Quality
Account
2014/15
Contents
Introduction
1
Patient safety
Board Statement on Quality
Assessment of patient safety
About Partnerships in Care
Monitoring patient safety
Quality and Clinical Objectives 2014/2015
Management of patient safety
Patients as partners in their care - Clinical Objectives 2015/2016
Physical healthcare
Governance
Medicines management including POMHS
Regulatory performance
8
Patient experience
24
28
Patients as partners in their care
Regulatory Performance Report
1. Engaging people in being healthy
Clinical effectiveness
10
2. Shared decision making
3. Supported self-management
Medium and Low Secure Network (QNFMHS), LD peer review (CRG-FIDD),
Brain Injury Services Network (INPA)
4. Employability
Every day counts – monitoring and managing average patient length of stay (AVLOS)
6. Choice of care closest to home
Ways we measure clinical effectiveness
7. Patient-focused research
Service overview by diagnosis
8. Evaluating services through feedback
5. Involving families and carers
MI/PD services
LD services
Our workforce
43
BIS services
Acute, HDU, PICU services
Introduction
EuroQol report
Staff Survey report
HoNOS Factor 4 report
Learning & development and mandatory training report
External views on the PiC Quality Account 2014/15
46
Audits, comments and views from our stakeholders
Glossary
Partnerships in Care would like to thank the four patient artists from Kemple View, The Dene, Arbury Court
and Kneesworth House Hospital for granting their permission for us to reproduce their art work.
47
Summary review of clinical performance 2014/2015
Every year, our Quality Account charts our contribution to a
journey to better health for thousands of patients across the UK.
It also reports on our constant measurement of patient outcomes
throughout considerable change and growth. In 2014/15 we
increased capacity from 1250 placements to approximately
1400 and extended care pathways with the addition of three new
hospitals. By June 2015, we have further grown and diversified our
services and continue to be a trusted partner to the NHS.
We have actively developed our services in line with national programmes for service
transformation. This account describes performance and future pledges that will focus on
quality governance, achieving parity of esteem for mental health, delivering patient choice
and providing least restrictive care as close to home as possible. Our approach to quality
governance actively involves all of our staff, patients, residents and their family and friends.
Through 2014/15 our services have been compliant with regulatory inspections. We fully
satisfied follow-up inspections to review specific issues raised in the previous reporting year
at two of our hospitals.
Our top priority is always to deliver safe and recovery-focused care. This account also
describes how we support and value our staff through good recruitment processes and
bespoke learning and development opportunities. The Board continuously seeks assurance
that staff share our values. Our Ward to Board approach is transparent, responsive and
effectively disseminated through all levels of the organisation. Staff can contact the Board
through various routes. Concerns can also be raised through our independent 24-hour
Concern Line.
Patient access to healthcare records has improved. We have made great strides in
this regard through electronic patient records (EPR), IT improvements and our new bespoke
system, PathNav (see page 31). Our patient survey and CPA Audit results evidence this
improvement.
We strive to embrace technology and make it accessible to patients and their families and
our staff. We improved broadband speeds, introduced video conferencing equipment
and made our EPR faster to use.
In this account a number of sections demonstrate our commitment to reducing restrictive
intervention through positive and preventative management of risk, including collaborative
risk assessment and promotion of appropriate behaviour.
Statement on data quality
We are proud of our increasingly accurate methods of achieving data integrity in the
measurement of patient outcomes and clinical effectiveness and sought to validate this
independently. This year, Partnerships in Care have commissioned PriceWaterhouseCoopers
to undertake internal audit on the Quality Report to determine if it meets the requirements
outlined in the Department of Health’s Guidance for NHS Trusts on arrangements for
external assurance 2014/15 publication. This includes work to confirm the content of
the report, the consistency with supporting documentation and sample testing of two
performance indicators, Care Programme Approach Survey results and HONOS score
change – improvement in total HONOS score and sub scores. The results of the work
will be reported internally, once the work has been undertaken in July 2015. The Board is
satisified that the data presented here is of a high quality and that it evidences our delivery
of recovery-focused care.
We hope you find our Quality Account informative. We are always pleased to receive
your comments.
Patients and residents too, have many direct routes to raise concerns, including advocacy
provided by Rethink Mental Illness. The Board is confident these systems work well to
provide accountability and transparency; to reduce risk and enhance patient safety.
e have delivered compassionate, recovery-focused
W
patient care. The extension of our care pathways means
we now also care for people in community placements.”
Joy Chamberlain
Group Chief
Executive
Dr Quazi Haque
Executive Medical
Director
Introduction
Board statement
on quality 2014/2015
Patients as partners in their care
Summary review of clinical performance 2014/2015
Fig. 2 Occupancy by diagnosis at each year end
Partnerships in Care is one of the UK’s most experienced, expert
and geographically well-spread independent specialist providers
of secure and step down mental health care. We provide services
across a wide diagnosis base and with a growing range of care
settings, from medium secure to open rehabilitation and specialist
residential services in community facing houses. In 2015 it will be
30 years since we were first established.
We have steadily grown our capacity for patient placements and at 31 March 2015 are
set for significant further growth due to the commitment to investments made possible
with Acadia healthcare, our parent company since July 2014. By end March 2015, we had
added three new units – Burton Park in Leicestershire, serving people with acquired brain
injury (ABI) (50 beds); The Copse in Weston-super-Mare, Somerset for people with mental
illness (24 beds) and Fern Lodge in Chester, community housing for people recovering
from mental illness (17 beds).
This extended our capacity from 1250 last year to 1400 patient placements, in particular
increasing capacity for step down to rehabilitation and more provision in ABI. Within
our existing hospital base we also expanded capacity for assessment and shorter term
placements for patients in services such as Acute wards, High Dependency Units (HDU)
and Psychiatric Intensive Care Units (PICU). This year PICU, HDU and Acute served
625 people. Overall, we treated 2,096 patients, an increase of 6.5%.
The new hospitals in Somerset, Leicestershire and Chester expands our care pathways
and we look forward to announcing further expansion in 2015/2016. At time of publication
of this report (June 2015) we have already announced several new acquisitions which
represent significant expansion and so for comparative purposes please see the maps
on page 3.
About our patient groups and services
Diagnosis
31.03.2014
31.03.2015
Acquired brain injury
4%
5%
Conditions within autism spectrum
2%
2%
Intellectual / learning disability
20%
21%
Mental illness
52%
51%
Personality disorder
19%
18%
Assessment services such
as Acute/PICU/HDU
4%
4%
Looking at Figure 2 we see the proportion of patients across diagnoses remains broadly
the same.
Fig. 3 Total patients treated by security level (over 2 years)
30%
25%
20%
15%
10%
5%
Fig. 1 Total patients treated (3 years)
2013/2014
965
951
1967
2014/2015
1079
932
2096
Security level
2013/2014
2014/2015
2
Partnerships in Care Quality Account 2014/15
PICU
1685
HDU
683
Acute
730
Community
2012/2013
0
Open
Patients treated
Locked
Discharges
Low
Admissions
Medium
Patient
Introduction
experience
About Partnerships in Care
Summary review of clinical performance 2014/2015
Map of PiC Services March 2015
Map of PiC Services June 2015
Location
Kemple View
Blackburn, Lancashire
The Spinney
Atherton, Manchester
Arbury Court
Cheshire, Warrington
Fern Lodge
Cheshire, Chester
Abbey House
Malvern Walls
Aderyn
Pontypool, Wales
Llanarth Court
Monmouthshire, Wales
The Copse
Weston-super-mare
The Ayr Clinic
Ayr, Scotland
Stockton Hall
Stockton-on-the-Forest, York
Hazelwood House Chesterfield, Derbyshire
Burton Park
Melton Mowbray, Leicestershire
The Willows
Newark, Nottinghamshire
Annesley House Annesley, Nottinghamshire
Calverton Hill
Arnold, Nottinghamshire
Kneesworth House Royston, Hertfordshire
Lombard House Norfolk
Richmond House Norfolk
St John’s House
Diss, Norfolk
and Burston House
Grafton Manor,
Grafton Regis, Northampton
The Chantry and The Drive
Oaktree Manor
Tendring, Essex
Elm Park,
Colchester, Essex
Elm Cottage and Elm House
Lily Close
Rainham, Essex
Suttons Manor
Romford, Essex
Pelham Woods
Dorking, Surrey
The Dene
Hassocks, West Sussex
North London
Edmonton, London
Clinic
Mental
Illness
Personality
Disorder
Learning
Disability
Autism
Spectrum
Disorder
Brain
Injury
Taking quality to the highest level • Working together • Caring safely • Uncompromising integrity • Valuing people
Introduction
Map of PiC’s services
Beds
90
92
74
17
32
19
114
24
36
24
10
112
14
50
6
28
64
157
7
9
80
27
47
24
10
26
21
86
61
20
75
Mental
Illness
Personality
Disorder
Learning
Disability
Autism
Spectrum
Disorder
Brain
Injury
Taking quality to the highest level • Working together • Caring safely • Uncompromising integrity • Valuing people
Partnerships in Care Quality Account 2014/15
3
Summary review of clinical performance 2014/2015
Patient
Introduction
experience
Clinical performance and patient outcomes in 2014/15
Our objectives for 2014/15 were within the NHS National Outcomes Framework and CQUINs agreed with NHS England.
More information on performance indicators described below is provided in the body of the Quality Account.
Objective
Achievements
Sustainability & Assurance
Physical health strategy
•• We measure, record and monitor patient health scores through dashboards.
•• At end March 2015 we had physical health assessment records for 98.53% of patients.
•• Obesity continues to be a problem nationally in inpatient psychiatric services and 75% of our
patients are overweight or obese. We have managed to reduce the BMI of obese patients by
2.27% although we acknowledge that there is a great deal more to be achieved.
•• Smoking cessation, diet / nutrition and exercise are central to our health promotion programmes
in place in all our hospitals.
•• Our patients have good access to physical healthcare through liaisons with GPs and hospital
services and PiC practice nurses. Patient health indicators are monitored through dashboards.
We have in particular improved the monitoring of people with long term physical health conditions.
•• This year we did more training for staff in the use of the NHS Early Warning Score.
Physical health of our patients is
a primary focus for PiC and these
components continue to be included
in our Physical Health Strategy and our
Service Development Improvement Plan.
Our Physical Health Group oversees
performance indicators and has promoted
standardised training, policies and
processes. This group reports to our
Clinical Governance Committee.
•• 88% of patients receive some form of medication as a routine part of treatment. 72% of them
are satisfied with the level of information and choice they have.
•• This year we participated in the POMH-UK audit ‘Pescribing for Personality Disorder’.
We performed above the national average (PiC 81% national average 62%).
•• We have a Clozapine care pathway which screens for the earliest warnings of side effects.
•• We are piloting the potential benefits to patients of nurses trained in non-medical prescribing
at Stockton Hall hospital in York. We aim to optimise patient choice and minimise side effects.
Medicines management continues to
be a standing agenda item for clinical
governance meetings where we routinely
review performance against audits
conducted by our pharmacy provider.
We also continue with our membership
of the Prescribing Observatory for Mental
Health services.
•• We routinely use clinical dashboards to monitor treatment outcomes. The Ward to Board reporting
dashboard generates reports at hospital, region and group level.
•• 55% of patients said available treatments were well explained and 70% felt either partly or well
supported on their arrival to their ward.
•• Our new PathNav tool, (see Page 31), permits patients greater access to and control over
their care pathway.
•• Feedback from the Ward Quality Matters process, which engages patients in information
about ward quality, has resulted in many changes at the point of service delivery.
•• Our patient surveys give us clear direction to prioritise improvements.
We will continue to develop and shape
clinical outcome dashboards with
feedback from patients. We continue
to participate in peer reviews through
the QNFMHS and we will be rolling out
PathNav across all our services. We
will continue to promote Ward Quality
Matters across all our services and remain
committed to our annual satisfaction survey.
•• There has been a small but steady trend towards a better quality of life evidenced by
EuroQol’s EQ-5D.
•• More patients each year say they have found our care ‘good to excellent’.
•• 81% say they are treated with respect and dignity and that clinicians listen to them well.
•• Patient involvement in their own risk assessment is embedded across PiC and earned us
finalist status in the 2014 LaingBuisson Independent Specialist Care Award in the category
for personalisation in risk assessment.
We will continue to use EQ-5D to help us
measure quality of life with our patients
and use collaboration in risk assessment
and planning. We will continue to promote
a recovery ethos across PiC through
developing a specialist Recovery Network.
Improve patient safety and life
expectancy with measured
outcomes. Promote parity
of esteem. Reduce risk and
improve care for people with
long term health conditions
such as COPD and diabetes.
Medicine management
To achieve highest possible
effectiveness and patient
choice in the prescribing of
antipsychotic medication.
Patient reported outcomes
To measure effectively, using
dashboards. To improve
appropriate access to records
throughout the pathway from
admission to discharge.
To improve response to
feedback.
Recovery and quality of life
To measure and enhance patient
recovery and quality of life.
To give a daily positive
experience of care to all people
who use our services.
4
Partnerships in Care Quality Account 2014/15
Summary review of clinical performance 2014/2015
1
Engaging people
in keeping healthy
2
Shared
decision-making
3
Supported
self-management
My care plan
8
4
Evaluating services
through feedback
Not
joined up
Patients as
partners in their
care and
treatment
Poor
information
Staff were
kind
7
Patient-informed
research
6
Choice of care
closest to home
5
Employability
Involving families
and carers
Introduction
Patients
asaspartners
Patients
partnersin their care and treatment
in their care and treatment
ur objectives are built on a
O
philosophy that the best outcomes
arise when patients / residents
are actively involved in all aspects
of services.”
e support people to have personal
W
control in achieving and sustaining
progress and recovery.”
e provide a culture of care in
W
which clinical and research activity
is focused on how the individual
patient / resident will receive the
greatest benefit.”
Dr Quazi Haque
Executive Medical Director
Partnerships in Care Quality Account 2014/15
5
Summary review of clinical performance 2014/2015
Quality objectives and clinical strategy 2015/2016
Patient
Introduction
experience
Clinical objective
Improving patient safety
Context and implementation
Measurement and assurance
Although the CQUIN ‘Demonstrate best practice in managing risk using
supportive observation’ is not one that applies to our services we have
included elements of this as a service quality improvement plan.
The project will involve developing an evidence based approach
to patient observations developed from research, staff and
patient experience.
In line with the revised Mental Health Code of Practice we will be implementing
a Positive Behaviour Support (PBS) strategy including Restrictive Intervention
Reduction Programmes.
Each patient will have a PBS Plan and restrictive interventions
will be monitored Ward to Board.
The CQUIN ‘Improving Physical Healthcare to reduce premature mortality in
people with severe mental illness (SMI)’ continues this year. We will continue
to promote the wellbeing of our patients through our physical health strategy.
We will continue to offer smoking cessation, promoting a healthy
diet and exercise. We will monitor routine physical health data
through the dashboards.
Our information technology programme to improve bandwidth and internet
speeds and upgrade hardware and software completes in 2015. This supports
clinical effectiveness through speed and accuracy of patient records, staff
rostering and improves reporting to commissioners.
Staff hours saved, reduced duplication; uptake by family/carer/
inpatient/clinician of video conferencing and Skype.
PathNav is a unique software programme developed by PiC which takes
patient participation in their care and treatment to a new level. This supports
and measures clinical effectiveness and focuses on collaborative risk
assessment. We will be rolling this programme out across all services.
Patient and clinician feedback data relating to length of patient
stay, visual pathway report reduces delayed discharge.
This CQUIN has a head start with the PiC Family, Friends and Carers strategy,
our carer networks, inpatient community contact and support for visitors.
We have developed an evaluation tool for carer involvement.
We measure patient/family contact and satisfaction.
Our Recovery Strategy supports NHS domain 3 – helping people to recover
from episodes of ill health. We have launched a specialist Recovery Network.
We will measure performance against TRIP and ERFS standards
at the second audit cycle this year.
Our new national PiC Learning and Development Programme was externally
evaluated and now applies to all professions. We offer the Care Certificate for
unqualified staff and a Preceptorship Academy for newly registered nurses.
We have had independent assessment of PiC’s Nurse
Leadership Programme; audit of Care Certificate-qualified staff;
a report on training compliance; we audit the appraisal process;
we measure against the CQC ‘Well-Led’ inspection domain.
The quality of care patients experience depends on high quality staff. Patients’
questions are included for interview panels. Staff engagement and recruitment
are conducted all year.
Records of starters, leavers, sickness, and complaints are
monitored. PiC’s Staff Survey measures staff morale and
identifies areas for improvement. Investors in People is an
external source of scrutiny.
Improving clinical effectiveness
Promoting involvement
Maintaining an effective
workforce
6
Partnerships in Care Quality Account 2014/15
Summary review of clinical performance 2014/2015
Governance
Introduction
How we govern our services
A full review of our governance processes prompted not only our Ward to Board model which we
discussed in last year’s Quality Account, but also a far reaching Governance Awareness Campaign
for all staff, involving face to face discussions, posters, training, leaflets to convey the importance of
personal responsibility and accountability. We will continue to survey levels of awareness among staff
to sustain the impact of this in the future.
Part of how our campaign explained the structural elements of our governance framework to all staff:
Within Partnerships in Care, professionalism means being accountable. Our message to staff delivered this year has been “It is your
responsibility to speak up about any concerns. It is PiC’s responsibility to support you in doing so.” We also encouraged all line managers
and staff to review their job descriptions, roles and responsibilities so that this expectation is clear. The launch of the Duty of Candour
statutory responsibility reinforced this message in April 2015.
•• Audits, policy, and procedure
•• Proven clinical treatments
•• Ward to Board / Board to Ward
•• Listening and responding to feedback
•• Values-based recruitment
•• Continuous learning & development
•• Internal and external inspections
•• Ward quality monitoring by staff and patients
•• Hospital Risk Registers
•• Staff appraisal
•• Complaints & Whistleblowing
•• Patient/Staff Community meeting
Information Governance
Data integrity, confidentiality and security are of the utmost importance.
All PiC staff use both NHS and PiC training modules including the NHS Information
Governance Toolkit. We submitted a compliance figure of 96.5% to the Health and Social
Care Information Centre for the 2014/2015 year. New staff are trained at induction. Our
electronic patient record system, CAREnotes complies with our data security protocols.
Our approach to record keeping is standardised across all hospitals in the group,
overseen by our Group Information Governance Lead.
In 2014 every member of staff discussed governance
through our awareness campaign. We consulted, listened
to staff and patient ideas, and totally refreshed the ways
staff engage in our governance framework.”
Joy Chamberlain, Group Chief Executive
Delivering the
service
(High quality care)
Improving what
we are doing
Knowing how
we are doing
(Quality improvement)
(Quality assurance)
Guidance leaflet for staff
PiC 24-hour independently operated
Concern Line
0800 1972980
Partnerships in Care Quality Account 2014/15
7
Regulatory performance 2014/2015
Regulatory
Patient experience
performance
Regulatory performance 2014/15
Partnerships in Care services throughout the UK are subject to
regular inspection and review by several organisations and we are
pleased to report that in 2014/15 we performed well against all
national regulatory standards with no concerns raised.
The bodies who review our services include Care Quality Commission (CQC) in England,
Healthcare Inspectorate Wales; Healthcare Improvement Scotland; and internally, our own
compliance team. We also report to the NHS and General Medical Council (GMC) with
respect to medical revalidation of all our doctors with their respective professional bodies
in England, Scotland or Wales.
The CQC’s Mental Health Act (MHA) reviewers continued visits as in previous years
and undertook 40 visits covering 42 PiC wards. In January 2015, the CQC published a
revised Mental Health Act Code of Practice. There is now a strong focus on improving
the experience and outcomes for people subject to the MHA as well as testing provider
governance. We are pleased that we met all required standards.
Healthcare Inspectorate Wales conducts regular inspection to confirm that the Mental
Health Act Code of Practice for Wales is being followed. During visits, reviewers talk to
detained patients in private and meet with managers and other staff to talk about things
that affect patients’ care and treatment and to raise issues on behalf of patients. Llanarth
Court was inspected on 3 June 2014, performed to a high level with no concerns raised.
Healthcare Improvement Scotland inspected Ayr Clinic in January 2015 and rated
as follows:
Our hospital directors and clinical teams also work closely at local level to liaise with
safeguarding teams, community mental health teams, police, and medical health
organisations as well as local community groups.
Fig. 4 Ayr Clinic inspection results
Inspection domain
Rating
Medical Revalidation
Quality of information
Very good
Partnerships in Care is a designated body for its employed doctors for the purposes
of medical revalidation. This year Dr Quazi Haque, who is PiC’s Responsible Officer,
commissioned an external review of our appraisal and revalidation systems by a specialist
healthcare training organisation. We are pleased to report that our appraisal system was
rated as ‘excellent’ and all PiC doctors are fully engaged in an appraisal framework that is
integrated with wider governance activity.
Quality of care and support
Very good
Quality of environment
Very good
Quality of staffing
Very good
Quality of management and leadership
Very good
Note that ‘very good’ is Point 5 on a scale of 1 - 6
I am pleased that an external review of our appraisal and
revalidation systems confirms that we have robust policies and
practices in place to support our doctors, and also to reassure
patients and their families of our commitment to the highest
standards of medical care.”
Dr Quazi Haque, Executive Medical Director
8
Partnerships in Care Quality Account 2014/15
Partnerships in Care compliance team
PiC’s internally run compliance team conducts inspections and is led by the Director
of Policy and Regulation. The team has conducted 104 inspections of our services in
2014/15. They inspect for compliance with national regulation as well as PiC policy and
procedures. Their reports are reviewed by PiC Clinical Governance Committee and then
sent on to the appropriate regulator.
Regulatory performance 2014/2015
2012/13 CQC inspection format used until 31 March 2014
The CQC changed its inspection process from 1 April 2014. Several visits satisfactorily
concluded reviews from the previous year’s inspections. (Fig 5).
Fig. 5 Visits under CQC 2014 inspection format. See Fig. 5a
Outcome
Hospital
Date
of Visit
1
2
4
7
9
13
14
16
17
Report
Status
Calverton Hill
25 June
2014
Final
Annesley House
26 June
2014
Final
Above: Green indicates that people who use services are experiencing the outcomes
relating to a selection of essential standards. The numbers above indicate which
standards were specific to these particular inspections and what they are is detailed
in (Fig 5a)
Standard
Description of what is required to meet the standard
1
Respecting and involving people who use services
2
Consent to care and treatment
4
Care and welfare of people who use services
7
Safeguarding vulnerable people who use services
9
Management of medicines
13
Staffing
14
Supporting workers
16
Assessing and monitoring the quality of service provision
17
Complaints
Regulatory performance
Fig. 5a
Note: This is not the full list of CQC standards.
2014/2015 new CQC inspection format
Fig. 6 shows the results of all inspections conducted in the new format in 2014/15 year.
Fig. 6
Hospital
Date of Visit
Grafton Manor
18 November 2014
St John’s House
24 November 2014
Overall Rating
Safe
Effective
Caring
Responsive
Well-led
Good
Good
Good
Good
Good
Good
No rating is given as this inspection relates to St John’s being a pilot site
to test the new standards.
Report Status
Comments
Final
Unannounced
Comprehensive
Inspection
Final
2 day Announced
Comprehensive
Inspection
Partnerships in Care Quality Account 2014/15
9
Clinical
Patienteffectiveness
experience
Clinical effectiveness 2014/2015
Clinical effectiveness
Commissioning for Quality and Innovation (CQUIN) Report
CQUINs applicable to PiC in 2014/15
CQUINS applicable to PiC in 2015/16
Improving physical
health care to
reduce premature
mortality in people
with severe mental
illness
This required 90% compliance and this was met.
Improving physical
health care to
reduce premature
mortality in people
with severe mental
illness (SMI)
The next phase of PiC’s Physical Health strategy involves
training all clinical staff and to continue to be responsive
to observation data and to give a consistent high quality
of physical healthcare. We will participate in the national
Royal College of Psychiatry-commissioned Physical
Health Audit in Autumn 2015/16.
Needs formulation
at transition
This required 100% compliance and this was met.
Mental health
carer involvement
strategy
The benefits to families and carers of the PiC family
and carer involvement strategy implemented in 2014/15
will be measured this year using a new evaluation tool.
Responses to findings will inform a review of strategy by
year end for implementation during 2016/17.
Friends and
Family Test
No specific target score has been set. PiC has achieved a 63%
recommendation rate for the year.
Secure service user
active engagement
programme
(collaborative risk
assessment)
PiC will develop an evaluation tool to assess the
effectiveness of the training package delivered last
year in terms of the collaborative risk assessment
CQUIN. This will test the nature, extent and on-going
involvement of our patients within the risk assessment
process. Findings will inform refining of training,
systems and processes.
Improvements to EPR now make it easier for all patients to have
comprehensive physical health records in a format which can be
shared with primary care and other mental health providers upon
discharge. The physical health dashboard was improved with inclusion
of additional physical health areas. This efficiently provides clinicians
with performance information on patient physical health.
PiC developed a ‘Needs Formulation’ document, that clearly identifies
for the patient what care and treatment they should expect to receive
and why. The document was incorporated into our pre-admission
and care and treatment pathway, ensuring transparency throughout.
Clinicians use a dashboard to monitor compliance with patients
receiving this document within 7 days of admission and again following
any security level changes.
The NHS Friends and Family Test (FFT) was introduced into PiC during
2014 and is applied to all patients who arrive at ‘end of episode of care’
and so are leaving the service to be transferred or discharged. It helps
us understand how our services are experienced by patients and how
we can make improvements. PiC uses a dashboard to review the score
and initiate improvements within services based on the findings. The
information is accessible for staff and patients.
Collaborative risk
assessment
The target, to deliver training to 90% of staff and to offer this
opportunity to 100% of patients, was met.
In the past in forensic psychiatric settings, few patients would have been
actively involved in assessing and developing their risk management
plans. During 2014, PiC delivered education to patients and relevant
staff on collaborative risk assessment and management. This promotes
general collaboration between patients and clinical teams.
10
Partnerships in Care Quality Account 2014/15
Clinical effectiveness 2014/2015
Benchmarking through peer review
Peer Review Networks of which PiC is a member:
We participate in national audit and we are members, or founder members, of a number
of peer review networks which enable our performance to be reviewed in an independent
and transparent way. Our Quality Account is an opportunity for us to present evidence
of patient outcomes and service quality as it compares with previous years and with
other providers.
•• Quality Network for Forensic Mental Health Services (MSU and LSU)
Clinical effectiveness
Partnerships in Care is committed to reporting clinical performance
in a way that will support the creation of aligned national
frameworks to permit comparison across NHS and independent
service providers. We have continued making policy and
procedure changes that support the mandates for greater patient
involvement and engagement, greater staff transparency and more
engaged leadership that have emerged following reports such as
Winterbourne, Francis, Berwick, Bubb and Clwyd–Hart.
•• The Mental Health Research Network-funded Clinical Research Group in Forensic
Intellectual and Developmental Disabilities (CRG-FIDD)
•• Independent Neurorehabilitation Providers Alliance (IN-PA)
•• Prescribing Observatory for Mental Health Services (POMHS)
Medium and Low Secure Peer Review – Quality Network for Forensic
Mental Health Services (QNFMHS)
This year, we can report on the Cycle 8 (2013/14) MSU review published in February 2015.
The next Low Secure Network report is expected to publish in June 2015. There is no new
report since that we reported last year, when PiC exceeded the national LSU average for
13 out of 16 domains.
In the Cycle 8 MSU review, 65 hospitals (227 wards) participated including nine PiC MSU
services. Participant services are measured on 11 key standards:
Fig.7 Our performance against the targets for clinical performance we set last year
Target
Met?
All PiC hospitals to have access to dashboard data across quality
domains to enable performance to be measured and benchmarked
over time.
More patient reported outcome measures to be in use, reflecting
holistic patient-centred indicators.
More choice to be offered to patients and commissioners by
extending care pathways geographically and in service variety.
To improve physical healthcare for patients to improve life
expectancy.
To improve recording and analyis of patient movements on care
pathways with a view to recovery and better patient outcomes.
Fig. 8 The Quality Network ran a competition to find a piece of patient artwork to use on
the front cover of the ‘Standards for Medium Secure Services 2014.’ The winning design,
left, is named“It is Tomorrow’s Dream that will Survive” and came from a patient at The
Spinney MSU, Partnerships in Care.
Partnerships in Care Quality Account 2014/15
11
Clinical effectiveness 2014/2015
PiC MSU performance
Clinical
Patienteffectiveness
experience
Fig. 9 PiC performance in QNFMHS cycles 6 - 8
Six of PiC MSU services – Llanarth Court, Stockton Hall, Kneesworth House, Arbury Court,
and Learning Disability Services Norfolk/Suffolk, all exceeded the national average score
of 83%. Two were not far below - Calverton Hill (79%), The Dene (78%). North London
Clinic scored 66%. This ranking puts Stockton Hall and The Spinney within the top ten
MSU services nationally and a total of five of our MSU services in the top 20.
94
90
PiC / National scores by standard in QNFMHS Cycle 8
National score
PiC Average
82
National score
84
PiC Average
86
National score
88
PiC Average
% score across MSU standards
92
80
A number of PiC’s average standards by domain are above national average. For example,
relational security (94%); and SUIs (96%). PiC score for accessible and responsive care
is 17% higher this year than last, Patient focus has grown by 1%, environment by 3% and
physical security by 5% compared to last year.
To review areas where scores are lower than we expected, such as procedural security,
we will review to see if this is related to the new method of assessing policy.
Fig. 10 PiC / National scores by standard in Cycle 8
78
76
80
60
40
PiC Average
12
Partnerships in Care Quality Account 2014/15
National Score
Public health
Environment and
amenities
Accessible and
responsive care
Patient focus
F ive of PiC MSU services are in the top 20 of
QNFMHS services surveyed. Two are in the top 10.”
Governance
0
Clinical and cost
effectiveness
20
Safeguarding of
children and adults
A reduction in score is evident for all participants nationally compared to last year. This,
according to the QNFMHS Cycle 8 Annual Report, is related to the change in standards
effected during this cycle and also in methodology for evaluating organisational policies,
which for the first time this year, are required to have been reviewed annually. The
report stated: “The change in the method of collecting data about policies has affected
scores on policies, and in particular the requirement that policies are annually reviewed,
compared to previous years.” and “A steady increase of the number of standards met
by services over the past 4 years indicated the need to review the standards and to drive
up quality nationally.” Standards were reviewed, and Cycle 8 achievements have been
measured against these tougher new targets.
100
Reporting and
follow up on SUIs
QNFMHS reporting cycles over last 3 years
120
Relational security
Cycle 8
Procedural security
Cycle 7
Physical security
Cycle 6
Clinical effectiveness 2014/2015
For full information readers can refer to the Royal College of Psychiatrists
website. Here are just a few standards explained:
Safeguarding children and vulnerable adults: This applies to adult patients in MSU, for
example on admission, a record is made for each patient of any children known to be
in their social network, their relationship to those children and any known risks.
Serious Untoward Incidents: This is measured on, for example, if there is a clear
system in place to identify, record, report and follow up on SUIs.
Public Health: Providers are to promote, protect and demonstrably improve the health
of the community served, and narrow health inequalities by among other things,
having good collaborative relationships with local services.
Policies: All policies relating to measured standards require to be reviewed annually.
Brain Injury Services Peer Network – Independent Neurorehabilitation
Providers Alliance (INPA)
To join INPA, as a service provider we have undergone a peer review process to ascertain
our Brain Injury Services meet the standards upheld by the Alliance. This was completed
this year, and Professor Alderman was elected the Chair of the Research & Outcomes
subgroup. Outcome measures for people in treatment have been diverse across providers.
As Chair of this group, Professor Alderman is leading on standardising this to make
benchmarking possible.
Every day counts – measuring patient average
length of stay (AVLOS)
Fig. 11
April 2012 –
March 2013
April 2013 –
March 2014
April 2014 –
March 2015
Acquired Brain Injury
33
20
20
Acute
1
1
1
ASD
17
12
18
Diagnosis
Learning Disability Peer Network – Clinical Research Group in Forensic Intellectual
and Developmental Disabilities (CRG-FIDD)
PiC Learning Disability Services (LDS) treats around 360 people who have intellectual/
learning disability or diagnoses on the autism spectrum. We care for people in the least
restrictive conditions appropriate for their safety and care, across specialist residential
services, rehabilitation wards and secure wards. PiC founded, and hosts the CRG-FIDD
which brings together leading clinicians in this field from over ten UK universities and 25
service providers, both NHS and independent sector.
PiC LDS’ system of routine measures collected during treatment were audited and created
a minimum dataset for evaluation of long and short term treatment outcomes for patients
with learning disability and autism. Patient outcome variables are divided into measures
of symptom severity, patient safety and patient experience. This dataset has been peerreviewed and was published as the minimum dataset recommended for services to use
nationally in the Royal College of Psychiatrists Report published in 2013 entitled “People
with learning disability and mental health, behavioural or forensic problems:the role of
in-patient services. This report was well received and the Care Quality Commission (CQC)
planned to incorporate the bed categories proposed in the report for use in census
reports. For more information on clinical effectiveness in our Learning Disability Services
see page 17.
3
HDU
Learning Disability
31
29
28
Mental illness
17
20
18
Personality disorder
20
20
20
1
PICU
TOTAL
13
11
9
Note to Fig.11
AVLOS is calculated in months at each individual spell at a particular security level and is shown here
as a total across security levels for each patient group. This means patient numbers differ as some
patients will be reflected twice as they changed security level. For more information on performance
by diagnosis see pages 15 to 21.
We work with case managers and patients to ensure that length of stay within each
element of the care pathway is as short as possible or is optimised. Organisation wide
data may be of some use, year on year, to evaluating trends however our approach is to
look at each person individually.
Partnerships in Care Quality Account 2014/15
13
Clinical effectiveness
About the QNFMHS standards and how they are measured
Clinical
Patienteffectiveness
experience
Clinical effectiveness 2014/2015
Ways we measure effectiveness of therapies
and quality of life of people in our services
Recovery, or a person aiming to reach a next step on a care
pathway is a very individual and personal goal. We also use
physical health care measurement tools to work towards better
physical wellbeing, improved life expectancy and quality of life.
No one method or source of information is enough, so for
everyone, a basket of measurements will be collected and carefully
considered by the clinical team, with some chosen by the service
user and including patient reported outcomes. Here are a few, and
some, you will hear more of in this account.
> START – Short Term Assessment of Risk and Treatability
This measures patient perception of their ‘strength’, and separately, of their ‘vulnerability’.
This exercise is done between the patient and clinical team twice in the year, 6 months
apart. In clinical terms, these scores are used for individual patient therapy. For reporting
purposes here, we report them as an aggregate as one way of looking at treatment
effectiveness. The size of the ‘samples’ for this year’s patient group scores is 981 for
‘vulnerability’ and 1004 for ‘strengths’.
It is to be expected that patient awareness of vulnerability, which rises with insight into
their state of health, may heighten within a treatment context. We would hope to see a
corresponding rise in patients’ perception of ‘strength’.
> HCR 20 / SVR-20
Historical Risk Management HCR-20 and Sexual Violence Risk SVR-20 assesses a
person’s risk of violence and aggression, or risk of their committing a violent sexual
offence in the future. This takes into consideration past, present and future considerations
as part of a clinical risk assessment process. This year, all staff have been trained in the
use of HCR-20 version 3.
14
Partnerships in Care Quality Account 2014/15
> EuroQol and EQ5D
The EQ-5D. This measure, which is applicable to a wide range of health conditions,
provides a simple descriptive profile and a single value for health status. It is part of the
6 monthly PiC CPA questionnaire. Consequently, it is possible to compare the EQ-5D
results between (a) different diagnostic groups and (b) changes over time. We report
our EQ5D performance on page 20.
> HoNOS – Health of the Nation Outcome Scale
Developed in 1993 by UK Department of Health and the Royal College of Psychiatrists’
Research Unit,this is a basket of measuring tools for a range of variables experienced
by people with mental illness including symptoms, behaviour, impairment and social
functioning. The scales are completed using data from clinical assessment. HoNOS is
the most widely used outcome indicator for severe mental illnesses. Varieties include
HoNOS Secure and HoNOS ABI.
Partnerships in Care uses the most clinically appropriate HoNOS tool as one way of
gauging patient progress with treatment. The tools are regularly used by clinician and
patient/ resident together, to assess clinical symptoms and recovery across a range of
areas of functioning. At a national organisational level, the HoNOS findings are regularly
evaluated as part of the analysis of the effectiveness of the treatment plans and patient
care pathways. We report HoNOS scores for the year on page 22-23.
> Examples of other clinical observation and rating tools
used at discretion of the clinician and the service user
•• OAS-MNR, Overt Aggression Scale Modified for Neurorehabilitation
•• ICD10 physical health diagnosis
•• Early Warning Score
•• Rosenberg Scale for Self-Esteem
•• Goal Attainment Scaling
•• CORE – Clinical Outcomes in Routine Clinical Practice
•• Global Impression Scale (CGI)
•• Model of Human Occupation Screening Tool (MOHOST)
•• Recovery Star, My Shared Pathway, Diaries specific to therapy interventions
Clinical effectiveness 2014/2015
Clinical effectiveness in Mental Illness /
Personality Disorder services
With the permission of the patients and families concerned, we are pleased to be able to
share these extracts from letters of thanks to our staff.
Partnerships in Care provides gender-specific services across
the life span for people with severe mental health conditions.
Fig. 12 Patients with mental illness
by security level 2014/2015
Fig. 13 Patients with personality
disorder by security level 2014/2015
3%
3%
20%
22%
38%
43%
39%
Medium
Low
L
ocked
O
pen
33%
Medium
Low
Locked
Open
Hey all, may I just say a big thank you to all the staff and patients
for being there when I needed someone to talk to. Ever since I’ve
come home I’ve been eating well and for breakfast, cereal with toast
and fruit. I feel my new life is just starting and I am missing everybody.
I would give The Dene 10 out of 10. I’m taking my new meds when I
need to. I can’t thank you all enough.”
Patient discharged from acute service at The Dene
I wish everyone to know how grateful we, the family, are to the
management and staff of Kemple View and Elmhurst Ward. I have
been overwhelmed with the amount of care and attention accorded to our
son in the last months; the sensitivity shown towards him and to us, the
family. ’A’ has complex needs which have been met with real individual
care, attention, kindness and good humour. This is giving him a wonderful
opportunity for recovery in his life.”
Margaret, mother of patient ‘A’
There is no distinct change in pattern or trend between the proportion of patients being
treated in each security level over the past two years and to see a trend we would need to
look further back as we know that over time there has been a shift towards more patients
requiring locked and open rehabilitation settings. We do however over the past year see a
definite trend towards reduction in average length of stay for patients with mental illness
indicating a positive impact of PiC’s recovery-focused approach to care and treatment.
Partnerships in Care Quality Account 2014/15
15
Clinical effectiveness
Patient and family comments on our MI / PD services
Clinical effectiveness 2014/2015
Fig. 14 Patients with a diagnosis of MI – awareness of strengths and vulnerability
following treatment
Fig. 15 Patients with a diagnosis of Personality Disorder – awareness of strengths
and vulnerability following treatment
18
12
16.3%
11%
10.7%
16
13.0%
12
10
8
6
5.0%
Difference from last score out of 25
10
14
Difference from last score out of 25
Clinical
Patienteffectiveness
experience
START scores
8.4%
8
6
4
3.6%
2.7%
4
3.6%
2.2%
2
3%
2.7%
2.7%
2.7%
2
1.7%
1.7%
0
0
2013/2014
2014/2015
Female
2013/2014
2014/2015
Male
Values reflect the percentage increase compared to the previous year’s score
Difference at second scoring for vulnerability
Difference at second scoring for strength
2013/2014
2014/2015
Female
2013/2014
2014/2015
Male
Values reflect the percentage increase compared to the previous year’s score
Difference at second scoring for vulnerability
Difference at second scoring for strength
START – Short Term Assessment of Risk and Treatability – MI/PD patients
This year, 532 patients were assessed for ‘vulnerability’ (133 women and 399 men) and
546 for change in rating on ‘strengths’ (139 women and 407 men). It is to be expected that
patient awareness of vulnerability, which rises with insight into their state of health, may go
up within a treatment context. We would hope to see a corresponding improvement in
16
Partnerships in Care Quality Account 2014/15
their perception of their own empowerment to recover ‘strength’. The scoring is out of a
possible maximum of 25 on each variable. We compare last year’s and this year’s findings.
Last year we measured 740 patients (241 women and 499 men).
Clinical effectiveness 2014/2015
Fig. 17 Proportion of people with
learning disability by type of care
setting in 2014/2015
Fig. 18 Proportion of people with
ASD by type of care setting in
2014/2015
3%
3%
Partnerships in Care is one of the leading providers of specialist
care for people with severe learning disability including forensic
history, detained under the Mental Health Act, as well as people
with mild learning disability, dual diagnoses, and people within the
autism spectrum.
Clinical effectiveness
Clinical effectiveness in services for people
with Learning Disability or diagnoses within
Autism Spectrum Disorders
8%
22%
20%
38%
43%
39%
Fig. 16 Average months in treatment – patients with LD or ASD (last 3 years)
33%
Months in care and treatment
35
Medium
Low
Locked
Open
Community
30
25
20
15
Patients are benefiting from our active management of length of stay in inpatient settings
and regular CTR. Our care is proactive and our communication with all stakeholders is
effective. The type of recommendations that have flowed from the CTRs include close
working between social work teams, MAPPA and other community services. Following
treatment, people can transfer to lower levels of restriction and experience community
facing rehabilitation in supported houses.
10
5
0
2012/2013
LD
Medium
Low
L
ocked
O
pen
2013/2014
2014/2015
ASD
We are one of the most geographically and pathway diverse providers in the UK which
means we can offer people a choice of care as close to their home area as possible and
a full range of care settings for transfer to reducing levels of restriction as they progress
with treatment.
This year, as part of NHS England’s accelerated hospital discharge programme, a number
of patients with learning disability and mental illlness were subject to Care & Treatment
Reviews (CTR). The treating teams within PiC have actively engaged in this process.
PiC LDS is a founder member of the Clinical Research Group in Forensic Intellectual
and Developmental Disabilities (CRG-FIDD) Our Norfolk and Suffolk services, led by
Dr Regi Alexander, were finalists for the Royal College of Psychiatrists team of the year
award. Dr Pancho Ghatak, PiCs lead for the LD Network, is working with the Midlands
and East Transforming Care Programme Board, reporting throughout the network and
to PiC’s clinical governance committee.
We cared for 320 people with Learning Disability and 24 people with ASD this year
compared to 275 and 21 respectively the previous year. Charts 2 and 3, of proportion
of patients at each security level, reflects the acuity of our patient group as well as our
provision of a full care pathway.
We are pleased to demonstrate a reduction in average length of stay (AVLOS) for our
patients with LD. The number of patients with the diagnosis of ASD is too small a number
on which to base an AVLOS trend. (Fig. 16)
Partnerships in Care Quality Account 2014/15
17
Clinical effectiveness 2014/2015
Fig. 19 Patients with a diagnosis of Learning Disability – awareness of strengths
and vulnerability following treatment
Fig. 20 Patients with a diagnosis of Autism Spectrum Disorder – awareness of
strengths and vulnerability following treatment
12
20
11.1%
16.6%
15.7%
10
9.5%
15
8
Difference from last score out of 25
9.0%
Difference from last score out of 25
Clinical
Patienteffectiveness
experience
START scores
7.6%
6
4.5%
4.5%
4.5%
4
10
5
4.5%
4.5%
4.5%
4.5%
–3.7%
0
2
0
-0.05
2013/2014
2014/2015
Female
2013/2014
2014/2015
Male
Values reflect the percentage increase compared to the previous year’s score
Difference at second scoring for vulnerability
Difference at second scoring for strength
18
Partnerships in Care Quality Account 2014/15
2013/2014
2014/2015
Female
2013/2014
2014/2015
Male
Values reflect the percentage increase compared to the previous year’s score
Difference at second scoring for vulnerability
Difference at second scoring for strength
Clinical effectiveness in
PiC Brain Injury Services
Patient outcomes within PiC Brain Injury Services in the 2014/15 year
Brain Injury Services comprises three separate services with units at Grafton Manor
(Northants), Elm Park (Essex) and Burton Park (Leicestershire) offering up to 100 beds
for people with acquired brain injury (ABI). Referrals to the service are typically made
because disorders of awareness, emotional and behavioural consequences of ABI inhibit
engagement in mainstream neurorehabilitation services. BIS provides neurobehavioural
rehabilitation, a proven service model with demonstrable outcomes, which creates a
positive therapeutic climate that enables recipients to achieve their potential and increase
personal autonomy.
This evidence based approach to rehabilitation is underpinned by routine evaluation of all
service users through a basket of outcome measures conceived and validated for ABI.
These outcome measures:
•• are made at admission, every 3-6 months during rehabilitation and at discharge
•• enable the diversity of behavioural, social, emotional, physical and functional problems
that can arise from ABI to be captured
•• enable identification of goals; track response to treatment; and quantify the
effectiveness of BIS as a service.
27%
of those assessed were rated as being able to be sustained
in placements with less supervision reflecting increased
autonomy in half the time considered the norm for time in
neurobehavioural rehabilitation.
As part of the continual assessment and improvement of what we provide, outcome
measures completed for people admitted during 2014/15 were examined by comparing
the most recent assessment made, with that on admission. Effect sizes were calculated to
determine if ‘meaningful changes’ had been made as a result of the programme.
Particularly meaningful changes were noted in reduction of symptoms of neurobehavioural
disability, especially aggression, decline in disability associated with impaired cognitive
function, improvements in relationships, interpersonal behaviour and communication abilities,
and adjustment to the consequences of ABI and improved participation in activities.
There was an association between time spent in the programme and the above
improvements, sufficient for 27% of those assessed being rated as being able to be
sustained in placements with less supervision, reflecting increased personal autonomy.
Whilst time in neurobehavioural rehabilitation varies considerably, the norm cited is 18
months to two years. Given that the above improved patient outcomes were all achieved in
less than half this time, further endorses the effectiveness of the BIS programme and the
potential for further gains.
We have calculated an Aggregate Aggression Score (AAS) using information compiled
from the Overt Aggression Scale – Modified for Neurorehabilitation (OAS-MNR), an
observational recording measure routinely completed by the clinical team whenever one
or more of four categories of aggression (verbal, and physical towards objects, self and
other) is observed.
The OAS-MNR is a standardised method of recording aggressive behaviour. Previously,
lack of a united approach did not enable meaningful benchmarking or comparison of the
ability of services to safely manage risk behaviours, including aggression. Many services
report change in frequency of behaviour, but not type of aggression and severity.
As a result, Professor Alderman, Dr Knight and colleagues proposed the AAS in a paper
published in the British Journal of Neuroscience Nursing in 2011* as a reliable and valid
indicator. The person’s most recent AAS score is expressed as a percentage of the first
score at admission, to express a standardised indicator of change. 0% would indicate
no improvement; 100% would reflect no aggression at all in the most recent assessment
period. The higher the score, the less aggression or severity of aggression there has been
relative to behaviour at admission. For patients admitted to BIS during 2014/15, there
was a 33.5% median reduction in the frequency of aggression over the mean period of
rehabilitation of 9 months. However, the overall AAS score of 61.7% suggests the figure
of 33.5% underestimates the degree of positive change and reflects the further benefits
of the programme in reducing risk, with a move from physical to verbal aggression and
a decrease in severity during this period. This compares favourably with compatible data
from the Neuropsychiatry Service, St Andrew’s Healthcare, Northampton, which previously
published an AAS of 53.2%.
Meaningful changes were apparent on all five measures in the basket (HoNOS-ABI,
FIM+FAM, SASNOS, MPAI-4, SRS) (see glossary for acronyms). The diversity of areas
assessed confirmed improvements made by the group across the board.
Alderman, N., Knight, C., Stewart, I. and Gayton, A. (2011). Measuring behavioural outcome in neurodisability.
British Journal of Neuroscience Nursing, 7, 691-695.
*
Partnerships in Care Quality Account 2014/15
19
Clinical effectiveness
Clinical effectiveness 2014/2015
Clinical effectiveness 2014/2015
Clinical
Patienteffectiveness
experience
Professor Alderman is the Director of Clinical
Services for PiC Brain Injury Services. He was
co-winner of the Association of Psychological
Therapies (APT) 2014 Award for Excellence in Risk
Assessment and Management, and recipient of the
2014 United Kingdom Acquired Brain Injury Forum
(UKABIF) Stephen McAleese Award for Inspiration
by an individual in the field of acquired brain injury.
Fig. 21 Total people treated in PiC brain injury services (3 years)
2012/13
2013/14
2014/15
Patients treated
53
63
70
Admissions
14
25
29
Discharges
15
22
18
32.92
20.29
20.08
Average Length of stay
Some statistics about PiC Brain Injury
Services
26% of our current ABI
treatment group is receiving care
in a community setting.
28% in open rehabilitation
settings.
Fig. 22 Proportion of people
with ABI in each type of PiC
care setting 2014/2015
3%
26%
43%
Case study
28%
A story of rehabilitation following brain injury
Peter is a man who, prior to his brain injury, had a long standing forensic history
including many spells in prison. In 2006, Peter received significant damage to his
brain when he was involved in a road traffic accident. He had post traumatic amnesia
for four days.
In 2010, whilst on remand in prison, he was given a section 37 hospital order and
transferred to a low secure brain injury unit near Manchester. In 2013, in order to
return closer to home, he was transferred to open rehabilitation at Grafton Manor
where the assessing team had expressed hope he could respond well in this setting.
Whilst Peter could still be quite aggressive at times, he was keen to have a life in the
community.
Since then, he has been successfully supported to achieve employment, unescorted
leave and in 2014, he moved to Grafton Manor’s on-site open rehabilitation studio flat.
In 2015, he completed his transition program to one of PiC’s independent houses in
the community.
20
Partnerships in Care Quality Account 2014/15
Low
Locked
Open
Community
33.5%
median reduction in frequency
of aggression within 9 months
of treatment
Measuring Quality of
Life using EQ-5D
Health organisations, both
commissioners and providers,
are now giving increasing
attention to the patient or service
user’s experience of the care that
they receive. This can include the
patient’s perceived quality of life
as measured by a standardised
measure called the EQ-5D.
This measure, applies to a wide range of
health conditions, provides a simple
descriptive profile and a single value for
health status. It forms part of the six monthly
PiC CPA questionnaire. Consequently, it
is possible to compare the EQ-5D results
between (a) different diagnostic groups
and (b) changes over time.
Preliminary analysis of PiC’s EQ-5D data
indicate that it is a valid measure in that
the results:
(a) are in accord with the level of security,
with those at lowest levels of security
reporting higher perceived quality of life;
(b) d
iffer among diagnostic groups,
with those with severe mental illness
reporting the lowest perceived quality
of life, while those with intellectual
disability report the highest; and
(c) there is a trend for improved perceived
quality of life reflected in the measure
over time.
This analysis is on-going and will provide
an important index of the organisation’s
performance as the data accumulates.
Clinical effectiveness 2014/2015
Clinical effectiveness
Acute, HDU and PICU services for short term
assessment, care and treatment
This year we cared for 531 patients in our Acute service and
29 patients in our relatively new HDU wards. There is a very
different length of stay pattern within Acute and HDU services
than in other PiC services.
Fig. 23 HDU START scoring of
strengths 2014/2015
Fig. 24 HDU START scoring of
vulnerabilities 2014/2015
30
30
25
25
20
20
15
15
10
10
5
5
0
0
Score 1
Score 2
Fig. 25 People using Acute services
– START scores for ‘strengths’
2014/2015
Score 1
Fig. 26 People using Acute services
– START scores for ‘strengths’
2014/2015
30
30
25
25
20
20
15
15
10
10
5
5
0
Score 2
Score 2
Acute
HDU
Patients treated
531
29
Admissions
498
29
Discharges
505
17
Length of stay
0.68
2.64
Given that people admitted to Acute
services are most often experiencing
significant distress, we are pleased that
those who received two paired scores this
year had improved their perception of
strengths and reduced their perception
of their own vulnerability.
This impact is even more strongly evident
in the impact of treatment for people in
High Dependency wards as seen in figures
13 and 14.
Fig. 28 The typology of incidents
managed over 6 months, October
2014 to March 2015 in Acute wards
23%
41%
9%
14%
9%
4%
A
ggression
& Violence
Environmental
H
ealth
Other
Security
S
elf-Harm
The most frequently occurring types
of challenging behaviour dealt with in
the last six months of the year on acute
wards was behavioural, involving either
self-harm (23%) compared to 22% in the
same period across all of PiC, or violence
and aggression towards others (41%
compared to 42% across the group in the
same period).
0
Score 1
Fig. 27 Total people treated in PiC
Acute and HDU services in 2014/2015
Score 1
Score 2
Partnerships in Care Quality Account 2014/15
21
Clinical effectiveness 2014/2015
Clinical
Patienteffectiveness
experience
Health of the Nation Outcome Scale (HoNOS)
Partnerships in Care uses the most clinically appropriate HoNOS
tool as one way of gauging patient progress with treatment. The
assessment is done routinely and regularly by the clinical team and
patient/ resident working together, to assess clinical symptoms and
recovery across a range of areas of functioning. No one measure is
taken in isolation and clinicians always gain a holistic and individual
picture from a variety of measures. Group averages are some
indication of treatment effectiveness, and our data integrity for these
conclusions has been independently assessed. We are pleased
to report that in the last six month period, based on this sample of
patients, stability or improvement was achieved by 86% of patients.
In September 2014 we scored 900 patients and in March 2015, 974 patients using the
HoNOS 4 Factor approach which scores for patient outcomes under four domains –
personal, emotional, social wellbeing, and severe disturbance, by each of 21 ‘clusters’
which is a symptom-led grouping categorisation of patients. (See Fig. 31)
Reading from the scores, we see this measure statistically supports the finding that
therapy has been of small to medium benefit on at least some domains for our patients
in Clusters 5, 6, 8, 13,14,16, 17, 19 and 20.
Therapy has benefited, to medium effect, patients with:
•• severe non-psychotic disorders
•• non psychotic disorders with over-valued ideas
•• psychotic crisis and those with cognitive impairment with high needs.
Our highest (medium) effect sizes are achieved overall for clusters 6 and 14.
We would expect the average score at first HoNOS rating for each service type
to be higher than that taken at the second rating.
Fig. 29 Summary of HoNOS scores
86%
Patients maintained stability in symptoms or made progress
89%
Patients maintained or improved their perception of social wellbeing
88%
Patients maintained or improved their perception of personal wellbeing
85%
Patients maintained or improved their perception of emotional wellbeing
84%
Patients reduced their level of severe disturbance
22
Partnerships in Care Quality Account 2014/15
What is an Effect Size (ES) in this context?
An effect size is the variance between two comparable scores taken at different times
in the patient pathway to illustrate change in a patient’s presentation according to a
range of areas of behaviour, emotion, mental and physical wellbeing. Depending on
the effect size, this variance may be judged to be below any threshold of significance,
or of a small, medium or large significance. In the case of HoNOS Factor 4, this test is
applied across four main areas of functioning to compare them, as well as showing a
total across the four.
The approach to effect size we have used is based on that developed by
mathematician Professor Robert Coe and as applied in some NHS London forensic
mental health services. An ES of 0.5 represents a medium change of moderate
clinical significance and an ES of 0.8 is considered of critical clinical significance
because it is so difficult to achieve unless patients are acutely unwell at the start of
the treatment episode. An ES of between 0.2 and 0.5 is a small effect. An ES that
is negative up to 0.2 would be considered below the threshold and would indicate
stability over time in the patient as well as being unable to ascertain the impact of the
interventions being used in therapy.
Understanding Effect Sizes and their significance
It is not uncommon to see low variance in patient populations where patients are
recovering. Conversely, it is also common to see unstable (varying) effect sizes among
patients with chronic conditions, where symptoms are frequently fluctuating, eg. the score
for PiC patients in Cluster 2 where there is a small effect for social wellbeing but for the
cluster overall, a score below the threshold.
Fig. 30 Colour code guide to effect size table (Fig. 31)
Below threshold
0.19 or below
Small
0.2 – 0.49
Medium
0.5 – 0.79
Large
> 0.8
Indicator definition: The number of all patients who have either remained stable
or improved during treatment as a proportion of all patients tested using two paired
HoNOS scores. The second of the two scores falls within the 2014/2015 period.
Clinical effectiveness 2014/2015
HoNOS Factor 4 Model Clusters (patient groups)
Variance for
Factor 1 Personal
wellbeing
Variance
for Factor 2
Emotional
wellbeing
Variance for
Factor 3 Social
wellbeing
Variance for
Factor 4 Severe
disturbance
Overall effect size
per cluster
0
0
0
0
0
2: common mental health problems (low severity with greater need)
-0.04
0
0.23
0
0.04
3: non psychotic (moderate severity)
0.07
-0.1
-0.06
-0.17
-0.09
4: non-psychotic (severe)
0.19
-0.22
-0.05
0
-0.06
5: non-psychotic disorders (very severe)
0.57
-0.22
0.78
0
0.28
6: non-psychotic disorder of over-valued ideas
0.25
0.45
0.43
0.36
0.51
7: enduring non-psychotic disorders (high disability)
0.15
0.19
0.11
0.19
0.2
8: non-psychotic chaotic and challenging disorders
0.18
0.25
0.26
0.12
0.26
10: first episode psychosis
0.03
0.18
-0.12
0.08
0.08
11: ongoing recurrent psychosis (low symptoms)
0
-0.09
-0.03
-0.16
-0.09
12: ongoing or recurrent psychosis (high disability)
0
0.01
0.04
-0.02
0
13: ongoing or recurrent psychosis (high symptom and disability)
0.14
0.15
0.17
0.47
0.29
14: psychotic crisis
0.39
0.47
0.32
0.63
0.55
15: severe psychotic depression
-0.2
0.09
-0.21
0.16
-0.02
16: dual diagnosis
-0.12
0.26
0.1
0.28
0.17
17: psychosis and affective disorder - difficult to engage
0.04
0.17
0.15
0.31
0.21
0
0
0
0
0
19: cognitive impairment or dementia complicated (moderate need)
0.07
0.23
0.11
0.22
0.14
20: cognitive impairment or dementia complicated (high need)
0.29
0.15
0.74
0.87
0.44
0
0
0
-0.28
-0.06
1: common mental health problems (low severity)Note 1
18: cognitive impairment (low need)
21: cognitive impairment or dementia (high physical or engagement)
Note 1: PiC has no Cluster 1 patients.
Partnerships in Care Quality Account 2014/15
23
Clinical effectiveness
Fig. 31 HoNOS 4-factor effect size table
Patient Safety 2014/2015
Patient
Patient
experience
Safety
Patient Safety
Fig. 32 Most common ICD10 diagnoses among PiC patients
ICD 10 Diagnosis
No of patients
E66 – Obesity
258
J45 – Asthma
119
E78 – Disorders of lipoprotein metabolism and other lipidaemias
94
E11 – Non-insulin-dependent diabetes mellitus
92
I10 – Essential (primary) hypertension
78
G40 – Epilepsy
54
Assessment
E03 – Other hypothyroidism
40
J44 – Other chronic obstructive pulmonary disease
23
PiC’s approach to assessment applies parity of esteem and holistic
multidisciplinary care planning, which we find works best when
the user of service is actively involved and able to (with support)
self-manage areas of concern.
Z88 – Personal history allergy to drugs medicaments & biol subs
21
B18 – Chronic viral hepatitis
20
K21 – Gastro-oesophageal reflux disease
20
When we evaluate data about people in our services it is clear that
many arrive with us with multiple co-existing physical and mental
conditions and behavioural risks or vulnerabilities. Assessment and
treatment that will achieve highest safety requires a careful and
comprehensive appraisal of all of these. We recognise that patients
with poor mental health in hospital are more prone to reduced life
expectancy as well as unhealthy lifestyles. Our safety framework
involves assessment, monitoring and management.
We apply best practice in collaborative risk assessment, drawing on peoples’ strengths
and reducing risks. Our staff offer proactive and positive behaviour management. We
employ the full multi-disciplinary clinical team with the patient in the planning of care.
Monitoring
As explained in previous sections of this report, we apply caution and an individual
approach to interpreting data we gain in collaboration with the service user, using a range
of leading methods of assessment for both mental and physical health conditions, such
as HoNOS 4 Factor, START, HCR-20 v3 as well as quality of life indicators such as EuroQol
EQ-5D, and physical health monitoring scales such as the Lester tool, QRISK2 – an
algorithm which maps ethnicity and diabetes against risk of heart disease or stroke and
our Early Warning Score list of vital signs to monitor, as well as specific clinics associated
with antipsychotic medications to review side effects.
A rich patient-focused body of data is routinely recorded and also
reported in the form of dashboards in real time. This includes,
for example, incidents, complaints, safeguarding alerts, physical
healthcare metrics, care plans in date, patient leave, activity, and
progress.
This year, all our clinical teams were trained in using HCR-20 v3, with expert authors flown
to the UK to conduct this training.
An important achievement this year was the integration of our new incident recording
and informatics system, IRIS and full care planning information into our secured electronic
patient records, CAREnotes.
All assessments are integrated with CAREnotes and generate both individual, ward
based, and group level reports. Patients are also assessed against ICD-10 (international
classification of diseases) diagnoses. See Fig 32.
24
Partnerships in Care Quality Account 2014/15
We seek to effectively share information to inform our priorities and action plans from Ward
to Board / Board to Ward. Data is reviewed at local and Board level monthly. Dashboards
and CAREnotes are the window through which our nursing staff, clinicians and managers
monitor patient safety as a routine part of care delivery.
Summary review of clinical performance 2014/2015
Safeguarding
Fig. 34 Number of SUIs per 100,000 bed days by category, two year comparison
40
Patient Safety
Our staff are trained in how to spot and report concerns, including where appropriate,
‘Safeguarding of Vulnerable Adults’ (SOVA) or ‘Protection of Vulnerable Adults’ (POVA),
instigating independent investigation. We reported 255 alerts January to March 2014 and
242 in that period of 2015. We improved the number promptly resolved from 60% last year
to 64% this year.
35
30
Incident Reporting Informatics System, IRIS
25
PiC’s new Incident Reporting Informatics System, IRIS connects directly to the NHS
STEIS system and has reduced duplication as it replaced the former IR1 paper
recording method. IRIS directly records incidents into our patient electronic record
system, CAREnotes, in a way that is accurate, consistent, and can be reported direct to
management. As a result of the commissioning of IRIS, we changed our reporting method,
so statistics for this year are not directly comparable with last year. Due to the ease of
reporting, we expect to see an increase in incident numbers as these are captured
with greater accuracy. We do not have a full year of records under IRIS yet. We have
reviewed the proportion of incidents by type in the six months from October 2014 to end
March 2015 compared with the previous year. It shows a decrease in incidents involving
aggression or violence and a decrease in security related incidents.
20
15
10
5
0
Category A
2013/2014
Fig. 33 PiC incident reports by type (2 years)
Incident type as a % of total incidents
2013/2014
full year
Oct 2014 Mar 2015
Aggression or violence
60.0%
42.0%
Self-harm
18.0%
22.0%
Security incident
10.0%
8.5%
Other
11.0%
17.6%
Category B
Category C
Category D
Not category
2014/2015
Monitoring patient and staff communication and patient activity
Caring in a tangible way for people in our care is conducive to safety. This includes
monitoring aspects of patient engagement and achievement such as leave, access to
talking therapies, and one to one sessions with their primary or named nurse. This is
included in our monthly Ward to Board Report.
Quality of care planning
89% of all active care plans were in date at year end compared to 78% last year.
Patient and Staff Community meetings
The community meetings engage patients and improve communication on wards. We
monitor meeting cancellations. This year we reduced cancellations from 5.5% to 1.3%.
One to one sessions with primary nurse
The frequency of sessions has risen this year. 55% of patients engage weekly, another
27% two to three times a month. Those not engaging is down from 36% last year to just
13% this year.
Partnerships in Care Quality Account 2014/15
25
Patient Safety 2014/2015
Patient
Patient
experience
Safety
Management of patient safety
There are many facets to managing patient safety in PiC units and
hospitals including positive risk management, actively promoting
caring for patients in safe and least restrictive ways. We collect
and evaluate data on incidents, methods of managing challenging
behaviour and our level of therapeutic restraint measures such
as seclusion. We participated in an NHS Benchmarking Audit of
restraint in August 2014 which has given us baseline statistics.
We report in line with national frameworks. NHS England republished its Serious Incident
Framework policy in March 2015. This framework will apply to our report for 2015/2016.
We are pleased to report we have had no ‘never events’.
PiC uses an intervention framework developed under the National Audit of Schizophrenia
(NAS) to assess people who are prescribed antipsychotics for their risk of heart disease
and diabetes. This is part of our strategy to improve risks for people with long-term
conditions and improve life expectancy. We support patients to fill in assessments such as
Lester Chart to set their own goals for improving their physical health.
Our Practice Nurses oversee individual patient physical healthcare plans. All patients are
offered smoking cessation programmes, advice on diet and nutrition, and healthy menu
choices. When a patient is discharged into the community a discharge summary outlining
their physical healthcare is sent to the patient’s GP within 7 days. For patients who are
being transferred as inpatients the physical healthcare report is included in the discharge
summary.
Managing medicine dispensing and stock control
Fig. 35 Review of use of seclusion (2 years)
31.3.2014
31.3.2015
Patients in seclusion as a % of occupancy
5.8%
8.7%
This year we improved the recording of medicine dispensing with a medicines module in
our EPR system CAREnotes. We engage Lloyds Pharmacy Group to conduct pharmacy
audits; our own compliance team do unnanounced clinic room audits to check on
medicine storage; each hospital has an allocated medicines team comprising of
pharmacist and technician. Any incident involving medication would be reported through
our incident management system, which from this year is electronic and generates an
immediate alert to management where required. We have employed Practice Nurses at
most hospitals as part of our physical health strategy and we are piloting non-medical
prescribing at Stockton Hall hospital. We have a system to preventatively monitor for
potential allergies or adverse side effects to medication including Clozapine.
Patients in segregation as a % of occupancy
0.2%
2.4%
Prescribing Observatory for Mental Health (POMH-UK) Audits
Episodes of seclusion (number in progress)
125
189
Episodes of seclusion as a % of occupancy
12.3%
16.2%
PiC has once again performed well against national averages in a recent POMH-UK
national audit achieving a compliance of 81% compared to the national sample’s 62% on
full documentation for the audit topic this year which related to antipsychotic medicines.
% of total Seclusion Episodes
14.4%
23.8%
We reported 207 serious untoward incidents (SUIs) in 2014/2015, (191 in 2013/2014)
which in terms of patient bed days (per 100,000), is 52.17 (52.42). 76% of episodes
of seclusion are under 24 hours in duration.
Parity of esteem in physical and mental health – physical healthcare
PiC delivers a high quality of physical healthcare to the people using our services and
our Physical Healthcare Strategy will continue next year to make further improvements
98% of people using our services received a health check during the year, 92% within
the first 7 days of admission. We monitor the number of visits to hospital by people within
our services and this year there were 874 instances of hospital admission but only 151
instances of an overnight stay required.
26
Partnerships in Care Quality Account 2014/15
The Royal College of Psychiatrists College Centre for Quality Improvement (CCQI)
supports POMH-UK, which is funded by its member organisations and develops
audit-based quality improvement programmes (QIPs) to help specialist mental health
organisations improve their prescribing practice. In recent years, QIPs have included
prescribing for ADHD, Lithium monitoring (2013/14) and for 2014/15, prescribing for
people with a personality disorder (PD). In last year’s Quality Account we mentioned the
audit due for this year on Assessment of side effects of depot antipsychotic medication,
however this was postponed. The background to the audit on prescribing for PD is that
current UK guidelines state that, while it is important to treat co-morbid mental health
problems among people with PD, drug treatment should not be used specifically for
the treatment of antisocial or borderline PD (National Institute for Health and Clinical
Excellence, 2009). There are few studies into the risks and benefits of drug treatments
for most types of PD.
Summary review of clinical performance 2014/2015
Fig. 36 PiC / national sample performance each of 3 standards
98%
100%
90%
83%
80%
78%
68%
70%
58%
60%
50%
Patient Safety
Security underpins safe and effective
care of patients
POMH-UK scores
A therapeutic environment requires that people – patients, visitors
and staff – feel safe. It plays a positive role in service delivery and
provides the structure in which the clinical agenda can be safely
carried out and patient safety, privacy and dignity maintained.
Our Security Strategy and supporting policies ensures the application of least restrictive
practice evidencing security processes and subsequent restrictions are reasonable,
proportionate and justified to the risk and circumstances.
45%
40%
We educate and supervise all patient-facing staff on the therapeutic use of security and
associated risk management. This is included in comprehensive induction and refresher
training. Patients continue to be involved both in training and in the development of our
security policies as well as in collaborative risk assessment.
30%
20%
10%
0
A medication plan for a
crisis is fully evidenced
National Sample
Patient involvement in the
plan is fully evidenced
Partnerships in Care
Fig. 37 Average across total
of 3 standards
90%
The 3 standards for the POMH-UK
2014 Audit are:
81%
80%
70%
Clinical reason for
prescribing the most recently
prescribed antipsychotic is
fully documented
62%
Standard 1
A medication plan for a crisis is
fully evidenced
Standard 2
Patient involvement in the plan is
fully evidenced
60%
50%
40%
Standard 3
Clinical reason for prescribing the
most recently prescribed antibiotic
is fully documented.
30%
20%
10%
Physical
Procedural
Relational
0
National
Sample
Partnerships
in Care
Average across 3 standards
Partnerships in Care Quality Account 2014/15
27
Patient experience
Patient experience 2014/2015
Patients as partners
in their care
A positive experience of care in specialist inpatient services,
whether hospital or residential, involves independence, autonomy,
choice, and a pathway with a vision of their future – whether that
be an improvement of quality of life with continued support, or
recovery and a life in the community. We find that patients achieve
the best experience and outcomes when they fully engage with their
multidisciplinary team as partners in their own care and treatment.
Here we describe in 8 steps, key elements of Partnerships in Care’s approach
toPatients
deliveringasa partners
good patient experience.
in their care and treatment
1
Engaging people
in keeping healthy
2
Shared
decision-making
3
Supported
self-management
1. Engaging people in keeping healthy
We have described elsewhere in this report the many facets
of PiC’s Physical Health Strategy. We are motivated to address
parity of esteem and care for the whole person as well as to care
for all ends of the physical health spectrum, across the life span,
including long term physical and enduring mental health conditions.
Prevention is important and Smoking
Cessation, Healthy Diet, and Exercise
Programmes are offered to all patients
across our group. In 2015 PiC North
West is running a ‘Mission Fit’ programme
for both The Spinney (for men) and
Arbury Court which is a hospital for
women. All PiC hospitals are running
similar physical healthcare programmes,
have gymnasiums, grounds for outdoor
exercise, catering designed to offer
healthy food choice, and smoking
cessation programmes and advice.
Fewer of our service users have physical
My care plan
Fig. 38 How well did we care for
your physical health?
8
4
Evaluating services
through feedback
Not
joined up
Patients as
partners in their
care and
treatment
Poor
information
Staff were
kind
7
Patient-informed
research
6
Choice of care
closest to home
80%
Employability
60%
16%
21%
11.5%
40%
5
Involving families
and carers
20%
51%
46%
41.3%
2013/14
2014/15
0
2012/13
Yes partly
Source: PiC patient survey
28
Partnerships in Care Quality Account 2014/15
Yes completely
ill health but conversely, perception of
care quality has not risen. 53% of people
are satisfied with the level of physical
healthcare received compared with 67%
two years ago. In that period of time, PiC’s
physical healthcare strategy has produced
greater accessibility to GPs, more Practice
Nurses at sites, and continuously improving
levels of physical health monitoring.
Case study
A series of 12-week programmes for
weight management were run at The
Spinney. In one of these groups, of 8
patients, weight loss ranged from a few to
15 pounds. As part of routine activities,
patients made films about living with
chronic conditions such as diabetes
and COPD, and about diet, nutrition and
exercise.
To coincide with these activities staff
arranged an educational bus to tour
PiC’s hospitals in the north west of
England. Patients on ground leave were
able to ‘drop in’ for basic testing of
blood pressure, blood sugars and BMI.
Information was displayed on obesity and
smoking, with ideas about healthy eating
and snacking. In total over 160 patients
and staff visited the bus and learned
about healthy living. Patients could earn
prizes for choosing certain rated food
items using a loyalty card system.
Patient experience 2014/2015
Patients share in decisions about their care and treatment in a
number of ways, including the Care Programme Approach (CPA).
PiC conducts both an annual CPA survey and this year we also
did a CPA Internal Audit.
CPA applies to all patients in PiC services. 2,816 CPA meetings were planned this year, of
which 69% (1,937) were both held and effectively recorded on our EPR system. We did the
CPA audit because, during 2014, we amended CPA documents in response to contractual
changes and our adoption of leading recovery tools.
Fig. 40 Extract of CPA patient survey results 2014/15
Compliance
Involved in all parts of meeting
62%
Offered opportunity to chair CPA meeting
57%
Everyone I wanted to attend was there
54%
I reviewed my CPA report ahead of the meeting
43%
I was able to provide my own views
72%
I was offered, and accepted a break time
30%
I was told the next meeting date
53%
106 CPA documents across 20 units were audited for completeness (see Audit table and
the notes to explain what each section achieves for our our patients).
My care plan was clear and timescaled
60%
CPA patient survey
My CPA report was easy to understand
37%
765 Pre and Post CPA patient questionnaires were completed by patients and analysed.
Note to Fig.39
Fig. 39 Audit of CPA document completeness
Compliance
Essential information
81%
About me
91% Note 1
My safety, my risks, my security needs
76% Note 2
My pathway
72% Note 3
What I have achieved (since last CPA)
46%
Work I still need to do
26%
Have my needs been met?
32%
The plans I have agreed with my team
56%
My CPA meeting
84%
My CPA documents
84%
Total average of the above scores
65%
Note 1 The patient documents reasons that led to their admission into hospital, their health and
diagnosis. Note 2 This low score relates to our recent request that information from the START
assessment is transferred into the CPA report. A recurring theme is patients unable to identify who
supported them in filling in the document. Note 3 Where I am now’ scores 83% but fewer patients
can answer ‘my next step’ (67%) or ‘what I need to achieve’ (70%). We will seek to address this.
Fig. 41 Level of satisfaction with
information on medication
13.10%
Patient experience
2. Shared decision making
Fig. 42 If you had a talking therapy
did you find it useful?
22%
14.40%
54%
72.30%
Enough
Would like more
Not enough
Source: PiC Patient Survey
26%
Yes completely
Yes partly
No
Source: PiC Patient Survey
CPA Survey Indicator definition: Proportion of patients in positive agreement
with a range of CPA Survey questions.
Partnerships in Care Quality Account 2014/15
29
Patient experience 2014/2015
Recovery strategy
Patient experience
Care Programme Approach Survey continued.
Fig. 43 Do you receive copies of
Care Plan and /or CPA and
other outcome reports
5%
24%
19%
I feel chairing the meeting
put me on an equal basis
with the team and ensured
I could easily ask
questions of the team
and especially the Doctor
and put my own views.”
Patient who chaired their
own CPA meeting.
52%
Recovery is something best achieved in collaboration. Our strategy works with our service
users, friends and family, partner agencies and service user expert groups as well as
our staff. We conducted two audits: the ‘Team Recovery Implementation Plan’ (TRIP)
Audit among staff, and ‘Elements of Recovery Facilitating Systems’ (ERFS) Audit among
patients, with an over 50% response rate on both audits.
TRIP and ERFS are internationally-recognised leading tools which can make tangible the
concept of patient outcomes and recovery.
We report on the results of our audits which revealed that whilst 85% of patients feel they
are treated as a person who can learn, grow and change, only 15% feel confident of a
normal life in a home of their own in the community. Following the audits, results at local
level were analysed and local action plans prepared. The next step is to fully embed
recovery principles, complete local action plans then repeat these audits in the near future.
Fig. 44 Results of audit % of patients who agreed with the statement
I don’t receive any reports
I receive Care Plan reports
I receive other reports
I receive all reports
Next steps following the CPA Audit and Patient Survey
A detailed action plan has been agreed at Clinical Governance Committee and will be
actioned at the same time as we roll out the PathNav system our new patient / clinician
collaborative care planning software. The action plan includes review of each CPA report
for completeness before it is loaded to our EPR system. Clear guidelines for staff with
regard to the CPA process will be implemented consistently across the group during
2015/2016.
30
Partnerships in Care Quality Account 2014/15
I am told about my rights and how to uphold them
87%
I can receive services for as long as I need them
86%
I am treated as a person who can learn grow and change
85%
Staff seem to hold hope for me
85%
I have say in how the service is run
30%
Staff share information openly and clearly
15%
I can get support in my home and community
15%
I am supported to achieve a normal life
15%
In 2015, over 70 people in PiC services contributed to a creative project to express
recovery journeys. Some of this artwork is reproduced on the cover of this Quality
Account. It indicated that many service users relate strongly to the concept of personal
recovery, goal-setting and looking towards returning to the community.
3. Supported self–management
5. Involving families and carers
PathNav
PiC’s bespoke PathNav software takes patient involvement in
their own assessment, individualised goal-setting, treatment
and discharge planning, to an unprecedented level. PathNav
has been in development and pilot within PiC for two years.
By March 2016 it will be in use across the PiC group.
Research and reported experience indicates that involving relatives,
carers, friends, family and community in a person’s recovery from a
spell of mental illness is very helpful. Activities such as meaningful
work, productive activity and social interaction are very important.
Feedback from external groups is important to translate back into
service improvement.
The first phase of roll out began in January 2015 at Llanarth Court, Wales; Abbey House,
Worcestershire and Arbury Court, Cheshire. The next phase will commence when these
hospitals have completely integrated PathNav into their ways of working. A dedicated team
are training staff on wards and supporting the implementation at sites.
In this section, you will read about several ways we involve families and carers, or how
we gain patient and resident opinion on our services.
PathNav is interactive, enabling patients to plan their journey in services, not only within
PiC but with other services. Patients can work with clinicians and case managers to
forecast length of stay and potential discharge or transfer dates. They can see how they
have a role in adjusting the time of that journey based on their progress, possibly seeing
the relationship between this and their levels of engagement with treatment.
The system has an additional advantage of reducing duplication staff face in documenting
care planning or preparing for review meeting. The system automates reports. Efficiency
returns time to staff to engage more with patients.
4. Employability
What patients said in our Patient Survey 2015
Fig. 45 Does PiC help you stay in
touch with your family and friends
7%
18%
11%
64%
Our Real Work Opportunities programme is among the best
leader in the sector and has won a number of awards including
a LaingBuisson Award for Personalisation.
The power of work to engender recovery in mental health is well documented and PiC
research on RWO for people with learning disability was published this year in the Journal
of Learning Disabilities and Offending Behaviour (see Research list on page 35).
We have increased paid real work opportunity roles for patients from 18 in our first year
of the programme in 2011, to 131 in 2014. Unpaid real work opportunities (70 in first
year of RWO) numbered 88 at end 2014.
Yes definitely
Yes partly
No I want more help
Did not want help with this
Partnerships in Care Quality Account 2014/15
31
Patient experience
Patient experience 2014/2015
Patient experience 2014/2015
Patient experience
Friends and Family Test
The Friends and Family Test (FFT) applies to all providers of NHS funded acute services
for inpatients. That includes independent sector organisations like PiC and also patients
discharged from A&E. Initially when introduced this was to be scored using the Net
Promoter Score (NPS). The NHS England review of the patient FFT, published in July 2014,
recommended a move away from the NPS and the introduction of a simpler scoring system,
presenting the FFT results as a percentage of respondents who would or / would not,
recommend the service to their friends and family. This change was introduced across all
existing patient FFT settings on 2 October 2014. This new method is calculated by adding
those respondents extremely likely and likely to recommend, divided by the number of total
responses as a percentage. PiC has reported scoring according to the latter method.
Within PiC services, the FFT question "How likely are you to recommend our service to
friends and family if they needed similar care or treatment?" is included within our Discharge
Survey questionnaire.
I would recommend the ward to a friend or family if they needed it.
I have been reasonably happy here for over three years.”
Patient quote from FFT responses
It is a relatively good performance for a psychiatric inpatient
service that 65% of those leaving our services say that they
would recommend our care to a member of their family or
a friend should they need specialist mental health treatment.”
Dr Quazi Haque
55% of eligible patients answered the FFT question. We are reasonably pleased that 63% of
respondents said they would recommend our services. Many respondents additionally gave
detailed comment, which is a valuable source of feedback to inform service improvement.
Fig. 46
How the PiC FFT responses were distributed across possible answers
Number asked
F&F Question
853
Number of
responses
FFT Score %
490
63%
Extremely likely
142
Likely
Neither likely nor
unlikely
168
65
Unlikely
65
Extremely
unlikely
35
Don't know
15
Source: PiC CAREnotes – FFT Dashboard report
Note:
Our FFT performance can only usefully be compared with other specialist secure and rehabilitation mental health providers and there is no directly comparable benchmark available at this time. Physical
Healthcare and Primary Mental Healthcare services score more highly than Specialist Mental Healthcare services. This is to be expected. Within PiC, the majority of patients are detained under the Mental
Health Act with compulsion to be treated.
32
Partnerships in Care Quality Account 2014/15
Relative and Carer Survey
A national Award for PiC’s work with patients and families
PiC’s Relative and Carer Survey is conducted annually among the relative and carer
networks local to each of our facilities. These networks are in regular correspondence with
the hospital. Members attend regular events at the units as well as visits, either at the unit,
escorted or unescorted visits by the patient to home or other venues. This year’s survey
had 172 respondents.
PiC Kneesworth House Head of Social Work, Linda Ram, won the 2014 Mental Health
Social Worker of the Year Silver Award for her work with patients and their families
80% believe
PiC hospital
treatment is
benefiting
their relative
72% would
recommend PiC
treatment
81% are
satisfied with
the amount
of information
given
80% can
speak to hospital
staff when they
want to
Fig. 47 Issues that affect relative contact with patient
Just one example of the great work Linda and her team had done to earn them this Award
was the Peer Plus project. Patients with the appropriate health and wellbeing to become
‘Peer Plus Supporters’ help newer patients to settle in to life on the ward. The continuing
programme is a great success as judged by patients at Kneesworth House.
What a new patient said:
When I first arrived at the hospital I was nervous and apprehensive
about the ward. It was really comforting to have a peer plus
support worker with me after I arrived. This person showed me around the
ward, how things worked, introduced me to other patients and just made
me feel welcome. I have volunteered to be a peer plus supporter in the
future when I’m ready.”
What a Peer Plus Supporter patient said:
8%
27%
64%
22%
“Since I took on this role I can see my self-esteem has improved.
I feel I am doing something worthwhile and making a positive
contribution here at the hospital. I also feel really optimistic about my
own recovery. I think I gain more than I give in this work.”
What Linda said:
23%
Distance
Cost
Time
Transport
50%
Personal health or mobility
Childcare
I have always felt inspired at the courage and inner strength still
left in a person who has experienced a traumatic event or acute
distress and I believe that with the right help, as social workers working
with a skilled clinical team, we can support them to find that strength.
When I see a profound difference being made to a person, and the
benefits that brings not just to them but their family, I feel it’s worthwhile.”
Partnerships in Care Quality Account 2014/15
33
Patient experience
Patient experience 2014/2015
Patient experience 2014/2015
Patient experience
6. Choice of care closest to home
Partnerships in Care has in 30 years grown from a few specialist
secure hospitals and specialist residential care.
We care for people with diagnoses such as mental illness, personality disorder, learning
disability, autism spectrum disorders and acquired brain injury. However recently, our
scope of care has extended to a group of nearly 60 units at the time of this report’s
publication (June 2015).
Our scope of care has extended to older adults with long term and enduring mental ill
health and more recently, to child and adolescent mental health care, including services
for eating disorders. We have also recently acquired a clinic specialising in services
for adult addiction. Diverse care pathways and a full range of step down settings
means people can transfer to services within our group without the need for multiple
reassessments. Where people transfer out of PiC, we support the transition with detailed
assessment reports for GPs, case managers and clinical teams.
7. Patient-focused research to support
evidence-based care
PiC commitment to evidence-based practice and high quality
care is evidenced by the clinical research carried out by its staff.
We select research aligned with clinical objectives that will inform
improved care based on patient outcomes. Studies involving people
in our care must reflect back into the service. Our refinements to
our electronic patient records allow PiC to make available a wealth
of health care data to support clinical research.
While much of this is carried out exclusively in-house, increasingly links are also being
created with external academic institutions. This research endeavour is increasing as
evidenced by:
•• 30 published research papers by PiC staff in the past year. See pages 36-38
herever you are, we have a hospital or unit not too far away.
W
With further growth in 2015 extending our care pathways
we offer life-span care and a full range of settings from secure
to residential.”
Joy Chamberlain, Group Chief Executive
Home visits
PiC supports patients in reviving or sustaining links with their family, carers and community
and encourages visits to units, or where possible, home visits, or visits in other locations by
residents with their friends and family. This year, our learning disability services published
research “Home Visits: A Reflection on Family Contact in Specialist Forensic Intellectual
Disabilty Care” in the journal, Advances in Mental Health and Intellectual Disabilities.
•• 3 ongoing externally funded research projects in which PiC is an active collaborator.
These include:
(a) C
haracteristics and needs of long-stay patients in high and medium secure forensic
psychiatric care: Implications for service organisations (Principal Investigator:
Professor Birgit Völlm, University of Nottingham).
(b) People with autism detained within hospitals: defining the population, understanding
aetiology, and improving care pathways (Principal Investigator: Dr Peter Langdon,
University of Kent).
(c) Outcomes from forensic services for people with intellectual and developmental
disabilities: evidence synthesis and expert and patient consultation (Principal
Investigator: Dr Catrin Morrissey, Institute of Mental Health). Projects(b) and (c) were
the result of the activities of the Clinical Research Group in Forensic Intellectual and
Developmental Disabilities (CRG-FIDD) set up to identify priorities for research in
intellectual disabilities under the guidance of Dr Regi Alexander.
•• 32 other active internal research projects within PiC. See page 35.
PiC also supports the Institute of Psychiatry National Conference for Research in Forensic
Mental Health Services which held its 12th event in London on 16th April 2015.
34
Partnerships in Care Quality Account 2014/15
Patient experience 2014/2015
Patient experience
Research in progress
Research work currently in progress in PiC hospitals in 2014/2015
Research work currently in progress in PiC hospitals in 2014/2015 (continued)
Researchers
Researchers
Title of project
Abby Fenton, Forensic Psychologist,
Women’s Services, Kneesworth
House Hospital
Evaluation of a mixed gender fire-setting
treatment group.
Toyah Lebert (NHS)
Focusing on Clozapine-unresponsive
symptoms: a randomised controlled trial.
Verity Chester, Researcher, PiC Learning
Disability Services
Relational security within secure services
Verity Chester & Wendy Morgan of PiC
Evaluation of the clinical utility of the
relational security explorer.
L Symes, J Chilvers, M Henriksen,
V Chester, C Loveridge
Healthy Body, Healthy Mind: An
evaluation of a psycho-educational group
in a forensicintellectual disability setting.
Rebecca Start, Trainee Clinical
Psychologist & Dr Margo Ononaiye,
Clinical Psychologist, University of
East Anglia
Verity Chester & Cathy Thomas of PiC
The prevalence of low self-esteem in a
forensic learning disability population:
is there requirement for a specific selfesteem intervention?
Paul Mooney, Lead Psychologist
& Donna Harrison, Trainee Forensic
Psychologist, PiC Midlands
Self-reported emotional problems and
risk in forensic Intellectual Disability:
exploration of the Emotional Problems
Scale - Self-Report Inventory.
Paul Mooney - Regional Lead
Psychologist & Pancho Ghatak,
Consultant Psychiatrist, PiC Midlands
Use of the Short Term Assessment of
Risk and Treatability (START) in medium
and low secure Intellectual Disability
Services
Title of project
External research
Birgit Völlm, Associate Professor,
University of Nottingham
Dr Peter Langdon, Hertfordshire NHS
Trust
Catrin Morrisey, Lead Psychologist Rampton Hospital, Nottinghamshire
Healthcare NHS Trust
Characteristics and needs of long-stay
patients in high and medium secure
forensic psychiatric care: Implications
for service organisations (Nottingham
University)
People with autism detained in hospitals:
defining the population, understanding
aetiology and improving care pathways
(external funding)
Outcomes from forensic services for
people with intellectual or developmental
disability - Evidence synthesis and expert
and patient/carer consultation (external
funding)
PiC-driven research
Margot Brink, Head of Psychology
& Dr Lawson - Research Lead,
Oaktree Manor with a student from
Nottingham University
Effectiveness of therapy in reducing risk
and promoting recovery measured by
HCR-20 and HoNOS-LD among people
with learning disability in a low secure
setting (student from Norwich University)
Stephen Neil, Nurse Researcher
& Dr Adrian Cree
What factors are associated with reduced
seclusion of violent psychiatric patients?
Niamh Kennedy, psychologist
Kneesworth House, with a student from
University of Nottingham
Boundaries among staff working in a
specialist secure mental health setting.
Partnerships in Care Quality Account 2014/15
35
Patient experience 2014/2015
Patient experience
Research completed
Research on treatment effectiveness and patient outcomes
Author
Title
Publication
Duggan, C. & Dennis, J (2014)
The place of evidence in the treatment of sex offenders.
Criminal Behaviour and Mental Health.24; 153-162
Duggan, C. Parry, G., McMurran, M, Davidson,
K & Dennis J. (2014)
The recording of adverse effects from psychological
interventions in clinical trials: Evidence from a review of
NIHR-funded trials.
Trials. 15; 335
Duggan, C. (2014)
Personality and Offending. in A Dictionary of Criminal
Justice, Mental Health and Risk (eds Paul Taylor, Kate
Corteen and Sharon Morley).
The Policy Press
Hale, D.F., Waters, C.S., Perra, O., Swift, N.,
Kairis, V., Phillips, R., Jones, R., Goodyer, I., Harold, G.,
Thapar, A & van Goozen, S. (2014)
Precursors to aggression are evident by 6 months of age.
Developmental Science 2014 17(3), 471–480
Howard, R., Khalifa, N & Duggan, C. (2014)
Antisocial personality disorder comorbid with borderline
pathology and psychopathy is associated with severe
violence in a forensic sample.
Journal of Forensic Psychiatry and Psychology
Doi.org/10.1080/14789949.2014.943797
Huband, N., Duggan, C., McCarthy, L., Mason, L.
& Rathbone G.(2014)
Defense styles in a sample of forensic patients with
personality disorder.
Personality and Mental Health. 8; 238-249
Duggan, C (2014)
The Empirical Basis of Sex Offender Treatment Effectiveness.
Sexual Offender Treatment. 9 (2) 1–13
Kasmi, Y. (2014)
Options in managing clozapine induced hypersalivation: a
survey of secure services consultants.
Royal College of Psychiatry Central Faculty of Forensic
Psychiatry Annual Conference, Belfast (March 2014)
Kasmi Y, Phillipson P, Swires D (2014)
Real Work Opportunities: A Brighter Future.
Institute of Psychiatry 11th Annual Conference of
Research in Forensic Mental Health, King’s College,
London (April 2014)
Baliousis, M., Huband, N., Duggan, C.,
McCarthy, L., & Völlm, B. (2015)
Development and validation of a treatment progress scale
for personality disordered offenders.
Personality and Mental Health
Ottter, Z., Mooney, P. (2014) (in press)
Shame, violence and implications for recovery: use of the
compass of shame scale to explore shame coping styles in
female psychiatric inpatients.
Mental Health and Wellbeing
Clarke, M., McCarthy, L., Huband, N., Davies, S., Hollin,
C. & Duggan, C. (2015)
The Characteristics and Course after Discharge of Mentally
Disordered Homicide and Non-Homicide Offenders.
Homicide Studies, 1- 18. DOI:
10.1177/1088767915570312.
36
Partnerships in Care Quality Account 2014/15
Patient experience 2014/2015
Author
Title
Publication
Khan, O., Ferriter, M., Huband, N., Powney, M.J., Dennis,
J.A. & Duggan, C. (2015)
Pharmacological interventions for those who have sexually
offended or at risk of offending.
Cochrane Database of Systematic Reviews Issue 2. Art.
No.: CD007989. DOI: 0.1002/14651858.CD007989.pub2
Tyrer, P., Duggan, C., Cooper, S., Tyrer, H., Swinson,
N., & Rutter, D. (2015)
Commentary: The lessons and legacy of the programme
for dangerous and severe personality disorder.
Personality and Mental Health.
Wiley on line DOI 10.1002/pmh.1293
Duggan, C & Howard, R. (2015)
Mentally Disordered Offenders: Personality Disorders:
Assessment and Treatment.
(Chapter in Forensic Psychology,
2nd Edition Eds Crighton & Towl. Wiley.
Howard, R. & Duggan C. (2015)
Mentally Disordered Offenders: Personality Disorders:
Their Relation to Offending.
(Chapter in Forensic Psychology,
2nd Edition Eds Crighton & Towl). Wiley
Author
Title
Publication
Chester,V, & Henriksen, M. (2014)
Pain Experience and Management in a Forensic Intellectual
Disability Service.
Advances in Mental Health and Intellectual Disabilities,
8(2) 120-127
Devapriam, J., Alexander, R., Gumber, R., Pither, J. &
Gangadharan, S ( 2014)
Impact of care pathway-based approach on outcomes in
a specialist intellectual disability inpatient unit.
Journal of Intellectual Disabilities, 1–10
Kitchen, D., Thomas, C. & Chester (2014)
Management of aggression care plans in a forensic
intellectual disability service: a ten-year progress update.
Journal of Intellectual Disabilities and Offending
Behaviour, 5 88- 96
Patterson, C., & Thomas, C. (2014)
Life Skills Group: increasing foundation knowledge and
motivation in offenders with a learning disability.
Journal of Intellectual Disabilities and Offending
Behaviour, 5 (1) 4-13
Chester, V. (2014)
Exploring the past: a practical guide to working with
the memories of people with learning disabilities. Sarah
Housden. Speechmark 2012. 170pp. £35.99. ISBN 978 0
86388 907.
British Journal of Occupational Therapy, 77(6) 328
Cooray, S.E., Bhaumik, S., Roy, A., Devapriam, J., Rai, R.,
& Alexander, R. (2015)
Intellectual disability and the ICD-11: towards clinical utility.
Advances in Mental Health and Intellectual Disabilities,
9(1) 3-8
Chester, V., McCathie, J., Quinn, M., Popple, J., Ryan, L.,
Loveridge, C. & Spall, J. (2015)
Clinician Experiences of Administering the Essen Climate
Evaluation Schema (EssenCES) in a Forensic Intellectual
Disability Service.
Advances in Mental Health and Intellectual Disabilities,
9(2) 70-78
Patient experience
Research on treatmen effectiveness and patient outcomes (continued)
Research on Learning Disability
Partnerships in Care Quality Account 2014/15
37
Patient experience 2014/2015
Patient experience
Research on Learning Disability (continued)
Author
Title
Publication
Cox, A., Simmons, H., Painter, G., Philipson, P.,
Hill, R., & Chester, V. (2015)
Real Work Opportunities: Establishing an Inclusive and
Accessible Programme within a Forensic Intellectual
Disability Service.
Journal of Intellectual Disabilities and Offending
Behaviour, 5(4) 160-166.
Esan, F., Chester, V., Alexander, R. T., Gunaratna, I. J. &
Hoare, S. (2015).
An analysis of the clinical, forensic, and treatment outcome
factors of those with Autistic Spectrum Disorders treated in
Forensic Intellectual Disability Settings.
Journal of Applied Research in Intellectual Disabilities,
28(3) 193-200
Alexander, R.T., Devapriam, J., Michael, D.M., McCarthy,
J., Chester, V., Rai, R., Naseem, A.,
Roy, A. (2015)
“Why can’t they be in the community?” A policy and practice
analysis of transforming care for offenders with learning
disability.
Advances in Mental Health and Intellectual Disabilities,
9(3) 139 - 148
Alexander, R. T., Chester, V., Green, F. N., Gunaratna, I., &
Hoare, S. (2015)
Arson or fire setting in offenders with intellectual disability:
clinical characteristics, forensic histories and treatment
outcomes.
Journal of Intellectual & Developmental Disability, Vol 40
(issue 2)
Chester, V., Alexander, R., & Lindsay, W. (in press)
Women with Intellectual Disabilities and Forensic
Involvement. In W.R. Lindsay and J.L. Taylor (Eds).
The Wiley Handbook on Offenders with
Intellectual and Developmental Disabilities.
John Wiley and Sons Ltd.
Cheshire, L., Chester, V., Graham, A., Grace, J.,
& Alexander, R.T. (in press).
Home Visits: A Reflection on Family Contact in Specialist
Forensic Intellectual Disability Care.
Advances in Mental Health and Intellectual Disabilities.
We have published over 30 papers on specialist research this
year which promote understanding of patient needs. We were
successful in a number of external partnership research bids which are
now in progress and will yield significant findings.”
Professor Conor Duggan, Head of Research
38
Partnerships in Care Quality Account 2014/15
Patient experience 2014/2015
8. Evaluating services through feedback
Patient survey
Fig. 48 Patient satisfaction with
care received
Fig. 49 Yes, I am satisfied with how
clinicians listen to what I have to say
75%
100%
Our annual patient survey (February 2015) is more comprehensive than ever before,
reflecting a higher degree of patient participation in their own care and treatment as well
as in audit and monitoring of service and ward quality.
70%
Some indicators have three years of statistics and some are entirely new this year to cover
new priorities such as opportunity to work, to use internet-based communication, and
areas of greater scrutiny such as patient involvement and engagement.
The patient survey this year achieved our highest ever participation level, reflecting
46% of patients. Survey results give insight into both patient experience and clinical
effectiveness. The purpose of measurement is to direct continuous improvement and
to be able to evidence quality care.
80%
60%
65%
60%
74%
40%
83%
67%
63%
79%
66%
20%
0
55%
2012/13
2013/14
2012/13
2014/15
2013/14
2014/15
What does this feedback tell us?
• We are achieving satisfaction level for between 60 to 70% of service users and
we need to work harder for around 25% of service users who are not completely
satisfied.
• Around 80% of our service users feel they are listened to well; we need to work harder
to reach between 15 and 20% of people who don’t feel they are listened to enough.
• Around 80% of service users definitely understand and feel they can access our
complaints process should they require to; we need to explain this more fully if we
are to reach around 11% of people who feel unsure about this.
• 86.2% of people detained are able not only to understand their rights at point of
admission but remember this throughout their stay; it is understandable that some
people may be so unwell as not to be able to absorb this information and the
research suggests this is the case for around 4% of service users.
• Three years into our physical health strategy, fewer service users have physical
ill health but conversely, for the patient group who are ill, expectations may have
risen and slightly fewer people say they are satisfied with the level of care received
for their physical health. 52.8% are either partly or completely satisfied compared
with 67% two years ago. With the strategy now more developed, more Practice
Nurses in place and good links with primary care, we hope to help more people
to better physical health in the year ahead.
Fig. 50 Patient awareness of how
to raise a concern
Fig. 51 Were your rights under
detention fully explained?
85%
100%
80%
80%
18%
16.2%
60%
75%
70%
13%
83%
80.4%
40%
74%
60%
70%
60%
20%
65%
2012/13
2013/14
2014/15
0
2012/13
Yes Partly
2013/14
2014/15
Yes completely
Partnerships in Care Quality Account 2014/15
39
Patient experience
3-year comparisons at a glance
Among the ways we receive feedback on our service are the
annual Patient Survey, our Ward Quality Matters programme,
complaints process reports received through service users
using independent advocacy.
Patient experience 2014/2015
Patient experience
Complaints process
Fig. 53
This year we repeated our information campaign to patients on
understanding our complaints process. We also extended the
process to include greater formality around the reporting of informal
complaints so that all forms of complaint are recorded.
Types of complaint as a % of total
2013/2014
2014/2015
Attitude of staff
12.9%
12.3%
Alleged loss or damage to property
11.5%
16.8%
Alleged physical assault by patient
11.6%
12.3%
About staff conduct
3.3%
4.4%
About physical healthcare
4.9%
4.2%
About nursing care
4.1%
3.2%
Alleged bullying by staff
3.0%
3.7%
Alleged bullying by a patient
2.6%
2.9%
Clinical care
5.1%
4.8%
About lack of information
4.2%
2.1%
Looking at formal complaints, 94.3% were responded to within two days. 73% were
resolved within 25 days. 27% took longer than 25 days to investigate and resolve. 91%
were received either from patients / residents themselves or their family or friends. The
other 9% come from a variety of sources such as patient advocacy, legal representatives,
commissioners or our own staff.
About patient leave
2.7%
4.5%
About activities or OT sessions
2.9%
0.5%
About restraint
1.6%
1.9%
There are no strong trends of a change in the type of issues giving rise to complaints.
Other
25.5%
23.2%
The number of complaints has somewhat reduced this year, both in actual terms (by 15.2%)
and in terms of patient bed days by 22%. The number of patients who report they are
familiar with the complaints process and know how to raise a complaint is the same as last
year at 80.4%.
Fig. 52
2013/2014
No. of complaints
730
2014/2015
No. per 100,000
bed days
No. of complaints
200.37
619
As an organisation we are committed to:
•• follow up with complainants to hear their thoughts
•• learn from themes of complaints
•• listen with empathy
•• respond promptly and with investigation
•• be fair, accountable and auditable
•• offer patients independent advocacy as part of the process
40
Partnerships in Care Quality Account 2014/15
No. per 100,000
bed days
156.02
Advocacy
Rethink Mental Illness provides an advocacy service to people
using our services as required.
In 2014/2015 our patients used the advocacy service 2604 times. Analysis of the figures
by quarter indicates a growth in patient interest in the advocacy service. Trends are
reviewed by PiC’s Clinical Governance Committee.
Fig. 54 Advocacy usage by patients in PiC units by type of issue
11%
Partnerships in Care had approximately 96 wards in 2014/2015,
all of which had the opportunity to participate in the Ward Quality
Matters (WQM) scheme, which we launched last year and started
measuring from August 2014.
This programme gives patients the opportunity to be actively involved in monitoring service
quality as well as influencing service development.
This year we formally evaluated this programme and found patients are reporting greater
satisfaction with the care offered.2
7%
6%
Patients share in ward performance through
Ward Quality Matters
10%
We monitored the level of participation and in the period from 1st August to end
March 2015, the average rate of participation was 69%. See Page 42 for an example
of a WQM poster.
11%
At a glance for users of our services
20%
What do we mean by Ward Quality Matters?
9%
• Those records show if your house or ward is getting things right for you.
5%
Detention, conditions or restrictions
Care programme approach (CPA)
Care and treatment, ward round or staff
P
ersonal needs, hospital amenities
and services
M
ental Health Tribunal appeals
21%
• If you are a patient in a Partnerships in Care service, the staff who care for you,
want to know what matters to you. We want to know what matters to you most
about your daily life, about staff and about your care.
• Patients can ask to see ward records about things like family contact; leave,
feeling safe; choice of activities through the week and the weekend.
egal issues including consent to
L
treatment
Discharge planning, leave and transfers
Complaints / Safeguarding issues
Generic advice and advocacy
• Partnerships in Care wards and houses show your choice of records on
posters which can also be discussed in your community meetings whenever
you want. See page 42.
Presentation by Haque Q et al at 2015 conference of International Association of Forensic Mental Health
Services (IAFMHS)
2
Partnerships in Care Quality Account 2014/15
41
Patient experience
Patient experience 2014/2015
Patient experience 2014/2015
A sample Ward Quality Matters poster.
Patient experience
This example was done in February 2015 by patients with acquired brain injury
and their staff at Elm Park in Colchester.
Some of you stated
you do not get enough
time with your Primary
Nurse
“In the last quarter we have
held 285 Primary Nurse
Sessions. This is an
average out at 6 sessions a
patient each month.
You said these sessions
were invaluable. You have
been able to discuss the
progress you have made at
Elm Park, House or Cottage,
any wishes for community
access and other aspects of
rehabilitation such as
shopping.
43 episodes of leave
have been cancelled in
last 3 months
“We know you are
concerned when you do not
get to go out as planned.
We will reschedule your
leave as soon as possible if
your leave has to be
cancelled for any reason.
We will continue to work
with you on your behaviour
and safety to ensure you
maximise your episodes of
leave”
We will strive to ensure you
have time to meet with your
Primary Nurse. This is
monitored every day”
42
Partnerships in Care Quality Account 2014/15
30% of you have
improved your BMI in
last 12 months
“You have embraced the
gym workshops,
Horticulture & Maintenance
activities in addition to
healthy eating plans.
Well done to all those who
have achieved this
improvement.
We will continue to offer
healthy menu choices and
activities both on and off
the hospital/houses to
everyone”
We currently
have 5
open safeguarding
alerts
We currently have a
number of vacancies
within BIS Essex
“You said it is important for
you to feel safe in your
environment.
“We understand what a full
cohort of staff mean to you
and your rehabilitation.
We are aware that
sometimes you do not get
on very well with each
other.
We thank you for your help
and involvement in setting
staff interview questions and
orientating new staff.
To support and to ensure
your safety we follow
policies and plans. This
helps us to protect you as
far as reasonably possible
and prevent further
incidents whilst staying at
Elm Park, House or
Cottage”
We are currently advertising
and interviewing in order to
fill these vacancies”
Our workforce 2014/2015
Our workforce
‘Preparing a workforce for the future’ is a
strong theme within the organisation as
we go into 2015/16 and recruitment and
retention are important parts of our strategy.
We have a strong recruitment team and a
dedicated recruitment website.
Fig. 55 Staff by type 2014/15
6%
19%
56%
19%
Aside from work, the wellbeing of our staff is important to PiC and we offered a selection
of staff benefits including pension scheme, medical and dental insurance, childcare
assistance, discount schemes and a 24 hour employee support service for advice which
result in a referral to specialist advice where required. There is also a 24-hour independent
concern line where staff can raise concerns freely about any issue they may feel they
cannot deal with appropriately through line management channels. Our senior team have
a strong ward presence and are open to receiving calls, emails or appointments from staff
including have a ward to board email which goes direct to the PiC Board.
Appraisal and time for professional reflection is valued, with a new appraisal process
launched within the past two years, as well as learning and resources for staff on PiC
Governance policies, processes and vision. We refined and launched a process just after
the close of this year-end on Duty of Candour.
The Staff Survey
Leaders
Non-clinical support staff
Psychiatrists and other specialist
clinical staff
Registered nurses & Healthcare
workers
Staff sickness rate is 2% of available working days. Staff job satisfaction is higher, at 82%
compared to 79% last year. Staff retention is good with 40.2% of our staff have been with
PiC for more than five years.
Taking psychiatrists, psychologists, other clinical professionals, nurses and healthcare
workers as a group, clinical staff comprise 63% of our workforce. Management staff
comprise 6% of our workforce.
We highly value the staff who bring dedication and skill they to their work with patients
in their journey to better health. PiC is Investors in People bronze accredited (inspected
and re-awarded in May 2014). We have committed additional resource in the past 12
months to nurse training and leadership development; a suite of courses including the
PiC’s national staff survey was conducted by Digital Opinion over
four weeks in November 2014. 3050 employees were invited to
take part, 1370 (45%) responded. This indicated an overall staff
satisfaction rate of 82% which compares well with comparable job
satisfaction scores found for NHS staff in the most recent 2014
NHS staff survey, conducted by NHS England and reported in
February 2015. Although questions are not phrased exactly the
same way, a number of similar questions are asked.
A particular highlight of the survey is that 88% of staff believe that Partnerships in Care is
strongly patient-focused. 89% believe we are delivering a high quality of service. In a number
of areas shown below, we met our aim this year of improving scores by responding to
previous feedback. In order to give some degree of comparison, 77% of respondents in the
last NHS staff survey agreed that their team worked effectively in ways such as setting clear
goals and communicating closely and 73% said they felt well supported by their manager.
52% of NHS staff say they ‘often or always look forward to going to work’. Source for
comparison: The 2014 NHS Staff Survey in England (www.nhsstaffsurveys.com)
Partnerships in Care Quality Account 2014/15
43
Our workforce
Partnerships in Care’s workforce
has grown considerably in line
with growth in services and
capacity for patient placements
in the 2014/15 year and where at
the end of last year we employed
2,100 clinical staff, we now
employ 2,526, a growth of 20%.
Overall, our staff complement,
including permanent and bank
workers, stands at 4,016 at
end March 2015. We employ
833 registered nurses and 150
psychiatrists and psychologists.
Care Certificate. Our Nurse Leadership Development Programme has been independently
assessed, praised by auditors and also by those nurses who have participated in it. We
have close connections with Royal College of Nursing and hold many joint educational and
shared learning events.
Our workforce 2014/2015
Patient
Our workforce
experience
Fig. 56 Respondents who agreed /strongly agreed with each statement
% favourable 2014/15
In our unit/ward we work effectively as a team
84%
I am given clear objectives for my job
83%
I know what PiC’s values are
94%
I get the support I need to develop my knowledge and skills
(not necessarily professional training)
83%
My line manager gives me the support I need in order
for me to do a good job
85%
Personal performance and opportunity
64%
Source: PiC staff survey results
Fig. 57 Respondents who agreed /strongly agreed with each statement
Learning and Development
This has been a very exciting year for staff learning and
development, a highlight being our win of the health industry
analyst, Laing Buisson’s Independent Healthcare Award for Training
in 2014. An independent audit of our training offerings found
they were extremely cost effective, value for money and performed
very well against the National Qualifications Framework.
Early in the 2015/16 year we will launch our new i-Learn online learning resource which
gives a library of information and a wide range of both online and distance learning
options for staff.
In the year under review, we held ten 3-month Nurse Leader Development programmes
with qualification being successfully attained by 110 charge and deputy charge nurses.
300 people have completed government funded distance learning programmes at level
2. We held ten 2-day Assessors Workshops for 100 senior health care workers. We have
developed a PiC Care Certificate course for all new patient facing staff.
e-learning expands staff access to qualifications
% favourable
Quality of our services
89%
Job satisfaction and motivation
82%
Leadership and management
84%
Patient focus within Partnerships in Care
88%
Team work
85%
Learning and development
85%
Personal performance and opportunity
72%
Our e-learning offer includes five PiC-developed courses. We held 50 short management
courses. We are offering training in How to Conduct an Appraisal, Recruitment and
Selection Interviewing Skills and Understanding Root Cause Analysis. Many of our
mandatory training programmes are now available as e-learning modules which will
improve uptake and accuracy of recording of our compliance.
Mandatory Training
Whilst records indicate we attained 92% compliance to meet our mandatory training
requirements compared with 88% last year, we are mindful that there is room for greater
accuracy in the way we collect this data and this is a project in progress. Manager
interpretation of our mandatory training guidance requires greater consistency.
Compliance by training course
Medicines Management (99%), Immediate Life Support (99%), Special observations and
recording (99%); CPR & Defibrillation (99%), Rapid Tranquilisation (99%), First Aid at
Work (97%); Workstation and Display Screen Awareness (97%), Control of Substances
Hazardous to Health (93%) Information Governance (92%), Fire Evacuation (92%)
Complaints Procedure (90%), Equality, Diversity and Human Rights (89%), De-escalation
(83%), Breakaway (80%), Food Safety (80%).
44
Partnerships in Care Quality Account 2014/15
Our workforce 2014/2015
• Basic life support ( BLS) training includes CPR and defibrillation (AED).
All clinical staff based at hospitals must complete this annually. There is
one trainer for every 6 participants. In addition, all registered nurses then
go on to complete Intermediate Life Support (ILS).
• Conflict resolution, personal safety awareness, de-escalation and breakaway
(challenging behaviour) This is a practical face to face training course for all
PiC staff with direct patient contact. It is conducted annually, by our trained
MVA tutors.
• Equality, diversity and human rights Training is delivered at induction and
refreshed every three years.
• NHS information governance training Data protection law and safeguarding
patient confidentiality is an online training package that is repeated by all
staff annually.
• Fire safety training This is important for all our staff and patients. All nurses
are trained as Fire Marshals twice a year. Every hospital, unit or residential
home holds a practical fire exercise at least twice a year.
• Food hygiene All staff who handle food receive basic food hygiene training.
Catering staff require professional qualifications depending on their level
of responsibility.
• Health and Safety All staff receive Health and Safety training a minimum
of every two years. Infection control and safeguarding are among many
courses we complete annually.
Security Training Portfolio
Introduced last year, the Security Portfolio continues to be a process of assurance with
regard to competence for staff who perform risk assessment, overseen by security leads.
This year a great deal of work has been done to increase patient involvement in risk
assessment, including giving patients a better understanding of structured professional
judgement (SPJ) tools such as HoNOS and HCR20-v3. Patients are frequently involved in
risk assessor and security training for staff as well so that a joint perspective is gained.
Security training is well embedded in PiC’s comprehensive 12 week induction programme
for new staff, followed up with a session in the employee’s third month which is interactive
and gives the employee an opportunity to talk about their experiences and observations
in their work. All evidence of the employee’s security competencies and training, from
previous employment and with PiC is displayed within the Portfolio. The local Security Lead
supports employees by agreeing, based on their competence, what types of assessment
they will do and reviews the resources for each assessment. It is then over to the patient
and staff member, who meet to agree method, then to do the assessment, to allow time
for supplementary questions. Currently our records indicate we have 80% compliance in
security training.
Implementing the Care Certificate
Following the Government’s introduction of the Care Certificate, which requires all staff
in non-registered clinical roles to be assessed and to demonstrate their skills, PiC have
embraced the Care Certificate framework guidance produced by Skills for Care, Skills
for Health and NHS Health Education England (2015). This is now a module within
our 3-month Induction Programme for all new health care staff, with the support of a
specifically trained mentor. The Care Certificate’s national standards underpin skills,
knowledge and behaviours to ensure staff provide compassionate and high quality care
and support. PiC is among the first in the sector to have qualified staff who have already
received the Care Certificate. Since June 2015, as part of our Preceptorship Programme,
the PiC Care Certificate is the first step of the employee’s clinical development whilst
working within PiC. It also includes the Continuous Professional Development Portfolio.
Partnerships in Care Quality Account 2014/15
45
Our workforce
Fig. 58 Some information on our approach to mandatory training
External views on the PiC Quality Account 2014/15
Patient
External
experience
views
Comments
I am really pleased to be able to comment on what is a very
well written summary on the workforce within the PiC Quality
Account. The RCN continues to have a fruitful relationship with PiC
built on partnership working at all levels. Of particular note in the report
are what I believe are really positive messages:
• high levels of staff satisfaction
• growth in the numbers of staff employed
• the provision of an independent concern line for staff to access
if they wish to raise concerns
• investment in professional development of staff
I am once again impressed by the breadth of content in this year’s PiC
Quality Account. As with the accounts of previous years, there is a
great honesty in the appraisal of the current situation and when things aren’t
as good as they could be, there is always a description of the steps that will
be taken to ensure improvement. This year I am struck by PiC’s commitment
to enabling patients to be partners in their care and treatment, with an
emphasis on shared-decision making. This is clearly an area where much is
going well, with good feedback about the CPA process, an essential part of
receiving the best care and treatment while in hospital, while planning for
future discharge. The Ward Quality Matters initiative is also a great way of
enabling people to influence the quality of all the services they receive.
I am also very pleased indeed with the reinvigorated emphasis on recovery
with the comprehensive Recovery Strategy well underway and clearly leading
to further embedding of recovery principles throughout PiC’s services.
• the embracing of the Care Certificate.
PathNav is another great innovation that promises to revolutionise the way
patients are involved in managing and driving their own care and treatment.
I believe the PiC Nurse Leadership Development Programme will
I very much look forward to hearing more about its progress as it is rolled out
develop a generation of leaders who are able to contribute towards
throughout PiC over the coming year. Finally, I am very impressed indeed by
PiC’s success and take it forward as it continues to grow.
the efforts PiC have made in supporting the involvement of the family and
Implementing the Care Certificate ensures non-registered staff, many
friends of people using their services, which is such a crucial part of many
of whom are RCN members, have access to recognised quality training.”
people’s sustained recovery.
• the continued success of the Nurse Leadership Development
Programme
Gary Kirwan, Senior Employment Relations Adviser Royal College of Nursing
I have read the Partnerships in Care Quality Account for
2014/2015. From a commissioning perspective this
contains a lot of clear and concise information about PiC’s values,
policies and procedures.”
Victor Trimble, Supplier Manager NHSE South
46
Partnerships in Care Quality Account 2014/15
I am delighted to endorse this year’s Quality Account, and believe it gives
great hope for the future as PiC expand their services further. As the Recovery
Strategy survey discovered, the overwhelming majority of patients in PiC’s
services believe staff hold hope for them. I believe this Quality Account is a
reflection of this hope.”
Ian Callaghan, a former user of PiC services at Kneesworth House, winner of the Mental
Health Hero Award 2015 and National Service User Lead, Recovery and Outcomes Group
Glossary
AAS
Aggregate Aggression Score
FAM
Functional Assessment Measure
NPS
The Department of Health’s Net Promoter Score method
of scoring the Friends and Family Test
ABI
Acquired Brain Injury
FFT
Friends and Family Test
ADHD
Attention Deficit Hyperactivity Disorder
FIM
Functional Independence Measure
OAS
Overt Aggression Scale – a measuring sytem.
ASD
Autism Spectrum Disorder
FIM+FAM
The two measures are always used together
OAS MNR
Overt Aggression Scale Modified for Neurorehabilitation
AVLOS
Average Length of Stay
GAS
Goal Attainment Scaling
PathNav
Name of PiC-designed new software application for
collaborative patient and clinician care pathway planning.
BIS
PiC’s Brain Injury Services
GP
General Practitioner
PBS
Positive Behaviour Support
BMI
Body Mass Index – a value based on a person’s weight and
height
HCR-20
Historical Risk Management – a way of measuring patient
risk of violence in the present and future.
PD
Personality Disorder
CCQI
HDU
High Dependency Units
PICU
Psychiatric Intensive Care Unit
College Centre for Quality Improvement
COPD
Chronic Obstructive Pulmonary Disease
HIS
Health Improvement Scotland
CORE
Clinical Outcomes in Routine Clinical Practice
HIW
Health Improvement Wales
CPA
Care Programme Approach – a national system which sets
out how ‘secondary mental health services’ should help
people with mental illnesses and complex needs
HoNoS
Health of the Nation Outcome Scales - a group of measures
of health outcomes used nationally to assess patient
improvement or deterioration.
CQC
Care Quality Commission
ICD-10
CRA
10th revision of the World Health Organisation’s International
Classification of Diseases list.
Collaborative Risk Assessment
CRG-FIDD
Clinical Research Group in Forensice Intellectual and
Developmental Disabilities also known as LD Network
INPA
Glossary
Glossary
POMH-UK Prescribing Observatory for Mental Health-United Kingdom
QIP
Quality Improvement Programme
QNMFHS
Quality Network for Forensic Mental Health Services
RCP
Royal College of Psychiatrists
RWO
PiC’s Real Work Opportunities programme
SASBA
The St Andrew’s Sexual Behaviour Assessment
Independent Neurorehabilitation Providers Alliance
SASNOS
The St Andrew’s-Swansea Neurohabilitation Outcome Scale
IR1
The paper-based method of NHS incident reporting
SMI
Severe Mental Illness
Care and Treatment Reviews, part of NHSE’s accelerated
hospital discharge programme
IRIS
PiC’s bespoke Incident Recording and Informatics System
SPJ
Structured Professional Judgement
LDS
Learning Disability Services
START
EPR
electronic patient records
EQ5D
One of the EuroQol Group’s measures. It is a questionnaire
which gives a single index score to indicate a person’s quality
of life.
Lester
chart
An RCP-developed Positive Cardiometabolic Health
Resource chart (Lester UK) adaptation. PiC uses its own
adapted version of this.
Short Term Assessment of Risk and Treatability - scoring
system to assess patient perceptions of their strength or
vulnerability
STEIS
LSU
Strategic Executive Information System - an NHS defined
categorisation for the reporting of incidents
Low Secure Services
Multi-agency Public Protection Arrangements teams
SUI
Serious Untoward Incident
MAPPA
MHA
Mental Health Act
SVR-20
Sexual Violence Risk - a way of measuring patient risk of
sexual offending in the present and future.
MI
Mental Illness
TRIP
MOHOST
Team Recovery Implementation Plan – a care approach
for staff
Model of Human Occupation Screening Tool – a way of
measuring a person’s level of occupational functioning.
WQM
MSU
Ward Quality Matters – a PiC programme for patient and
staff collaborative quality review
Medium Secure Services
NHSE
NHS England
CTR
ERFS
Elements of Recovery Facilitating Systems – a questionnaire
for patients
ES
Effect Size – a measure of variance between paired scores.
EuroQol
The name of an international research network, the EuroQol
Group which established measures for evaluating quality
of life among people with health disorders.
EWS
Early Warning Score – a method of scoring physical health
vital signs developed by the NHS
Partnerships in Care Quality Account 2014/15
47
Notes
Notes
48
Partnerships in Care Quality Account 2014/15
Our Values
Valuing People
Respecting our staff, patients, their families and communities
Caring Safely
Caring safely for ourselves, our patients, our customers
and communities
Integrity
Uncompromising integrity, respect and honesty
Working Together
Working together with everyone
Quality
Taking quality to the highest level
For further information please
visit our website:
www.partnershipsincare.co.uk
Email us on
info@partnershipsincare.co.uk
Or call our head office
020 8327 1800
020 8327 1900
Central Referrals 0800 218 2398
Partnerships in Care
2 Imperial Place
Maxwell Road
Borehamwood
Hertfordshire WD6 1JN
Registered in England Number
05409563