ Use of recovery wheel
ƒ Review and revision of welcome
packs
Trust priorities for suicide prevention is
informed by the key areas for
prevention identified within the national
confidential inquiry report ‘Avoidable
deaths’ (December 2006).
The Trust reported on implementation
of its local avoidable deaths action plan
in 2009 (specific targeted action on key
risk areas – absconsion, transition,
CPA, attitudes to prevention, safe ward
environment).
No specific action identified as fully
compliant with all NICE requirements.
Framework revised following the audit.
The non-medical prescribing steering
group will re-audit following
implementation of the revised
framework.
Review of previous audit report led to
the following actions implemented in
09/10: the framework for the prevention
and management of pressure ulcers
reviewed; modern matrons and ward
managers ensured that all clinical staff
working in inpatient areas were fully
aware of Trust policy and procedures
for the prevention and treatment of
pressure ulcers; all staff understood the
importance of documenting pressure
ulcer information. Current audit report
will shortly be completed, results
reviewed and actions determined. The
audit process and findings support
locally identified CQUIN priorities.
33
Local audit and data
collection period
(sample numbers)
Health and safety
annual audit
Summary results
Analysis and report in progress
Nov 2009 – January
2010
Annual audit of case
note management
policy
Ongoing
Actions
Review of previous audit report led to
the following actions implemented in
2009/2010: Specific policies reviewed
and updated (such as COSHH,
RIDDOR, Waste disposal). Action on
risk assessments promoted by
introduction of minimum target of 80%
for teams/departments to achieve in
2009/2010. The health and safety Trust
action group are to determine further
action following review of the current
audit report.
Review of previous audit report led to
implementation of following actions in
2009/2010: Anomalies in layout and
format reviewed by health records staff
and resolved. Feedback, guidance
given to clinical teams. Tool adapted to
reflect increased use of electronic
record keeping before re-audit.
34
Table 7: local clinical audit – reports not yet completed
The following were new local audits in 2009/2010 - reports were not yet completed at the time
this quality account was produced.
Audit and data collection
period and sample
numbers
CPA audit.
December 09 to March 2010
Level 1 (electronic records)
820
Current status
Report completion
Closing date was 12th March
2010.
The audit will provide a baseline for
future audit.
Data analysis and summary
report to be produced by
March 2010.
The early results have been
reviewed by the CPA Trust action
group and will inform developments
in CPA recording and quality of care
planning.
Level 2 (qualitative review of
records) 135
Level 3 (service user and
carer survey) 25
Annual
prescription
chart
April 2009
April 2010
Annual
missed dose
audit
February 2010
Annual
antibiotic audit
February 2010
Privacy and dignity
Drugs and
therapeutics
audit
programme:
December 2009 to March
2010
183 service users
Essence of Care – care
environment
A benchmark report will be
produced comparing both
year’s data
Analysis and reports in
progress
Safe medicines practice group and
the pharmacy team will review the
report and develop action plans.
Audit completed on 3
occasions over a 3 month
period to support the DSSA
data collection:
ƒ 97% did not share a
bathroom area
ƒ 91% felt safe
Summary report to be completed by
31st March.
Data collection ongoing
To be completed early 2010/11.
March 2010
7 wards
35
2.2.3 Participation in research
The number of patients receiving NHS services provided or sub-contracted by South West
Yorkshire Partnership Foundation Trust (the Trust) in April 2009 to March 2010, that were
recruited during that period to participate in research approved by a NHS research ethics
committee was 38.
In 2009/2010 the Trust was involved in conducting 19 clinical research studies, including 6
National Institute for Health Research (NIHR) adopted studies.
This number of NIHR portfolio studies, demonstrates the Trust’s commitment to improving the
quality of care we offer and to making our contribution to wider health improvement.
One member of staff has been awarded a British Association for Behavioural and Cognitive
Psychotherapies research award hosted by the University of Huddersfield.
The Trust, works in collaboration with the West Yorkshire Comprehensive Local Research
Network funded posts of lead clinician and clinical studies officer working on Mental Health
Research Network (MHRN) projects. These posts have facilitated an important link with the
MHRN hub in Newcastle, and provided access and support to Trust staff wishing to engage with
MHRN supported studies. Whilst in its infancy, this development provides a significant
opportunity to increase the level of patient recruitment to clinical research studies and NIHR
portfolio activity within the Trust, previously outside this network’s activity.
As we move into a more challenging financial climate, research and innovation will become even
more important in identifying the new ways of understanding, preventing, diagnosing and
treating disease that are essential if we are to increase the quality and productivity of services
into the future.
36
2.2.4 Goals agreed with commissioners
A proportion of South West Yorkshire Partnership Foundation Trust’s income in 2009/2010 was
conditional on achieving quality improvement and innovation goals agreed between South West
Yorkshire Partnership Foundation Trust and any person or body they entered into a contract,
agreement or arrangement with for the provision of NHS services, through the Commissioning
for Quality and Innovation (CQUIN) payment framework. The Trust had agreed CQUIN goals
with the following Primary Care Trusts (PCTs) and local authorities:NHS Kirklees; NHS
Calderdale; NHS Wakefield District; NHS Barnsley (for the medium secure forensic multicommissioning group); Wakefield Metropolitan District Council. Further details of the agreed
goals for 2009/10 and for the following 12 month period are available on request from, Chief
Executive’s Office, South West Yorkshire Partnership NHS Foundation Trust, Trust
Headquarters, Fieldhead, Ouchthorpe Lane, Wakefield, West Yorkshire, WF1 3SP.
2.2.4(i) Commissioning for Quality and Innovation (CQUIN)
The CQUIN payment framework makes a proportion of providers' income conditional on quality
and innovation. Its aim is to support the vision set out in High Quality Care for All (the NHS next
stage review report) of an NHS where quality is the organising principle. The framework was
launched in April 2009 and helps ensure quality is part of discussions between providers (like
our Trust) and commissioners (like the PCTs). In response to the national NHS next stage
review, NHS Yorkshire and the Humber, the Strategic Health Authority (SHA) produced their
next stage regional review report called Healthy Ambitions which sets out eight clinical
pathways. Since then, all NHS organisations in the region have signed up to the SHA’s quality
assurance and improvement scheme, Quality Counts. This scheme covers the eight clinical
pathways set out in Healthy Ambitions as well as the three quality domains of patient safety,
effectiveness of care and patient experience. Quality Counts helped the delivery of a regional
set of quality indicators as the mechanism for delivering the nationally set CQUIN policy in
2009/2010.
Quality Counts set out the objective for the first year for provider organisations (like the Trust) to
deliver a comprehensive data set for each area. Delivery of all the data associated with each
relevant set of indicators gave trusts a payment of 0.5% of their total contract value. Data for
each relevant indicator was submitted at the end of each quarter to the SHA and commissioning
PCTs. The total Regional CQUIN contract monetary value for the Trust in 2009/2010 was
£482,937. The list of regional CQUIN indicators and Trust performance against these is shown
as table 8.
The Trust also agreed delivery against the regional CQUINs within its agreement with Wakefield
Metropolitan District Council. The contract monetary value for the Trust in 2009/10 being
£19,061.
Medium secure (forensic) services have been assessed against a number of CQUIN indicators
on safety, innovation, patient experience and effectiveness. In 2009/2010 the service has
worked with commissioners and other medium secure providers to identify and agree a suitable
tool to measure service user outcomes. Staff have been trained in the use of Health of the
Nation Outcome Scale (HoNOS) Secure and work is ongoing to develop a system for accurately
recording outcome data. To meet best practice guidance, service users must have a minimum of
25 hours structured activity and, with reference to the mutual respect work, a range of structured
activities have been identified and data collection and reporting mechanisms are being
established. The Trust’s medium secure service has also implemented all the required CPA
standards as well as using date to determine if any ethnic groups have higher length of stay,
detention rates and more frequent use of seclusion than expected The total CQUIN contract
monetary value for the Trust’s medium secure service in 2009/2010 was £112,243. The list of
medium secure CQUIN indicators and Trust performance against these is shown as table 9.
37
Table 8: Regional Commissioning for Quality and Innovation (CQUIN) 2009/2010
Regional CQUIN –
indicator and threshold
A. Improving access to assessment for
people experiencing acute mental health
problems
Responsive services leading to improved
client experience, reduced distress for
clients and families and lower suicide rates
• Baseline data collection
B. Improving access to assessment for
people experiencing non-acute mental
health problems
Early initial assessment as a first step
towards a ‘zero wait’ policy for mental
health problems across the region
• Baseline data collection and audit
C. Improving health outcomes for black,
minority and ethnic (BME) clients
Robust and comparable data on ethnicity of
service users across the region will give an
accurate picture of relative usage. Audit
will determine if any ethnic groups have
higher length of stay, detention rates and
use of seclusion than expected
• Baseline data collection
Measurement
Specified data
Trust action
• Quarterly data from Q2 09/10 on the number
of referrals to crisis intervention, leading to a
face to face assessment by a qualified
practitioner within 4 hours of referral being
made
• Quarterly data from Q2 09/10 on the number
of adult acute inpatient admissions gate-kept
in the quarter / total number of adult acute
inpatient admissions in the quarter
• Referrals to crisis
• Admissions
• Gate kept admissions
All data
submitted to
agreed
specifications,
meeting all
required
timescales
• Quarterly data from Q2 09/10 on number of
referrals received, requiring non-urgent
assessment, leading to an assessment by a
qualified practitioner within 14 days of referral
being made, and to appropriate first treatment
by a qualified practitioner within 28 days of
referral being made.
• Utilising HoNOS (Health of the Nation
Outcome Scale) (or variant eg
HoNOS+/SARN) publish quarterly data from
Q2 on number of unique service users with a
HoNOS score of 20+, whose HoNOS score
decreases by 20 or more within the quarter
• Referrals, non-urgent
assessment
• Summary of
Assessment of Risks
and Need (SARN)
scores
• In paid employment
• In settled
accommodation
• Age bands
All data
submitted to
agreed
specifications,
meeting all
required
timescales
• Provider will publish quarterly data from Q2
09/10 on the ethnicity of service users. Data
will be collected on entry into mental health
services, and by a range of service areas.
• Provider will publish quarterly data from Q2
09/10 to determine, by ethnic group, access
to inpatient services.
Unique service users
• Accessing psychological
therapies/crisis/
assertive outreach/early
intervention
• Newly detained (Mental
Health Act)
• subject to seclusion
• discharged from
inpatient
• Average length of stay
inpatient
All data
submitted to
agreed
specifications,
meeting all
required
timescales
38
Regional CQUIN –
Measurement
indicator and threshold
D. Improving standards of care and
• Data from Q2 09/10 on the percentage of all
compassion
inpatients who had a nutritional screening tool
Improved focus on care of elderly clients
administered during the quarter, broken down
with mental health problems, including
by Q2’s figures to be published in the return
dementia. Use of nutrition screening will be
following the end of Q3.
encouraged to reduce rates of malnutrition
• Undertake a point prevalence survey during a
and associated adverse outcomes.
single week of Q1 of all inpatients aged 65 or
Benchmarking of pressure sore rates
over.
across the region will allow identification of
outliers and development of remedial plans.
• Baseline data collection
• Annual pressure sore ‘point prevalence’
survey
E. Meeting the health needs of people
with a learning disability (LD)
An improved focus on learning disabled
clients with protocols which reflect the need
for admissions to be client appropriate.
Use of health and wellbeing plans will
increase the focus on the higher than
average physical health needs of this client
group and allow greater integration with
local primary care services.
• Baseline data collection
• Develop a protocol
• By the end of Q2 09/10 develop jointly agreed
admission protocols which aim to support
people with learning disabilities who may be
admitted to psychiatric services or acute
trusts.
• Quarterly data from Q2 09/10 on the number
of learning disability service users who have a
documented health and wellbeing plan /
number of learning disability service users of
assessment and treatment beds occupied by
someone who has their discharge delayed at
the end of the quarter / number of people
occupying assessment and treatment beds at
the end of the quarter.
• Quarterly data from Q3 09/10 on number of
service users surveyed that received a quality
of life review in the quarter / total number of
service users surveyed in the quarter of
learning disability service users who are in
paid employment and the number of service
users who are in settled accommodation.
Specified data
Trust action
• Admitted/stay over 48
hrs
• Screened using
nutritional screening tool
• Copy of screening tool
• Evidence tool meets
NICE guidance
• Evidence for how
screening informs care
planning
• Pressure sores
prevalence
All data
submitted to
agreed
specifications,
meeting all
required
timescales
• Protocol for admission
of LD to acute
• Number of LD service
users
• Number of LD service
users with documented
health and wellbeing
plan
• LD occupying
assessment and
treatment beds
• LD delayed discharges
• LD quality of life review
• LD in paid employment
• LD in settled
accommodation
All data
submitted to
agreed
specifications,
meeting all
required
timescales
39
Table 9: Medium secure services Commissioning for Quality and Innovation (CQUIN) 2009/2010
Medium secure
CQUIN
Safety
Key performance indicator
Frequency Threshold
Target
Trust action
Introduction of system for recording and
monitoring outcomes within the secure service.
Quarterly
Definition of
outcome
measuring tools
agreed across all
secure services.
Q1: Outcome measures
agreed for each area
Q2: System designed
for accurately recording
outcome data
Q3: System piloted and
information shared with
Commissioners
Q4: System rolled out
across service
All data
submitted to
agreed
specifications,
meeting all
required
timescales
Quarterly
Individual patient
care plans reflect
and record 25
hours per week
per patient of
structured activity.
Q1: Baseline activity
agreed across all
services with
commissioning team
Q2: system in place to
measure therapeutic
activity within the
service
Q3/Q4: system piloted
and information shared
with commissioning
team
All data
submitted to
agreed
specifications,
meeting all
required
timescales
Outcomes have been agreed through
commissioner/provider workshops and cover
the following areas; clinical; risk reduction; user
experience; therapeutic use of secure
environment.
Innovation
Expected outcome: consistent system for
measuring agreed therapeutic outcomes will
allow commissioning team and provider to
monitor outcomes accurately.
Introduction of system for recording and
monitoring outcomes within the secure service.
Secure providers will meet the quality standard
A81- best practice guidance for medium
secure units - DH health offender partnerships
2007: There will be a minimum of 25 hours
structured activity.
This will be a planned programme of treatment
education and work, taking into account: week
and day routine; range of therapy programmes
(including occupational therapy); psychological
sessions; structured activity programmes;
structure leisure time; unstructured free time;
access to real opportunities to work; substance
misuse; and offence-related therapy.
40
Medium secure
CQUIN
User
experience
Key performance indicator
Frequency Threshold
Target
Trust action
Providers will implement 'My future plan'
across secure services as the Yorkshire and
Humber standard for advanced directives.
Quarterly
Every service user
to be offered the
opportunity to
complete a plan.
Future plans to be
reviewed formally
at least at every
CPA meeting.
100% of service users
capable of completing
an plan to be offered the
opportunity of
completing a future plan
or equivalent as at end
of reporting period.
All data
submitted to
agreed
specifications,
meeting all
required
timescales
Providers will implement those service user
defined CPA standards as agreed across
Yorkshire and Humber by involvement group.
Quarterly
10 of the 20 CPA
standards to be
achieved within
2009/10 including
standards 1, 7 and
13.
Q2: 5 Standards
implemented including
1, 7 and 13
Q3: 8 Standards
implemented
Q4: 10 Standards
implemented.
All data
submitted to
agreed
specifications,
meeting all
required
timescales
Total number of service
users by ethnic group
• admitted to inpatient
services
• subject to seclusion
at any point in the
quarter by ethnic
• newly detained under
the mental health act
in the quarter
• discharged
Average length of stay
for service users
discharged.
All data
submitted to
agreed
specifications,
meeting all
required
timescales
All 20 Standards
to be achieved by
end of 2010/11
Effectiveness
Expected outcomes: robust and comparable
data on ethnicity of service users across the
region will give an accurate picture of relative
usage.
Audit will determine if any ethnic groups have
higher length of stay, detention rates and use
of seclusion than expected.
Quarterly
(from Q2)
Baseline data
collection.
41
2.2.4(ii) Commissioning for Quality and Innovation (CQUIN) scheme 2010/2011
The NHS in Yorkshire and the Humber have been working to develop indicators for the
2010/2011 CQUIN scheme on a regional level during 2009/10.
On the 22nd January 2010 the PCT chief executives determined that the allocation of money will
be broken down into the following:
ƒ
0.5% regional determination
ƒ
1.0% local determination
There are therefore two sets of indicators for 2010/11 – regional indicators and local (PCT
determined).
The total regional and local CQUIN contract monetary value is £1,362,453. The tables on the
following pages describe the regional indicators (table 10 on page 43) and the local indicators
(table 11 on page 45).
The contract with Wakefield Metropolitan District Council includes a CQUIN commitment in
respect of meeting the needs of people with a learning disability - Development and
implementation of integrated pathways for all clients with learning disabilities requiring mental
health services across all mental health provision: leading and working on partnership trust
elements of the pathway in partnership with all key stakeholders. The CQUIN contract monetary
value is £53,530.
Medium secure (forensic) and low secure services will be assessed against CQUIN indicators
agreed with the forensic multi-commissioning group in 2010/2011. The total CQUIN contract
monetary value for medium and low secure services is £356,354. Medium and low secure
indicators are described in table 12 on page 46.
42
Table 10: Regional Commissioning for Quality and Innovation (CQUIN) indicators 10/11
Regional CQUIN – Goal
Improving access for people
experiencing acute mental health
problems
Quality
domain
Experience
Indicator
ƒ Total
of all referrals to intensive home treatment, in the quarter
of those in 1a who required a face to face assessment, in the quarter
ƒ Total of those in 1b who are seen within four hours, in the quarter
ƒ Total
Adults of working age only (16-65)
Experience
ƒ Total
Improving outcomes for black,
minority and ethnic (BME) clients
Experience
ƒ Reduce
Improving standards of care and
compassion
Experience/
Safety
ƒ Number
Improving access for people
experiencing non acute mental
health problems
Adults of working age only (16-65)
Nutrition
- achieving best practice standards set
out in Essence of Care
number of referrals (by specialty) requiring a non urgent assessment in the
quarter
ƒ Total number of referrals for non urgent assessment who are assessed within fourteen
days
ƒ Total number of referrals (by specialty) assessed as requiring non urgent treatment in
the quarter
ƒ Total number of referrals (by specialty) assessed as requiring non urgent treatment
who receive treatment within six weeks in the quarter
the average length of stay within acute pathways of BME patients
ƒ Reduce number of BME patients detained under the Mental Health Act
ƒ Reduce number of BME patients subject to seclusion
ƒ Demonstrate annual equality impact assessments on all services
of patients admitted and remaining for more than 48 hours during the quarter
of these patients who were screened using appropriate screening tool during
the quarter
ƒ Number of these patients who were screened at discharge during the quarter
ƒ Number of patients admitted who were at “high” nutritional risk with appropriate
referrals/continuing care plans in place during the quarter
ƒ Essence of Care action plan
ƒ Number
Inpatients only
43
Regional CQUIN – Goal
Improving standards of care and
compassion
Pressure ulcers
- achieving best practice standards set
out in Essence of Care
Quality
Indicator
domain
Experience/ ƒ Providers must reduce the grading of pressure ulcers setting a downward trajectory, to
Safety
be agreed locally, for NICE grade III and above.
ƒ Providers must undertake 100% root cause analysis investigations of pressure ulcers
of NICE grade III and above
ƒ Providers must submit action plans to commissioners detailing delivery of Essence of
Care by the end of quarter 2.
Inpatients only
Meeting the needs of people with a
learning disability
Experience
ƒ Participation
at a senior level from clinical and management staff at steering group
meetings
ƒ Development
of a documented, agreed, access to mental health pathways / services,
with an associated dataset and an agreed action plan for piloting and implementation
ƒ Piloting / auditing of the pathways with adjustments made where indicated
ƒ Demonstrate that patients with learning disabilities in the Trust are following the
pathway, and care is given according to the pathway (threshold to be agreed)
ƒ Mental health and learning disability awareness training is commissioned and
commenced across the respective care group staff as part of the pathway development
Development and implementation of
integrated pathways for all clients with
learning disabilities requiring mental
health services across all mental
health provision: leading and working
on partnership trust elements of the
pathway in partnership with all key
stakeholders.
Dementia
Development and implementation of an
integrated dementia pathway across
mental health & learning disability,
community and acute sectors: leading
and working on partnership trust
elements of the pathway in partnership
with all key stakeholders
Experience
Participation at a senior level from clinical and management staff at all multi-sector
steering group meetings
Development of a documented, agreed, integrated sector pathway with an associated
dataset and an agreed action plan for piloting and implementation of the Trusts
elements of the integrated pathway
Piloting of the pathway with adjustments made where indicated
Demonstrate that patients with dementia in the Trust are following the pathway, and
care is given according to the pathway (threshold to be agreed)
Dementia awareness training commissioned and commenced as part of the pathway
development
44
Table 11: Local Commissioning for Quality and Innovation (CQUIN) indicators 2010/2011
Local CQUIN
Meeting the mental
health needs of
children and young
people (aged 16-18
yrs) within age
appropriate
environments
Supporting
appropriate, safe
information sharing
across professional
organisations
Improving patient
experience
Improving the
physical health
needs of mental
health clients
Care packages and
pathways
Falls reduction and
prevention
Description of Indicator
Development and implementation for age appropriate environments, for c hildren and young people; aged 16 – 18
years requiring emergency mental health assessment. To lead and work on partnership trust elements of the pathway
in partnership with all key stakeholders, (CAMHS) across Community and acute services.
The components of this indicator are:
a. Participation at a senior level from clinical and management staff at steering group meetings
b. Development of a documented, agreed, access to short term (max 72hrs) Age appropriate mental health pathways /
environments, with an associated dataset and an agreed action plan for piloting and implementation.
c. Piloting / auditing of the pathways with adjustments made where indicated
d. Demonstrate that 100% of children and young people requiring emergency assessment in the Trust are following
the pathway, and care is given according to the pathway
e. Enhanced CRB checks and children’s safeguard training is commissioned and commenced across the agreed
services as part of the pathway development (to achieve 90% I n with in patient staff retention rates)
Development and implementation of a multi agency information sharing protocol. The components of this indicator are:
a. Participation at a senior level from clinical and management staff at all multi-sector steering group meetings
b. Development of a documented, agreed, integrated protocol with an associated dataset and an agreed action plan
for piloting and implementation of the Trusts elements.
c. Piloting of the protocol with adjustments made where indicated
d. Demonstrate that information shared across the signed up agencies, is provided according to the agreed criteria,
timeframe identified within the protocol (threshold to be agreed)
e. Awareness training is commissioned and commenced as part of the policy implementation (to achieve 60%)
Develop Patient Reported Experience Measures (PREMS). Review true experience of patients throughout their
healthcare cycle and evidence improvements in patient reported experience. Patients reporting following discharge
from within acute in-patient settings that they were satisfied with treatment received and treated with privacy and
respect
a. Implement a programme of training in very brief anti-smoking and exercise interventions for mental health and
learning disability community team and inpatient professionals, to improve delivery of effective stop smoking and
exercise advice to patients. Brief advice can consist of three simple steps - Ask, Advise and Act.
b. % of patients who confirm they smoke at initial assessment who are referred to the local nhs stop smoking services
using the dept of health programme
Readiness to implement Care Pathways and Packages
Prevent and reduce the number and severity of falls sustained on Trust premises by older mental health patients
45
Table 12: Medium and Low Secure Commissioning for Quality and Innovation (CQUIN) indicators 2010/2011
Quality domain
Safety
Innovation
Service user
experience
Description of goal
Medium and low secure providers will use: Health of the Nation
Outcome Scales (HONOS) secure (including Payment by Results
elements subject to Dept of Health guidance when available) and
Historical Clinical Risk (HCR) 20
Medium and low secure providers will use the EssenCES Climate
Evaluation Scheme
Medium and low secure providers to demonstrate a robust
system/process that promotes the empowerment and involvement of
service users
Service user
experience
Medium and low secure providers will implement one new service
user defined service improvement
Service user
experience
Medium and low secure providers to further develop the quality
standard A81 of the best practice guidance for medium secure units
- Dept of Health health offender partnerships 2007 by developing a
benchmarking tool linking 25hr activity to personalisation and
recovery.
Medium and low secure providers will implement a recognised tool
for recovery planning.
Effectiveness
Description of Indicator
Use of HONOS secure and HCR20 for all
patients
During 2010/2011 all providers will introduce
the use of the tool
Providers will work in partnership with service
users to develop a service wide involvement
and personalisation strategy outlining
development of involvement at all levels of
the organisation (individual, ward, unit and
decision making).
i) Service providers will implement all 20 of
the service user defined CPA standards (2 yr
CQUIN).
ii) Service providers will meet the standards
outlined in the "whole dining experience audit
report".
To build on the 25 hour structured activity
using the Yorkshire and Humber service user
defined activity plan to link structured activity
to outcomes, personalisation and recovery.
Providers will implement a recognised tool for
recovery planning e.g. Recovery Star, WRAP
or "Working towards Recovery Plan" by Q4.
Once implemented every patient should be
offered the opportunity to complete a
recovery plan.
46
2.2.5 What others say about the Trust
2.2.5(i) Care Quality Commission (CQC)
The CQC are the independent watchdog of health and adult social care services across
England. To be registered with the CQC our Trust Board had to formally declare that we are
meeting all the new CQC registration regulations.
South West Yorkshire Partnership NHS Foundation Trust is required to register with the Care
Quality Commission and its current registration status is (registration from April 2010) ‘registered
without any imposed compliance conditions’. The CQC has not taken enforcement action
against South West Yorkshire Partnership NHS Foundation Trust during 2009/2010.
South West Yorkshire Partnership NHS Foundation Trust is subject to periodic reviews by the
CQC and the last review (for which the CQC have produced results) was the annual healthcheck
2008/2009. The CQC’s assessment of SWYPFT following that review was:
Table 13: CQC annual health check quality of services 2008/2009
Quality of service components
Component rating
Core standards
Excellent
National priorities
Good
Overall rating
Good
The specific reason the Trust did not achieve an overall ‘excellent’ rating was because we failed
one of the indicators under national priorities. The indicator we failed related to our selfassessment against something called the ‘Green light toolkit’ - a national priority that looks at
how good mental health services are for people with a learning disability. For this we had to
assess ourselves against 12 specific criteria and we had to do this across each of the 3 primary
care trusts (PCTs) in our area. There were two criteria that we rated red (we were not meeting
them), relating to culturally specific services and mental health promotion.
South West Yorkshire Partnership NHS Foundation Trust intends to take the following action to
address the points made in the CQC’s assessment.
We have implemented an action plan to address the indicator we failed against. Joint work has
been undertaken with the PCTs and local authorities (our commissioners) and during 2009/2010
the self-assessment ratings have moved towards green - meaning we now believe we are
meeting all the criteria. We are therefore hopeful that the Trust will successfully achieve the
national target in the 2009/2010 assessment.
The Trust has submitted all required information to the CQC in respect of the quality of services
review 2009/2010 but results have not yet been published.
Table 14: CQC quality of services review 2009/10
Quality of service components
Core standards
National priorities
Trust action
The Trust has declared itself compliant with all
core standards in 2009/2010.
The Trust has submitted all required information
and awaits the results.
47
In 2009/10 the Care Quality Commission hosted a series of regional meetings with partner
regulators and representatives from the strategic health authorities to support a common
approach to risk assessment and coordination of actions with NHS organisations. The Yorkshire
and Humberside planned collaborative review was held on the 8th December 2009 where there
was a systematic review of concerns for all trusts in the region. Through this discussion, there
was collective agreement that there are currently no areas of concern arising for the Trust that
were not already being addressed through contact with the regulator and/or the Strategic Health
Authority.
South West Yorkshire Partnership NHS Foundation Trust has not participated in any special
reviews or investigations by the Care Quality Commission during 2009/2010. However the trust
will participate in relevant reviews from the CQC 2009/10 special review programme such as the
‘physical health needs of those with mental health needs and learning disabilities’ once the data
collection period begins. (May/June 2010).
The trust did participate in some reviews conducted in 2008/09 for which the CQC published
results in 2009/10. These included Information Governance in healthcare organisations and
Safeguarding Children. The trust did not directly participate in the former as one of the selected
organisations to be visited by the CQC, but national data related to all NHS trusts in England
was examined by the CQC.
In regard to the Safeguarding Children survey, the trust was able to provide positive responses
for most of the survey questions. Areas of trust practice that were examined and strengthened
following the review were training (clarification of the training strategy and increasing levels of
trained staff) and ensuring safeguarding responsibility is covered explicitly in job descriptions for
clinical staff.
The trust has also participated in the CQC national staff and service user surveys. The 2009
service user survey related to the acute inpatient population and specifically targeted service
user views related to the priority improvement areas. The survey involved adult service users
who had a stay of 48 hours or longer within an acute inpatient unit between July and December
2008.
The Trust’s highest scores related to the survey section about the service users stay on the ward
(single sex accommodation, feeling safe, food, cleanliness). The Trust did least well on the
section related to the provision of activities on the ward. The Trust was ‘about the same’ in
comparison with other Trusts for all sections other than ‘about the ward’ where the scores were
‘better’. 75% of service users rated the overall care received as good, very good or excellent.
13% gave an overall rating of ‘fair’ and 12% ‘poor’. We have a detailed action plan to address
these concerns and a summary of these results are shown in the next tables.
48
Table 15: CQC acute inpatient service user survey 2009
Section heading
About the ward
Leaving hospital
Physical health checks
Talking therapies
Nurses
Introduction to the ward
Rights
Psychiatrists
Care and treatment
Medications
Activities
Overall
Score out of 10
for the Trust
7.82
7.18
7.23
6.94
6.91
6.88
6.79
6.72
6.66
5.02
4.24
5.96
How this score compares
with other Trusts
Better
About the same
About the same
About the same
About the same
About the same
About the same
About the same
About the same
About the same
About the same
About the same
Table 16: CQC acute inpatient service user survey - overall ratings
Excellent
Very good
Good
Fair
Poor
25% of service users
26% of service users
24% of service users
13% of service users
12% of service users
Table 17: CQC acute inpatient service user survey - highest/lowest scoring
questions
Top scoring questions
Lowest scoring questions
(Scores out of 100)
• During your most recent stay, did you ever
• During your most recent stay, were there
share a sleeping area, for example a room,
enough activities available during evenings
with patients of the opposite sex? (93)
and/or weekends? (36)
• When you arrived on the ward, did staff make
• Did the hospital staff explain the possible side
you feel welcome? (87)
effects of medication in a way you could
understand? (42)
• In your opinion, how clean was the hospital
room or ward that you were in? (87)
• During your most recent stay, were there
enough activities available during the day on
• During your most recent stay, were you ever
weekdays? (49)
bothered by noise at night from staff? (84)
• During your most recent stay, were you made
• How clean were the bathroom and toilets that
aware of how you could make a complaint if
you used in hospital? (83)
you had one? (53)
• During your most recent stay, did you have any
medical tests for your physical health? (83)
2.2.5(ii) Monitor
Monitor is the independent organisation who regulates all foundation trusts, including ours,
making sure we comply with the terms of our authorisation. Throughout 2009/2010 the Trust
has continued to prove that we are complying with all the terms of our authorisation. We had to
say how much at risk we were of our governance failing - which means whether the measures
put in place in order to ensure smooth functioning and control of the Trust work. We submitted
governance risk ratings of green throughout 2009/2010, which means we think we are meeting
all the terms and there are no risks around this. The Trust is required to report against national
targets for both Monitor and the CQC. Table 18 shows performance against national targets in
2008/2009 and year to date in 2009/2010.
49
Table 18: National targets 2008/2009 and 2009/2010
Assessed by CQC
Results
08/09
09/10
Target
09/10
Threshold
Access to crisis
resolution/home treatment
services
Access to healthcare for
people with a learning
disability
Best practice in mental health
services for people with a
learning disability
Not
specified
achieved
Awaiting
result
Not
specified
Not
included
Awaiting
result
Not
specified
Failed
Care Programme Approach
(CPA) 7 day follow up
Not
specified
Delayed transfers of care
Assessed by Monitor
Results
08/09
09/10
At March
09
97%
97.4%
Target
09/10
Threshold
100% enhanced CPA patients
receiving follow up contact
within 7 days of discharge
Minimising delayed transfers of
care
75%
No more
than 7.5
2.8%
3.1%
Awaiting
result
Admissions to inpatient services
had access to crisis resolution
home treatment teams
90%
93.4%
95.1%
achieved
Awaiting
result
Maintain level of crisis resolution
teams set in 03/06 planning
round (or subsequently
contracted with PCT)
8.3
8.9
Not
specified
Not
specified
Not
specified
achieved
Awaiting
result
Awaiting
result
Awaiting
result
achieved
Delayed transfers of care
(learning disabilities)
Not
specified
Not
specified
Not
specified
Not
specified
Care plans (learning
disabilities)
Not
specified
Ethnic coding data quality
Mental Health Minimum Data
Set (MHMDS) data
completeness
Mental Health Minimum Data
Set (MHMDS) patterns of care
Patient experience
Staff satisfaction
(see page 47 for
explanation)
achieved
achieved
satisfactory
achieved
achieved
achieved
-
Awaiting
result
Awaiting
result
Awaiting
result
Awaiting
result
Awaiting
result
50
2.2.6 Data quality
2.2.6(i) NHS number and medical practice code validity
South West Yorkshire Partnership NHS Foundation Trust submitted records during 2009/2010 to
the secondary uses service for inclusion in the hospital episode statistics which are included in
the latest published data.
ƒ The
percentage of records in the published data which included the patient’s valid NHS number
was 99.8% (to date) for admitted patient care (08/09 percentage was 99.7%)
ƒ The
percentage of records in the published data which included the patient’s valid general
medical practice code was 100% (to date) for admitted patient care (08/09 percentage was
100%):
(Outpatient care and accident and emergency care are not applicable to the Trust)
2.2.6(ii) information governance toolkit attainment levels
South West Yorkshire Partnership NHS Foundation Trust’s score for 2009/2010 for information
quality and records management, assessed using the information governance toolkit was 66%.
2.2.6(iii) Payment by Results (PbR)
PbR is a transparent, rules-based financial system which rewards Trust’s efficiency and supports
patient choice.
South West Yorkshire Partnership NHS Foundation Trust was not subject to the PbR clinical
coding audit during the reporting period by the Audit Commission.
51
Part 3 52
3.1 Review of quality performance
On the following pages we present data that is relevant to local stakeholders (people who take
an interest in the Trust). These have been determined by quality priorities and identified
indicators.
The Trust identified five key quality priority areas:
ƒ mutual respect between service users and teams/ individuals
ƒ personalised care
ƒ improving practice and positive outcomes for service users
ƒ environment and hotel services
ƒ suicide prevention and risk management
These relate to the three quality domains of ‘safety’, ‘service user experience’ and
‘effectiveness’. Read more about how we chose these priorities on pages 24-25.
The Trust has specified a selection of indicators against each of the above five priority areas and
the three quality domains – safety, service user experience and effectiveness. The underlying
reason for the choice of each indicator is described and, wherever possible, historical and
benchmarked data is referenced.
Within this part of the account there is also specific information relating to indicators used in the
Trust’s 2008/2009 quality report. This includes reasons for any changes to the use of these
indicators in the 2009/2010 quality account.
We have chosen to use this part of the report to focus specifically on performance against the
indicators. In part 1 of this quality account there is descriptive detail of many examples of service
interventions and innovations implemented by the Trust in 2009/10 against the three quality
domains. (Read these on pages 9-20)
Commissioning for Quality and Innovation (CQUIN) payment framework makes a proportion of
providers' income conditional on quality and innovation. Read more about CQUIN on page 37.
CQUIN indicators are extremely important parts of any quality plan as they represent what the
commissioners have identified as demonstrating quality, according to local needs. However, as
CQUINs have been fully identified and already reported in part 2 of this quality account (pages
37-46) they are not repeated in part 3.
National targets reported to the regulators (Monitor and CQC) are also important indicators of
service quality. Information relating to national targets is shown on pages 47-50 under ‘What
others say about the Trust’ and so are not repeated in part 3.
Read on to see how we have reviewed our quality performance for 2009/2010.
53
There are in total 16 local quality indicators identified within this section of the Quality Account. 6
indicators relate to safety; 10 indicators relate to patient experience; 10 indicators relate to
effectiveness. (Some indicators relate to more than one of the three quality domains)
Table 19: How the local quality indicators relate to the quality domains
Indicator
Related Domain
Safety
Experience
Effectiveness
Complaints upheld with staff attitude as an issue
Annual community service user criteria related to
dignity and respect
National CQC inpatient survey criteria related to
dignity and respect
Service users on new CPA offered a copy of their
care plan
Annual community service user criteria related to care
planning
Trust-wide CPA audit criteria
Service user survey criteria related to positive
experience
Compliance with NICE standards
Staff receiving appraisal in last 12 months
Implementation of integrated packages of care
Eliminating mixed sex accommodation
Hygiene code criterion 2 - clean and appropriate
environment
PEAT audits - good quality environment, food and
privacy and dignity
Staff awareness and knowledge of safeguarding
All service users have a clinical risk assessment
Prevention of deaths within most preventable high
risk factors – absconding and within 1 week of
discharge
54
3.1.2 Priority area - mutual respect between service users and teams/ individuals
Rationale for indicators inclusion
To improve the quality of services it is important to understand what people who receive our care feel about their treatment. Staff attitudes and
behaviours consistently feature as one of the most important aspects of care in feedback from service users and carers. Complaints and national and
local service user experience survey results can be used to identify and target areas for improved performance.
Local quality indicator
Complaints upheld with
staff attitude as an issue
Construction
% average across 12 months
Minimum
target 09/10
< 45%
Performance
08/09
Performance
09/10
30%
21%
80%
75%
89%
88%
Achieved 09/10
Domain – service user experience
Annual community service
user (local) survey criteria
related to dignity & respect –
‘yes definitely’ scores.
Did the psychiatrist treat you with
respect & dignity?
75%
Did the CPN treat you with respect &
dignity?
Domain – service user experience
National CQC Inpatient
Survey Criteria related to
dignity & respect – ‘yes
definitely’ scores
Did the psychiatrist treat you with
respect & dignity?
Score within top
half of all Trust
scores
(> 80)
75
N/A
74
Did the nurses treat you with respect
& dignity?
Score within top
half of all Trust
scores
(>74)
Domain – service user experience
55
3.1.3 Priority area – personalised care
Rationale for indicators inclusion
Care planning is a fundamental aspect of care within mental health and learning disability services. Service users should feel they have been fully
engaged in care planning, that it is a beneficial process and should be offered a copy of the care plan to support their full involvement. Care planning
should be properly recorded and include critical aspects to ensure an appropriate service response to service user needs.
Local quality indicator
Service users on new CPA
recorded as being offered or
given a copy of their care
plan
Construction
Minimum
target 09/10
Performance
08/09
Performance
09/10
80%
Month 12
76.6%
Month 12
85%
75%
58%
79%
79%
48%
52%
% of all those on new CPA recorded on the electronic
information system as being offered a copy of their care
plan
Achieved 09/10
Domain – effectiveness
Told who their care coordinator is
Annual community service
user (local) survey criteria
related to care planning –
‘yes always/definitely’
Can contact care coordinator if have a problem
75%
If had care review found it helpful
Domain – service user experience
Trust-wide CPA audit criteria
2
Electronic case records (n= 820) completed: Care plan;
Relapse indicators; Contingency plan; Crisis plan; 24/7
contact details
75%
N/A
Score range 79
96%
3
75%
N/A
Score range 81
95%
Care plan identifies: Needs/ aspirations; How these are
addressed; Desired outcomes
4
CPA audit service user survey (n = 20) Have a care plan;
agreed the care plan; fully involved in production of the
care plan; care plan identifies what is expected from me;
how other people support me; what services/support will
be provided.
50% or
more
against all
criteria
CPA audit carer survey criteria (n = 10) Been involved in
(service user’s) care plan; reviewing their care; able to
identify and discuss risks.
50% or
more
N/A
Above 50% for
all criteria
N/A
Above 50% for
all criteria
Domain – safety, effectiveness and service user experience
2
CPA audit - Includes working age adults, older people and forensic services but learning disability (LD) figures are excluded as LD was brought under new CPA processes later in year
CPA audit – Different criteria used for forensic (medium secure) in this part of the audit so forensic not included
4
CPA audit – lower target set as piloting audit process and seeking to establish baseline from first year of conducting the audit
3
56
3.1.4 Priority area - improving practice and positive outcomes for service users
Rationale for indicators inclusion
The Trust must respond to national regulator findings such as the CQC who have stated that too great a proportion of service users feel let down in
important aspects of care such as feeling safe on the ward. Effectiveness may be demonstrated by compliance with national standards (such as NICE).
Workforce development is recognised as critical in underpinning good practice.
Local quality indicator
Construction
Minimum
target 09/10
Performance
08/09
Performance
09/10
75%
80%
83%
National CQC inpatient survey criteria
overall, how would you rate the care you received
during your recent stay in hospital
Score within top half
of all Trust scores
(>57)
N/A
60
During your most recent stay were there enough
activities available: during the day on weekdays;
during evenings and weekends?
5
Score within top
half of all Trust
scores (>45/31)
N/A
49/36
CQC inpatient survey criteria
During your most recent stay did you feel safe?
Score within top half
of all Trust scores
(>64)
N/A
71
Achieve all 4 criteria: All relevant guidance placed
with lead group for initial review/implementation
within 4 weeks of publication; Quarterly
compliance & risk updates received for all relevant
guidance; No ‘red’ internal risk gradings (relating to
compliance & action plan status); No ‘amber’
internal risk grading reported for same piece of
rd
guidance for a 3 consecutive quarter.
100%
N/A
100%
% of staff who have had an appraisal in last
12 months
> 80%
Month 12 – 76%
Average 09/10
80%
Local community survey - overall, how would you
rate the care you have received from mental health
services in the last 12 months (excellent/very
good/good)
Service user survey
criteria related to positive
experience
Achieved 09/10
Domain – service user experience
Compliance with National
Institute for Health & Clinical
Excellence (NICE) standards
Domain – effectiveness
Staff receiving appraisal (in
last 12 months?)
Domain – effectiveness
Implementation of
integrated packages of care
% of service users assessed using the
integrated packages approach to care
assessment
Month 12 – 77%
Month 12 –
84%
Domain – effectiveness
5
Although within the top 20% of trusts nationally the performance against this criterion is low and part of improvement action planning
57
3.1.5 Priority area - environment and hotel services
Rationale for indicators inclusion
Service users should be seen in safe, accessible surroundings that promote their well being (CQC regulation 15) This encompasses national priorities such as
the elimination of mixed sex accommodation and effective infection prevention and control. Service users in inpatient areas are at increased risk of contracting
an HCAI due to potential exposure to infections in other service users, staff and visitors. Compliance with the food safety act requires that food handling areas
are thoroughly inspected. Having a choice of good quality food at mealtimes encourages people to eat and lessens the risk of malnourishment/ poor diet.
Local quality indicator
Eliminating mixed sex
accommodation
Construction
Provision of designated sleeping
accommodation for men and
women
Minimum target
09/10
Performance
08/09
100%
N/A
Performance 09/10
Achieved 09/10
The Trust is 100%
compliant in providing
designated sleeping
accommodation for men
and women.
Domain – service user experience
Hygiene code criterion 2
provide & maintain a clean
and appropriate environment
which facilitates prevention
and control of HCAI
Hygiene criteria scores from all
internal & external PEAT audits
throughout the year.
To maintain a
mean PEAT score
of 4/5.
Mean score of
4/5.
Mean score of 4/5.
The scoring range for PEAT
audits is 0 (unacceptable) to 5
(excellent).
Domain – safety, effectiveness and service user experience
Good quality general
environment, food and
privacy & dignity
‘Excellent’ PEAT scores reported
by National Patient Agency re:
General environment, food and
privacy & dignity
Peat audits - Average food safety
scores
Achieving Excellent
or Good for all units
assessed (11).
100%
100%
Average scores for
all units > 70%
100%
100%
Choice of Food at Main Meal –
internal and external PEAT
scores
100%
N/A
100%
Unannounced monitoring visits
Quality of Food acceptability
scores (re: appearance, smell,
taste, texture)
All units to score
above 70%
N/A
100%
Domain – safety, effectiveness and service user experience
58
3.1.6 Priority area - suicide prevention and risk management
Rationale for indicators inclusion
Staff must comply with safeguarding procedures and reporting. A key requirement is compliance with the statutory guidance "Working Together to
safeguard Children". Staff should have a clear understanding of abuse, local procedures of reporting and where to access further guidance/support.
Individual clinical risk assessment is a critical factor in suicide prevention. Learning from the national confidential inquiry into suicide and homicide is
that effective management of high risk factors can prevent deaths. People who abscond or who have recently transferred from inpatient units back into
the community can be particularly vulnerable and at risk of attempting suicide. (Anyone on CPA who is discharged should be contacted within 7 days).
Local quality indicator
All staff working in health
care settings (clinical and
non-clinical) have
awareness and knowledge
of who to report
safeguarding children
Construction
Minimum target
Performance
08/09
100%
N/A
100%
N/A
Performance 09/10
•
All staff have received
safeguarding
awareness information
•
Leaflets sent to all
new staff & induction
sessions
implemented.
•
N/A
March 2010 position
70% of staff trained.
Over 80% in clinical
grades.
80% across all care
groups
N/A
All care groups > 80%
80% in both adult
and older people
N/A
53% & 66%
Annual undetermined deaths
audit : Number of deaths of
people who had absconded from
an inpatient ward.
0
0
0
Annual undetermined deaths
audit: Number of deaths of
people within 1 week of
discharge.
0
4
0
• All staff made aware of
safeguarding children procedures
by one or more awareness raising
methods
• All new staff to be provided with
information on’ what to do if you
think a child is being abused’ via
leaflet sent with appointment letters
and safeguarding training session
on trust induction.
• All staff to have level 1/2 training
and to be updated 3 yearly (3 year
programme with start date Sept07).
>70% staff trained
at level 1 or 2 by
end of 09/10
Achieved 09/10
Domain – safety and effectiveness
All service users have a
clinical risk assessment
Trust-wide CPA audit (n = 820)
Sainsbury Level 1 Risk
assessment or HCR 20
(Forensic Services) Recorded
Trust-wide CPA audit – (n = 820)
Sainsbury level 1 risk
assessment completed /updated
in last 12 months
Domain – safety, effectiveness and service user experience
Prevention of deaths within
most preventable high risk
groups identified from the
national confidential inquiry
into suicide and homicide
Domain – safety and effectiveness
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3.1.7 Quality indicators which were reported in the Trust’s 08/09 quality report Domain
Indicator
Safety
100% of patients who are on ‘enhanced CPA’ receiving contact
from Trust staff within 7 days of discharge
Meeting all criteria in the Hygiene Code
Effectiveness
Experience
Key national
priorities
Reported in
09/10 quality
account
Yes
(now ‘new CPA’)
Yes
NHS Litigation Authority (NHSLA) risk management standards
level 1
No
Care Pathways and Packages – staff trained in new assessment
process
No
Care Pathways and Packages – percentage of service users
assessed using the integrated packages approach to care
NICE – as at 4th quarter of year – no relevant guidance assessed
as high risk (red) in relation to how the Trust has met the
guidelines and planned actions around them
Percentage of service users on ‘enhanced CPA’ being offered a
copy of their care plan and this action being recorded (adult and
older peoples services)
Improved scores against 4 particular statements against HCC
national service user survey – community mental health services
Yes
Where reported
Part 2, page 50
Part 1 – specified
within text. More
specific criterion
reported against in
part 3, page 58.
The Trust has maintained
level 1 and will not be
assessed for level 2 until
2010/2011
Indicator achieved in
2008/2009 and no longer a
key performance indicator
for the Trust in 2009/2010
Part 3, page 57
No
Yes
Improved NICE indicator
reported against in part 3
Part 3, page 56
(now ‘new CPA’)
No
Percentage of complaints replied to within agreed deadlines
No
Monitor targets
Care Quality Commission targets
Standards for Better Health – core standards
Yes
Yes
Yes
If not reported – reason
why
The national community
survey was not repeated by
the HCC/Care Quality
commission for 09/10
Specific indicator related to
staff attitude used in
2009/2010 to reflect one of
the identified quality
priorities – mutual respect.
Reported in part 3.
Part 2, page 50
Part 2, page 47
Part 2, page 47
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3.2 Statements from Local Involvement Networks, Overview
and Scrutiny Committees and Primary Care Trusts
o Commissioning PCTs are required to corroborate a provider’s Quality Account by
confirming in a statement, to be included in a provider’s Quality Account whether or not
they consider the document contains accurate information in relation to the services
provided to it by the provider. In addition PCTs can include in the statement any other
information they consider relevant to the quality of NHS services provided by the provider
for the year reported on.
o Local Involvement Networks (LINks) and local authority Overview and Scrutiny
Committees (OSCs) must be provided with the opportunity to (on a voluntary basis)
review and supply a statement, for inclusion in a provider’s Quality Account. The
statement is to indicate whether they believe, based on the knowledge they have of the
provider, that the report is a fair reflection of the healthcare services provided.
NHS Kirklees has provided the following statement for inclusion in the Quality Account on
behalf of all three Commissioning PCTs:
“On behalf of NHS Kirklees, Calderdale and Wakefield district: We would like to confirm that
we feel that the presented quality accounts for South West Yorkshire Partnership NHS
Foundation Trust are an accurate account. However we would like to see greater reference
within the content to the strong partnership arrangements in place between ourselves as
commissioner/provider organisations and the benefits achieved through joint approaches to
commissioning. Also further comment to reflect the strength of the partnering relationships
which you have developed to support the delivery of improved service quality and outcomes.”
Although all LINks and Overview and Scrutiny Committees were invited to comment, only
one Overview and Scrutiny Committee and one LINk decided to do so. The following is the
statement provided by Kirklees Council’s Overview and Scrutiny Committee:
“During 2009/10 Chief Executive Steven Michael and officers from SWYPFT have actively
engaged with Kirklees Council’s Overview and Scrutiny panels; providing regular and timely
updates on a number of key issues and topics, including the reconfiguration of mental health
services. The Trust has made a commitment to continue to have regular and ongoing
dialogue with Scrutiny as the plans for the reconfiguration develops and take shape.
Representatives from SWYPFT attended an Adults and Healthier Communities panel
meeting in October 2009, to provide information on the health services response to
dementia, a topic that was on the panels work programme following the development of a
local dementia strategy produced in partnership with the local authority, Health Trusts and
other key local stakeholders. Arrangements were made by the Trust for members of the
Panel to visit its facilities based at St Luke’s Hospital.
SWYPFT has also supported the work of the Health Inequalities Scrutiny Panel on a piece of
work the panel has undertaken on the causes and effects of Social isolation on people with
learning disabilities entitled “Independence without Isolation”. In its Quality Accounts the
Trust has highlighted that during 2009/10 significant work has been progressed around
developing accessible information in LD services. In addition, the Trust has highlighted the
work it is doing to support and help people with a LD gain employment within the Trust
including job restructuring.
Employment issues and clear signposting to services are areas that Scrutiny had identified
that needed to be improved and made a number of recommendations within its
“Independence without Isolation” report, and will be following up on these recommendations
during 2010/11.
The work being done by the Trust on issues in relation to dementia and learning disability
and other priority areas highlighted in the Quality Account will be considered by Scrutiny,
when it starts to develop and shape its work programme at the start of the municipal year.”
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The following is the statement provided by Kirklees LINk:
“Kirklees LINK welcomes the Quality Account from the South West Yorkshire Partnership
NHS Foundation Trust (SWYPFT).
This commentary seeks to discuss areas that the LINk has knowledge and awareness of. We
see this document as setting a baseline for future assessment. We welcome this approach
but know that its true effectiveness will only become evident over a period of time.
Kirklees LINk welcomes the extra resources that have been made available for Psychological
Services in the district. For many years’ people with deep seated common mental health
problems have relied on the services of family doctors. We welcome these new services that
have been made available with the support of NHS Kirklees.
We applaud SWYPFT’s involvement approach, the Dialogue Groups and other mechanisms
that have created real opportunities for people to influence how the organisation makes
decisions. We know that this builds on a deep culture of involvement embedded in the
organisation and believe that this demonstrates a real commitment to including people in
decision making. We hope that this will be extended and that the Trust will support service
user led services in Kirklees.
Kirklees LINk welcomes the Trust’s aspiration to reduce the detention of Black and Minority
Ethnic people and the time they spend in acute mental health care pathways. This population
group is over represented in this type of mental health care in every large metropolitan area
of the country for reasons that remain difficult to determine. An organisational approach to
engaging with this area of difficulty is welcomed.
Although the move off the St Luke’s Hospital Site, Huddersfield, is not within the reporting
period, Kirklees LINk must reflect they generally felt disappointment that psychiatric inpatient
services will not be available in Huddersfield. We know that services will be available in
Halifax and Dewsbury for an interim period. We wish to ensure that the impact of travelling to
visit relatives and to support discharge processes will play a part in these interim
arrangements. We are aware that these service changes only affect a small number of
people at a time; nonetheless Kirklees LINk looks forward to robust local mental health
services local to the people of Huddersfield and Dewsbury/Batley that are designed to
sustain their wellbeing in the most appropriate way.
Lastly we urge the Trust to develop services that match local requirements for the delivery of
services to people with a learning disability. We also urge the Trust to attend to creating
services that meet the needs and cultural expectations of the many communities and
cultures that make up Kirklees. Kirklees LINk believes that services that are flexible, dynamic
and sensitive to the range of human experience will help the Trust both meet its CQC targets
and provide a better service for all.”
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3.3 Your comments are welcome
We hope you have found our quality account interesting and easy to understand. We’d love
to hear what you thought of it, so please let us have your comments by using the contact
details below. Please also let us know if you would like to get involved in helping us decide
our priorities for improving quality.
This report can be made available in a variety of formats, available on request.
And stay in touch!
Would you like to stay in touch with the Trust by becoming a member and receiving our Trust
magazine? To become a member get in touch with us at:
Communications
Fieldhead
Ouchthorpe Lane
Wakefield WF1 3SP
comms@swyt.nhs.uk
01924 327689
Our website
The Trust’s website has been redesigned so it now not only gives more information about the
Trust but also about mental health and learning disabilities and how to look after your
wellbeing. You can also sign up as a member of the Trust on our website, read the latest
issue of our magazine, Like minds, and view our latest news and performance information.
Do all this at
www.southwestyorkshire.nhs.uk
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