QUALITY ACCOUNTS
2009 | 2010
CONTENTS
PART 1: CHIEF EXECUTIVE’S STATEMENT ON BEHALF OF THE BOARD
2
INTRODUCING AVON AND WILTSHIRE MENTAL HEALTH
PARTNERSHIP NHS TRUST (AWP)
5
PART 2A: OUR PRIORITIES FOR IMPROVEMENT 2010/11
6
Priority 1: To improve the service user and carer experience
7
Priority 2: To improve access to and the responsiveness of our community services, including crisis care services
7
Priority 3: To improve quality and safety 8
Priority 4: To improve compliance with best practice standards
9
PART 2B: HOW WE MANAGE QUALITY IMPROVEMENT AND
REPORT NATIONALLY ON ESSENTIAL STANDARDS FOR QUALITY
AND SAFETY
10
Reviewing the quality of our services
11
Participation in clinical audit
12
Research and development
13
Commissioning for Quality and Innovation (CQUIN) 14
How our regulator, the Care Quality Commission (CQC), views our services
15
Data quality
16
PART 3: OUR CARE QUALITY ACHIEVEMENTS IN 2009/10
18
3.1 How we have measured our service quality: Trust level
19
3.2 How we are measured nationally
22
3.3 Service user, carer and patient experience
23
3.4 Patient environment
25
PART 4: HOW WE DEVELOPED OUR QUALITY ACCOUNTS
26
APPENDICES
28
A Information by primary care trust and local authority area
29
B External assurances and comments
42
C Further information on measures and performance targets
46
D Glossary of terms
50
Other Formats
We aim to make our information as accessible as possible. This document is available as a
downloadable document via our website, www.awp.nhs.uk or by contacting the Communications
team on 01249 468088 or communications@awp.nhs.uk
For other formats and additional copies please write to us at Avon & Wiltshire Mental Health
Partnership NHS Trust, Jenner House, Langley Park Estate, Chippenham, Wiltshire SN15 1GG.
PART 1
CHIEF EXECUTIVE’S
STATEMENT ON
BEHALF OF
THE BOARD
I am delighted, on behalf of our Trust Board, to commend our
first Quality Accounts to you. These represent, in our view,
an open and honest account of the quality of the services for
which the Board is accountable.
The Board is committed to developing services of the highest quality and which transform
lives, support independent living and work with users, carers and our partners in other
agencies to deliver truly integrated care in the right place and at the right time. These
Quality Accounts give meaningful insight into how we are doing in relation to these
aspirations. They have been compiled in partnership with our clinicians, managers,
commissioners and, crucially, with service users and carers from across the Trust.
OUR JOURNEY TO EXCELLENCE
Like many providers Avon and Wiltshire Mental Health Partnership NHS Trust (AWP) is
on a journey. Over the past three years we have invested heavily to make sure that our
services are among the best and we can demonstrate this to our service users, carers,
commissioners and the public. Some particular successes include:
•
Achieving our specialist service targets in full in 2007/8 and 2008/9. This shows that
we deliver the right levels of specialist services and to the right basic standards
•
Achieving ‘fully met’ for our Standards for Better Health in 2009/10. This shows that
across all national standards of service quality and safety we rank among the best
•
Maintaining our ‘excellent’ rating in terms of the external assessment of the quality
of our adult inpatient services
•
Meeting all standards for registration with the Care Quality Commission
•
Driving quality through our nationally-regarded research and development
department thus putting the best available evidence into practice.
We are pleased with these achievements but AWP is determined to continue to improve.
We recognise that high quality services can only be delivered by motivated, skilled and
engaged staff and we need to continue to support them to deliver improved quality of
service. We have a rigorous process of internal performance management and assurance
of service quality, in all of our services, across the entire area we serve. We publish our
performance monthly at our Board Meetings and on our website. Increasingly, we are
involving service users, carers and the public in helping us judge how we are doing and
what we can do better. These Quality Accounts are an important part of that process.
PRIORITIES FOR 2010/11
Having established a solid reputation for core service quality, we recognise that we have
not made the progress we aspired to in 2009/10 and that you have the right to expect
from us. Feedback from users and carers indicate that we need to re-double our efforts
in 2010/11 in the following areas:
•
Quality of care programme approach (CPA) – making sure our assessments are made
as soon as possible and are truly expert. That care plans are developed in partnership
with users and carers, are reviewed regularly and that these plans are always shared
•
Crisis care – making sure that our most vulnerable service users, and their carers, get
24/7 access to high quality, caring services, consistently across the whole Trust
2/3
•
Carers – making sure that all carers are offered the assessment they are entitled to
and signposted to appropriate organisations to support their needs. We will provide
a support plan within four weeks
•
User and carer voice – making sure that we develop and extend our approach to the
user and carer voice to shape and improve our services and demonstrate that we have
listened and acted on the insights we are given.
SUCCEEDING TOGETHER
Partnership is a much used word. But, truly, it is the only way we can succeed as a
Trust. We are immensely grateful to all those service users, carers, Trust members,
commissioners and others who have supported and worked with us during the past year
and, in many cases, for far longer. Together, we can succeed in this journey to excellence
in our services.
I verify to the best of my knowledge that the information in this document is an accurate
and true account of the Trust’s quality of services.
Laura McMurtrie
Chief Executive
PART 1 CHIEF EXECUTIVE’S STATEMENT ON BEHALF OF THE BOARD
INTRODUCING AVON AND WILTSHIRE
MENTAL HEALTH PARTNERSHIP NHS
TRUST (AWP)
AWP is a major provider of mental health services with a
turnover of almost £200m in 2009/10. We provide high quality
mental health and social care services to communities totalling
1.6m people across Bath & North East Somerset (B&NES), Bristol,
North Somerset, South Gloucestershire, Swindon and Wiltshire
and to a wider population through our specialist, secure and
drug and alcohol services.
We employ approximately 3,400 (WTE) staff from a variety of professional backgrounds,
including psychiatrists, psychologists, mental health nurses and allied health professionals.
Our services during 2009/10 included:
•
Adults of working age psychiatry
•
Older people’s mental health
•
Child and adolescent mental health (CAMHS)
•
Specialised and secure services
•
Learning disabilities services for people with mental health needs
•
Specialist drug and alcohol services (SDAS).
All our services work within an ethos of supporting recovery: promoting health and wellbeing and the belief that all service users can work towards recovery in some measure.
Our aim is to help individuals to reach their potential and live fulfilling lives.
We currently operate from 97 community sites and 16 inpatient units across the core
catchment area. In 2009/10 we saw 38,836 individuals from over 29,000 referrals, 2,930
people admitted to our inpatient units and over 700,000 contacts with service users across
our community services.
Over recent years we have moved towards community based services, in line with more
effective practice and better outcomes for our service users. Our ambition, having started
this journey in 2007/8, is to continue to provide more locally based and accessible services.
We are committed to working in partnership with commissioners, local authorities,
the third sector, service users and carers to ensure that the quality of our services is
continually improved.
4/5
PART 2A
OUR PRIORITIES
FOR IMPROVEMENT
2010/11
Following extensive consultation we have identified the
following priorities for the coming year:
PRIORITY 1: TO IMPROVE THE SERVICE USER AND CARER
EXPERIENCE
Service users and carers identified the need for improved methods of communication and
involvement, more activities on wards and carers’ needs to be assessed and responded to
more systematically.
AIMS
The Trust will obtain immediate feedback from service users and act on their feedback.
Ward and team systems will be established to collect service user feedback, including
feedback about activities on the wards.
All service users will be asked if they have a carer. All carers will be offered an assessment
and where needs are identified a care plan and services will be put in place.
CURRENT POSITION 2009/10
User and carer involvement – the Trust is committed to service user and carer involvement
and has many examples of effective working. Trust wide groups have been developed to
ensure that we identify all opportunities to involve service users and carers, and to ensure
that the quality of that engagement is first class.
Carer’s assessment and services – improvements have been made during the year, but the
identification of carers, assessment and care planning is variable across services and very
low numbers receive a support plan and services.
KEY IMPROVEMENT INITIATIVES
•
To establish routine and regular local ward and team patient experience feedback
systems
•
To increase the number of carers who are identified, have needs assessed, support
plans developed and services put in place.
HOW WE WILL MONITOR, MEASURE AND REPORT
•
Improved patient satisfaction of activities on the ward – measured through patient
feedback and surveys
•
The % of new referrals with an identified carer
•
The % of carers with a support plan in four weeks
•
The % of carers receiving a service as a result of that support plan.
PRIORITY 2: TO IMPROVE ACCESS TO AND THE RESPONSIVENESS OF
OUR COMMUNITY SERVICES, INCLUDING CRISIS CARE SERVICES
Service users and carers have highlighted concerns about:
•
Crisis assessment availability and out-of-hours response
•
Appropriate support for carers
•
Quality and ‘compassion’ of care once in the service
•
Community service support for people admitted to hospital.
6/7
AIM
To ensure service users receive regular reviews in the community, with clear response
criteria at times of crisis and good discharge planning processes for inpatient services. This
should include early planning, good communication with the GP at time of discharge and
rapid follow up once discharged.
CURRENT POSITION 2009/10
A range of new indicators has been developed in 2009/10 to be introduced in 2010/11 to
measure this, as set out below.
KEY IMPROVEMENT INITIATIVES
•
To improve access to crisis services and the service user experience of them
•
To improve regular care co-ordination in the community
•
To improve the discharge planning processes (early planning and good
communication with the GP at time of discharge and follow up within seven days).
HOW WE WILL MONITOR, MEASURE AND REPORT
•
Active care co-ordination: 80% of community mental health team patients to be seen
at least every three months
•
Facilitated early discharge: 70% of patients to receive face to face services by the
crisis teams prior to admission, a weekly visit whilst an inpatient and intensive support
in the community in the two weeks after discharge to a community team
•
Follow up: wards to call patients within 48 hours of discharge and community teams
to see them face to face within seven days of discharge
•
Crisis teams: four hour assessment response and consistent access to out-of-hours care
•
Patient surveys: to be carried out to judge service user experience of crisis teams
•
Discharge protocols: GP and patient-discharge letter within 48 hours, 100% of the time.
PRIORITY 3: TO IMPROVE QUALITY AND SAFETY
The Trust works hard to ensure a safe environment for our service users, carers, visitors
and staff. We monitor the number of incidents and reporting levels to the National
Patient Safety Agency (NPSA) and other national bodies. Trusts with good response rates
for reporting minor/near-miss incidents have a more open attitude to learning from
events, better safety records and lower rates for serious incidents.
AIM
To provide the safest environment possible for our services.
CURRENT POSITION 2009/10
The Trust is registered with the Care Quality Commission (CQC) without conditions,
confirming compliance with all quality and safety outcomes. The Trust continues to
improve its data collection and reporting rates and is commended by the NPSA.
KEY IMPROVEMENT INITIATIVES
•
To increase the reporting of incidents to the Strategic Executive Information
System (STEIS)
•
To continue to meet quality and safety outcome standards.
PART 2A OUR PRIORITIES FOR IMPROVEMENT 2010/11
HOW WE WILL MONITOR, MEASURE AND REPORT
•
Increased reporting levels but reduced severity of incidents reported to STEIS
•
To continue to meet the quality and safety outcome standards to achieve registration
with the CQC
•
Demonstrate reduced rates of suicides and homicides by those in contact with
our services.
PRIORITY 4: TO IMPROVE COMPLIANCE WITH BEST PRACTICE
STANDARDS
Early identification and treatment of conditions improves outcomes. This requires early
diagnosis and appropriate therapeutic interventions in line with guidance from the
National Institute of Health and Clinical Excellence (NICE).
AIM
To improve early identification, diagnosis and treatment of mental health problems,
ensuring compliance with best practice as set out by NICE.
CURRENT POSITION 2009/10
Some of the Trust’s largest clinical diagnostic groups include psychosis and dementia.
However, in the community, waiting times are higher than we would want them to be
for dementia services and our recording of diagnoses needs to be significantly improved.
KEY IMPROVEMENT INITIATIVES
•
Improve diagnostic recording in the community (a new target for 100% of new
referrals to have a diagnosis (provisional or confirmed) within three months of
assessment)
•
Reduce time from referral to assessment for dementia (from eight to four weeks)
•
Reduce time from referral to treatment (a new target of 13 weeks for all referrals to
all community teams)
•
Improve compliance with NICE clinical guidelines
•
Improving the accessibility of our services to those with a learning disability.
HOW WE WILL MONITOR, MEASURE AND REPORT
Diagnosis recording: 100% of diagnoses recorded within three months of assessment
Early identification and treatment of dementia: maximum four week waiting for memory
clinic assessments and four weeks to having a care plan among those with a diagnosis
First episode psychosis – early intervention in line with best practice: achieve or exceed
national benchmark levels (Trust wide target of 182) for new cases of first episode
psychosis taken on to early intervention caseloads
Audit compliance with NICE schizophrenia guidance (compared to 2008 national audit):
including access to psychological therapies
Recording of service users with a learning disability: their care planning, care
co-ordination and carer.
8/9
PART 2B
HOW WE
MANAGE QUALITY
IMPROVEMENT AND
REPORT NATIONALLY
ON ESSENTIAL
STANDARDS FOR
QUALITY AND SAFETY
This section provides information to demonstrate that the
Trust is performing to essential standards, that we measure our
clinical processes and performance and are involved in national
projects to improve quality.
REVIEWING THE QUALITY OF OUR SERVICES
During 2009/10 the Trust provided NHS inpatient and community mental health services
organised across five Strategic Business Units.
Our service areas in 2009/10 included:
•
Adults of working age psychiatry
•
Older people’s mental health
•
Child and adolescent mental health (CAMHS)
•
Specialised and secure services
•
Learning disabilities services for people with mental health needs
•
Specialist drug and alcohol services (SDAS).
The Trust has reviewed all the data available to us on the quality of care in the above
NHS services.
The income generated by the NHS services reviewed in 2009/10 represents 100% of the
total income generated from the provision of NHS services by the Trust during 2009/10.
The Trust has a robust Performance Management Framework in place utilising scorecards.
All Trust scorecards, from Board level to frontline services, contain indicators of quality
covering patient experience, effectiveness and safety. These are reviewed monthly by
our Board, and all levels below, including external scrutiny with our commissioners and
a range of care forums across the Trust. In this way, we have systematically improved the
quality of services.
The Board and its Quality and Healthcare Governance Committee receive and review
assurance and progress reports on a regular basis. Recently, it approved a Quality
Improvement Strategy for 2010 to 2015. This is a five year plan which includes our first
year priorities as above (Part 2a).
During 2009/10 there were two specific service improvement initiatives that we wish to
highlight:
ADULT ACUTE INPATIENT SERVICES
We have continued to build on the successes of our improvement programme as
highlighted by the Care Quality Commission’s (CQC) Adult Acute Inpatient Improvement
Review in 2007. In July 2009 we asked for an additional revalidation by an external
team of assessors. This looked again at the standards measured by the CQC in 2007/8.
It confirmed the excellent improvements we made in 2008/9, noted further progress in
2009/10 and resulted in the maximum possible score. This demonstrates that we have
sustained and made further improvements to the standards of care in our adult
inpatient services.
10/11
IMPROVEMENTS TO CLEANLINESS AND THE PREVENTION AND CONTROL OF
INFECTION
In September 2009, the CQC carried out a series of unannounced visits to inspect
inpatient sites against their standards for hospital cleanliness and infection control.
Whilst many areas they examined fully met standards, six key areas for improvement
were identified by the CQC. The Trust is pleased to have been able to fully implement
all the improvements specified, which was verified by a follow up CQC inspection in
January 2010.
PARTICIPATION IN CLINICAL AUDIT
During 2009/10, eight national clinical audits and one national confidential enquiry
covered the NHS services that AWP provides. During that period AWP participated in 50%
of the national clinical audits and 100% of national confidential enquiries for which it
was eligible.
*National
Audit
National clinical audits that AWP was eligible to
participate in during 2009/10
AWP
participation
Cases
submitted/
**cases
required
131
submitted
POMH
Prescribing high dose and combination
antipsychotics on adult acute and Psychiatric
Intensive Care wards
YES
POMH
Screening for the metabolic side effects of
antipsychotic drugs in patients treated by assertive
outreach teams – (supplementary data collection)
NO
POMH
Benchmarking prescribing of high dose and
combination antipsychotics on adult acute and PICU
wards
YES
POMH
Assessment of side effects of depot antipsychotic
NO
POMH
Monitoring of patients prescribed lithium
NO
POMH
Medicines reconciliation
YES
48
submitted
POMH
Use of antipsychotic medication in people with a
learning disability
YES
75
submitted
Continence (Older people’s audit programme)
NO
NCAPOP
137
submitted
*Table above: Showing the National Audits the Trust was eligible to participate in, those it did participate in,
and the level of completion of data requirements.
POMH – Prescribing Observatory for Mental Health (Royal College of Psychiatrists)
NCAPOP – National Clinical Audit & Patient Outcomes Programme
**In all cases there was no set number of cases required
PART 2B HOW WE MANAGE QUALITY IMPROVEMENT AND REPORT NATIONALLY ON ESSENTIAL STANDARDS FOR QUALITY AND SAFETY
INVOLVEMENT IN NATIONAL CONFIDENTIAL ENQUIRIES
National confidential enquiries that AWP was eligible to
participate in during 2009/10
National confidential inquiry into suicide and homicide by people
with mental illness
AWP
participation
Cases
submitted/
**Cases
required
YES
36/39
The audits where data collection was completed during 2009/10 are listed above
alongside the number of cases submitted to each audit or enquiry against the number
of registered cases required by the terms of that audit or enquiry.
The reports of two national clinical audits were reviewed by the Trust in 2009/10. Each
audit was reviewed within the Trust’s quality and healthcare governance system, which
reports to the Board, and the following actions were identified to improve the quality
of healthcare provided:
1. Prescribing Observatory for Mental Health Audit of Medicines Reconciliation (Topic 8)
– new policy to be approved and training package for staff being developed
2. Prescribing Observatory for Mental Health Audit of the Use of Antipsychotic
medication in people with a learning disability (Topic 9) – the service is improving
compliance with physical healthcare monitoring.
The reports for the remaining national audits are awaited from the national body and
will be actioned once received.
The reports of 40 local clinical audits were reviewed by the Trust in 2009/10. Each audit
was reviewed within the Trust’s quality and healthcare governance system, which reports
to the Board, and an action plan developed to improve the quality of healthcare provided.
In 2010/11, the Trust will participate in a number of national audits including the
Prescribing Observatory for Mental Health Lithium audit.
RESEARCH AND DEVELOPMENT
We recognise the importance of research and development (R&D) in improving clinical
effectiveness, cost effectiveness and the service user and carer experience. The Trust has
a Board-approved R&D strategy that is aligned to the national R&D strategy for the NHS
(Best Research for Health) which means the Trust supports only high quality research. This
activity is either externally-funded non-commercial research, commercial research projects
or undertaken by students as part of university course requirements.
The Trust works in partnership with a range of organisations including three local
universities and national research funders. The Trust is an active member of the National
Institute for Health Research (NIHR) Western Comprehensive Research Network, and
holds two contracts with the Department of Health to host the South West Mental
Health Research Network and the South West Dementias and Neurodegenerative
Research Network.
12/13
The Trust works closely with the Western Comprehensive Research Network to ensure
that all R&D undertaken within the Trust has appropriate arrangements for quality
assurance, NHS Research Ethics Committee Review, regulatory and governance
authorisations, and that projects are conducted within the Department of Health’s
Research Governance Framework. The Trust has implemented the NHS Co-ordinated
System for Gaining NHS Permissions (CSP) and is adopting the NIHR Research Passport
system for streamlining approvals for external researchers. In addition, the Trust R&D
Office monitors and works to promote appropriate service user and carer involvement
with research.
Trust R&D income has increased year on year and was £3.4m in 2009/10. This included the
third largest national allocation to an English mental health NHS organisation of NIHR
Flexibility and Sustainability Funding.
In 2009/10 the Trust had 118 active research projects. The total recruitment recorded for
projects registered on the NIHR-Portfolio in 2009/10 reached 225 (an increase of 125%
on 2008/9). Additionally, there were 80 service users recruited into non-NIHR portfolio
projects in 2009/10. The total number of patients receiving NHS services from AWP during
2009/10 that were recruited during this period to participate in research approved by the
research ethics committee was 305.
This high level of research activity includes qualitative and quantitative research which
produces findings directly relevant to the patient experience. The results are made
available to the Trust as part of its participation and give early opportunity to improve
services as a result.
COMMISSIONING FOR QUALITY AND INNOVATION (CQUIN)
CQUIN 2009/10
Approximately £750,000 (0.5% of our Trust income in 2009/10) was conditional
on achieving quality improvement and innovation goals agreed with our six PCT
commissioners – known as CQUINs.
The Trust was required to meet some national standards in order to qualify for this
additional funding. Whilst the vast majority of these were met and exceeded, we were
unable to achieve the required performance on the Patient Survey and as a result the
Trust was unable to secure any of the CQUIN money in 2009/10.
CQUIN 2010/11
This coming year, almost £2.5m (or 1.5% of income) is conditional on achieving CQUIN
goals. A fresh set of initiatives has been agreed, as follows:
•
100% of crisis assessment requests to be seen face to face in their home within
four hours
•
70% of all adult inpatient admissions to have the support of the home treatment
team prior to admission, during their stay and intensively in their homes following
discharge. This will enable us, where it’s safe to do so, to reduce the length of stay in
hospital and support recovery at home where people are likely to recover more quickly
•
100% of new referrals to have diagnosis, CPA level and care plan within three months
of referral
PART 2B HOW WE MANAGE QUALITY IMPROVEMENT AND REPORT NATIONALLY ON ESSENTIAL STANDARDS FOR QUALITY AND SAFETY
•
Six service user ‘listening into action’ events – where we have to demonstrate that
user feedback has been acted on in-year, with 12 recommendations implemented
•
Training in ‘dementia early identification’ for community and primary care staff – by
our specialist older people service. This will foster partnership working and support
our ambition to provide leading edge dementia services that intervene at the
earliest opportunity
•
Reducing Trust-cancelled appointments. Feedback from users in our Patient Survey
suggested that patients felt the Trust too often cancelled their appointment and
at short notice. We will undertake a programme in 2010/11 to eliminate
avoidable cancellations.
HOW OUR REGULATOR, THE CARE QUALITY COMMISSION (CQC),
VIEWS OUR SERVICES
ANNUAL PERIODIC REVIEW
The most recent periodic review carried out by the CQC, previously known as the Annual
Health Check, made the following conclusions:
•
The CQC awarded the Trust a score for 2008/09 of ‘fair’ for the quality of services
element of their Annual Health Check annual assessment. The Trust is forecasting an
improved score of ‘good’ for 2009/10
•
The Trust met all of the CQC Standards for Better Health for 2008/09 and has
maintained the position of full compliance throughout 2009/10
•
The scores for the CQC national targets, as set out in Part 3.2 in Table 4, fell back
in 2008/09. This was due to the addition of seven new national priorities of which
the Trust achieved the required standard in full against all except two. Our current
forecast is to meet all in 2009/10. The two new targets where improvements were
needed in 2009/10 were the ‘Green Light Toolkit’ and ‘Staff Satisfaction’
•
The staff satisfaction indicator, derived from the national staff survey, has shown a
significant improvement for 2009/10. We now forecast that we will meet the required
CQC standard for 2009/10
•
The Green Light Toolkit (GLT) is a service improvement tool for improving mental
health support services for people with learning disabilities. It has proved to be
a particular challenge for the Trust as it relies upon effective contributions from
partner organisations with the added complexity of working across all six PCT areas.
Significant action has been taken in order to meet the required standards, led by the
Executive Director of Operations.
MENTAL HEALTH ACT ANNUAL STATEMENT
In October 2009 the Trust Board received an annual statement from the CQC as a
summary of its annual assessment of the Trust’s compliance with the Mental Health Act.
The report is based on the outcomes of the CQC routine annual visit programme of all
places where patients are detained under the Mental Health Act 1983.
The report noted that the Trust continues to demonstrate a commitment to responding
positively to most issues raised by the CQC as a result of visiting activity. Five areas were
identified for improvement and these were incorporated into an action plan for ongoing
work continuing into 2010/11.
14/15
REGISTRATION FOR CQC INFECTION CONTROL REGULATION 2009/10
In 2009/10 the CQC introduced the additional requirement for all NHS Trusts to register
with the CQC as compliant against the Health and Social Care Act 2008 (Registration
of Regulated Activities) Regulations 2009 for the prevention and control of healthcare
associated infections.
On 1 April 2009 AWP was successfully registered as compliant with this standard. In
line with the CQC’s ongoing assessment framework the Trust was inspected against
the regulations and successfully implemented improvements in response to the six
recommendations and requirements, all within the timescales specified.
REGISTRATION FOR CQC ESSENTIAL STANDARDS OF QUALITY AND SAFETY
(2010/11)
A new regulatory framework came into effect on 1 April 2010 as detailed in the Health
and Social Care Act 2008 (Regulated Activities) Regulations 2009 and associated guidance
document.
The Trust is required to register with the CQC and its current registration status is current
and unconditional. This means that on 28 January 2010, AWP registered with the CQC
as compliant against the 16 essential standards of quality and safety for the following
regulated activities:
•
Treatment of disease, disorder or injury
•
Assessment or medical treatment for people detained under the
Mental Health Act 1983.
Further guidance issued by the CQC on 9 March 2010 required the Trust to register an
additional regulated activity:
•
Diagnostic and screening procedures.
The CQC has not taken enforcement action against the Trust during 1 April 2009 to
31 March 2010.
SAFEGUARDING SPECIAL REVIEW 2009/10
AWP has participated in a special review by the CQC during 2009/10 relating to
arrangements for safeguarding vulnerable adults. The review was focused on the six local
authorities with AWP participating as a key partner in the arrangements. Not all of the
six reports have yet been published. A themed response to the recommendations will be
published on the AWP website following publication of all the reports.
DATA QUALITY
The Trust has a comprehensive and systematic approach to the management of data
quality held on its patient information systems, MHIS and RiO, that is then used for
reporting. Two internal audit reports in 2007/8 and 2008/9 have given substantial
assurance ratings to our systems and processes. Further, an Information & Data Quality
Management Strategy was approved by the Board in February 2010. This should
give everyone confidence that data reported in these accounts and routinely in our
information and performance reports is reliable and of high quality.
PART 2B HOW WE MANAGE QUALITY IMPROVEMENT AND REPORT NATIONALLY ON ESSENTIAL STANDARDS FOR QUALITY AND SAFETY
Two statistics that give insight into this are reported in every Trust Performance
Scorecard Report:
•
Data completeness (97% against a target of 90%). This assesses how well core fields
are completed
•
Data timeliness (63% against a target of 95%). This assesses how quickly information
is updated on the system following the actual event (eg referral, appointment)
against a target of three days.
Performance on the former is excellent and whilst timeliness with three day target is not
as good as we would like it to be, the introduction of a new system called RiO during
2010/11 will enable us to make great strides towards the achievement of the target.
Our performance against other key areas of data quality is as follows:
The Trust submitted records during 2009/10 to the Secondary Users Service for inclusion in
the Hospital Episode Statistics which are included in the latest published data. The % of
records in the published data which included the patient’s valid:
•
NHS number was 99% for admitted patient care
•
General Medical Practice Code was 98% for admitted patient care.
The Trust’s score for 2009/10 for information quality and records management, assessed
using the Information Governance Toolkit, was 56.6 out of 60 which equates to 94%.
16/17
PART 3
OUR CARE QUALITY
ACHIEVEMENTS IN
2009/10
3.1 HOW WE HAVE MEASURED OUR SERVICE QUALITY: TRUST LEVEL
The metrics or standards, set out in the tables below, have been chosen to summarise
our performance against key quality indicators for patient experience, safety and
effectiveness. These were chosen in consultation with our staff, clinicians, service users,
carers and other key stakeholders.
The data below is for the Trust overall. Area level breakdowns to enable local comparison
have been included in appendix A.
Further information on the definitions of the measures tabled below is given in
appendix C.
3.1.1 PATIENT EXPERIENCE INDICATORS
•
Speed of access for assessment: a timely and competent assessment reduces anxiety
for the user and carer, reduces risks and ensures that the appropriate treatment can
be started quickly once a care plan is agreed
•
Care plans: these should be negotiated jointly with the service user and, where
appropriate, their carer and other professionals. Once the assessment is complete a
care plan should be drawn up, agreed with the service user, and in all cases a written
copy should be given to the service user
•
How service users feel about the way they are treated: is it with dignity and respect,
as we would aspire to?
TABLE 1 PATIENT EXPERIENCE – HOW WE DID
Trust 09/10
Indicator
Data source
Trust 08/09
% of service
users seen
for their first
appointment
within six
weeks of their
referral
Electronic
Patient
Record –
Mental
Health
Information
System (MHIS)
90%
(June 2009)
% of service
users who
have received
a written
copy of their
care plan
Definitely
treated
with dignity
and respect
by their
healthcare
professional
MHIS
Community
Mental
Health Survey
2009
96%
87%
National
comparator
Comments
%
Numerator/
denominator
99%
2707 / 2744
NHS South
West target
is 100%
Trust target
is 100%
24,503 /
26,734
CPA policy
requires
that 100%
of patients
have a
copy of
their jointly
agreed care
plan
Trust target
is 98%
392 / 450
Average
score of 85%
across all
trusts
Trust target
to move to
top 25% of
all trusts
92%
87%
18/19
3.1.2 SAFETY INDICATORS
It is not only crucial that services are as safe as they can be, but that we can demonstrate
this to ourselves, our partners, our services users and carers and to the public. We chose
four indicators to help demonstrate this:
•
Incident reporting
•
Speed of investigating and reporting: when things may have gone wrong
•
How patients felt about service safety
•
Staff sickness absence: we believe a stable, healthy and consistent staff team makes
for a safer and more reassuring service for our users, carers and visitors.
TABLE 2 SAFETY – HOW WE DID
Trust 09/10
Indicator
Data source
Benchmark
position for
reporting
patient safety
incidents to
the National
Patient Safety
Agency
National
Patient Safety
Agency
Lowest
quartile
Serious
Untoward
Incidents
reported
to the Lead
Commissioner
and Strategic
Health
Authority
within 24
hours
Strategic
Executive
Information
System
(STEIS).
Internal
performance
monitoring
spreadsheet
Not assessed
During your
most recent
stay did you
feel safe?
National NHS
Inpatient
Survey Report
2009
Sickness
absence data
cumulative
average over
past three
months
Internal
Electronic
Staff Record
sickness
absence
monitoring
PART 3 OUR CARE QUALITY ACHIEVEMENTS IN 2009/10
Trust 08/09
%
Numerator/
denominator
Mid range
97%
104 / 107
Not surveyed
Score 64 out of 100
6.0%
5.2% Not available
National
comparator
Comments
N/A
The Trust
aims to
move to
the highest
quartile
100%
Trust target
is 100%
Lowest 20%
threshold
score ≤60
Highest 20%
threshold
≥69
All mental
health trusts
5.07%
Trust is in
mid point of
main 60%
of mental
health trusts
Trust 09/10
target 5%
3.1.3 EFFECTIVENESS INDICATORS
An effective service can be defined as one that provides the right service, to the right
person, at the right time. This section demonstrates how we are doing on key measures
of effectiveness.
•
Physical health checks: it is important that we assess and make sure that the physical,
as well as mental, healthcare needs of our service users are taken into account when
providing care
•
Carers’ assessments: those who care for people with mental health problems have
needs of their own, and may need help in their role as a carer. It is a statutory duty
that we assess those needs in all cases and put in place support plans and services to
meet those needs, and review them regularly
•
Reviews: care must be reviewed regularly to ensure that it is meeting service user
needs. National policy requires that a minimum annual review is carried out for every
service user. Most will have their care reviewed more frequently
•
Re-admission rates: high levels of re-admission to inpatient wards in the period
straight after discharge may indicate that the decisions to discharge were
inappropriate or there was insufficient aftercare to support people in the community.
It is also stressful for users and their carers. Keeping re-admission rates low is a key
Trust ambition.
TABLE 3 EFFECTIVENESS – HOW WE DID
Trust 09/10
Indicator
Data source
Physical
health checks
for inpatients
within seven
days of
admission
Adult Services
Inpatient
Audit
% of carers of
new service
users who
have received
an assessment
Electronic
Patient
Record
16%
–Mental
(June 2009)
Health
Information
System (MHIS)
% of service
users seen
during the
year who
have received
a review
Re-admission
rates
MHIS
MHIS
Trust 08/09
Over 90%
70%
4%
Numerator/
denominator
%
74%
3%
Comments
90%
achieved
by top 10%
of mental
health trust
CQC set
standard at 90%
1,481 /
2,575
National
target 100%
Carers
implementation
plans are in
place as are
systems to
measure this
18,815 /
25,256
CPA policy
requires a
minimum
12 monthly
review
Trust target set
at 98% of those
eligible
74 / 2371
< 5% is
national
upper
quartile
AWP is within
the top
performing
25% of trusts
Over 90%
58%
National
comparator
20/21
3.2 HOW WE ARE MEASURED NATIONALLY
In addition to the above indicators, we are required to report on our performance
against our national targets and standards. All mental health trusts must report these,
for comparison purposes. Table 4 sets these out.
TABLE 4 PERFORMANCE AGAINST NATIONAL TARGETS AND STANDARDS
2008/9
2009/10
forecast*
Achieved
95%
Achieved
99%
Not Assessed
Achieved
tbc%
Completeness of Mental Health Minimum Data Set (MHMDS)
ethnicity coding
Achieved
99%
Achieved
98%
Completeness of MHMDS record of care co-ordinator
Achieved
90%
Achieved
98%
Completeness of MHMDS core fields
(**additional data fields required for 2009/10)
Achieved
99%
**Under
achieved
Child & Adolescent Mental Health Services self assessment against
six key improvement standards
Achieved
Achieved
% of CPA inpatient discharges followed up within seven days
Achieved
99%
Achieved
97%
Delayed transfers of care
Achieved
4.1%
Achieved
tbc%
Best practice in mental health - self assessment against 12 key
requirements of the Green Light Toolkit
Not met
Achieved
NHS staff satisfaction
Not met
Achieved
NHS patient satisfaction
Achieved
Achieved
Care Quality Commission (CQC) national targets
% of adult admissions where the service user had a gate keeping
assessment from a crisis resolution home treatment team
% of drug users sustained in treatment
* 2009/10 forecast data awaits final verification from CQC in October 2010
PART 3 OUR CARE QUALITY ACHIEVEMENTS IN 2009/10
Other national standards and targets
2008/09
2009/10
Not assessed
Standard
met
Compliance with Hygiene Code and CQC Regulation for Infection
Control
Standard
met
Standard
met
Reduction in Clostridium Difficile
Standard
met
Standard
met
National Health Service Litigation Authority Risk Management
Standards Level 1
Standard
met
Standard
met
Standard for under 18 admission to adult inpatient wards
Standard
met
Standard
met
Number receiving assertive outreach and teams meeting required
standards
Standard
met
Standard
met
Number receiving crisis resolution and teams meeting required
standards
Standard
met
Standard
met
Number receiving early intervention and teams meeting required
standards
Standard
met
Standard
met
All met
All met
Compliance to Department of Health standards for eliminating
mixed sex accommodation
CQC Core Standards for Better Health
Further information on the measures tabled above is given in appendix C.
3.3 SERVICE USER, CARER AND PATIENT EXPERIENCE
The Trust places great importance on knowing first-hand how our service users and their
carers feel about our services. We participate in the annual NHS national patient survey
programme which, for 2009/10, focused on inpatient services. In 2009/10 we completed
our own survey of community services with a sample size of 2250 (over four times greater
than previous years).
Alongside the national surveys, the Trust collects information from our own internal
surveys, complaints, praise and feedback via the Patient Advice and Liaison Service (PALS),
incident data and CQC inspections and visits.
All information is co-ordinated to ensure a full understanding of evolving themes and to
ensure lessons are learnt. There is an ongoing improvement planning process in place to
respond to the feedback we receive.
In 2009/10 the Trust received:
•
252 complaints
•
1,554 enquiries to our PALS team
•
515 items of praise.
22/23
Complaints
PALS
Praise
Access and waiting
51
177
11
Safe, high quality co-ordinated care
86
294
100
Better information, communications and choice
53
982
4
Building relationships
53
58
396
Clean, comfortable place to be
9
43
4
252
1,554
515
Five themes from our feedback
Total
SOME OF THE KEY FINDINGS OF THE NATIONAL 2009 INPATIENT SURVEY
•
Overall, 48% of respondents rated the care they had received as inpatients as very
good or excellent. The Trust was rated as being in the intermediate 60% of trusts
•
63% of service users found talking therapies helpful
•
92% of service users said that they did not have to share a sleeping area with a
member of the opposite sex
•
53% of service users said that the ward was very clean and 50% said that toilets and
bathrooms were very clean.
PART 3 OUR CARE QUALITY ACHIEVEMENTS IN 2009/10
KEY SCORES CARE QUALITY COMMISSION (CQC) INPATIENT SURVEY 2009
Based on service
users' responses to the
survey – AWP score
out of 10
How this score
compares with other
trusts
Introduction to the ward
6.1
About the same
About the ward
7.2
About the same
Psychiatrists
6.7
About the same
Nurses
6.4
About the same
Medication
4.9
About the same
Care and treatment
6.4
About the same
Talking therapies
6.6
About the same
Physical health care
3.3
About the same
Rights
7
About the same
Leaving hospital
7
About the same
5.5
About the same
Questions about
Overall views and experiences
3.4 PATIENT ENVIRONMENT
The Trust takes part annually in the national programme managed by the National
Patient Safety Agency called the Patient Environment Action Team (PEAT) assessment. It is
a benchmarking tool which helps demonstrate how well individual healthcare providers
are performing in key non-clinical aspects of patient care and involves service users and
carers in the assessment team.
Our PEAT results for 2009/10 show continued improvement across all the fourteen wards
inspected and are presented in the following table:
PATIENT ENVIRONMENT ACTION TEAM (PEAT) SCORES 2009/10 (FOR 14 WARDS)
Environment scores
Food scores
Privacy and dignity scores
1 Excellent
10 Good
3 Acceptable
8 Excellent
6 Good
14 Good
24/25
PART 4
HOW WE
DEVELOPED
OUR QUALITY
ACCOUNTS
This is the first year that NHS Trusts have been asked to report
formally to the public on the quality of their services alongside
the more traditional financial and governance focused annual
report and accounts.
Much of the content of this report is set out to meet legal requirements. However
we have been able to determine much of what we report on, and our priorities for
improvement, in partnership with clinicians, users and carers.
Our aim has been to produce an end product that is a true and fair representation of our
services as well as including information that is meaningful, relevant and accessible to our
service users, their carers and the general public.
To guide us with our decisions we have engaged with service users and carers across the
Trust via our existing forums as well as holding a special event for these groups as well
as Local Involvement Network members and our new Foundation Trust members. This
event was attended by over 100 people and helped us gain valuable input to finalise our
priorities for improvement for 2010/11.
We have also engaged fully across the organisation with our staff and clinicians.
We provided a draft of these Quality Accounts to NHS South Gloucestershire, our
Co-ordinating Commissioner, all six local authority Health Overview and Scrutiny
Committees and Local Involvement Networks and invited them to review the document
and provide us with their comments. These are presented verbatim in appendix B.
The Trust is grateful to our users, carers, staff and all of the above organisations for
dedicating their attention towards verifying the information we have provided and for
their suggestions for improving this document.
We have responded to these comments wherever possible in the time available by adding
information or making appropriate amendments. For example we have added more
information on our service user and carer feedback and our PEAT scores as well as an
appendix to give more local information for our six PCT areas. We shall also take note of
all the comments for our development of the Trust’s Quality Accounts for 2010/11.
CONCLUDING COMMENTS
We very much hope that you found the information contained in this document useful
and meaningful as well as reassuring to you as a service user, carer or member of the
public that providing high quality and safe services is our highest priority and at the heart
of all that we do.
We would value your feedback as we are planning to produce our Quality Accounts for
2010/11. You can contact us via the details below. Alternatively, if you would like further
information, a hard copy of this document, or have any questions, please contact us.
CONTACT US WITH YOUR FEEDBACK OR FOR FURTHER INFORMATION AT:
Email: Communications@awp.nhs.uk
Telephone: 01249 468000
Or write to: Quality Accounts Communications Team
Avon and Wiltshire Mental Health Partnership NHS Trust
Jenner House, Langley Park Estate, Chippenham, SN15 IGG
26/27
APPENDICES
A) INFORMATION BY PRIMARY CARE TRUST (PCT)
AND LOCAL AUTHORITY AREA
B) EXTERNAL ASSURANCES AND COMMENTS
C) F URTHER INFORMATION ON MEASURES
AND PERFORMANCE TARGETS
D) GLOSSARY OF TERMS
PART 2A OUR PRIORITIES FOR IMPROVEMENT 2010/11
APPENDIX A
INFORMATION BY PRIMARY CARE TRUST
AND LOCAL AUTHORITY AREA
This section provides an overview for the services that we provide to each of our six PCT
and local authority areas. These areas are shown in the map below alongside the location
of inpatient sites.
A
B
2
1
E
5
3
C
D
F
G
K
M
L
H
4
I
J
N
O
6
P
The map shows where our inpatient services are currently based:
1. North Somerset
4. Bath and North East Somerset
Long Fox Unit (A)
Elmham Way* (B)
Hillview Lodge (I)
St Martins Hospital (J)
2. Bristol
5. Swindon
Southmead Hospital (C)
Callington Road Hospital (D)
Blaise View, Brentry* (E)
Blackberry Hill Hospital (F)
Lodge Causeway* (G)
Sandalwood Court (K)
Victoria Centre, (L)
Windswept* (M)
3. South Gloucestershire
Hanham* (H)
6. Wiltshire
Green Lane Hospital (N)
Charter House (O)
Fountain Way (P)
*Community based inpatient rehabilitation services
28/29
1. NORTH SOMERSET
KEY:
Adults of Working Age SBU
Older People’s SBU
Specialised and Secure Services SBU
Specialist Drug and Alcohol Services SBU
North Somerset
Multiple SBUs operate at this site
i
1
Inpatient facility
i
2
3
1
2
Elmham Way
Coast Resource Centre
i
4
5
Long Fox Unit
4
47 Boulevard
5
Carlton Centre
3
1.1 OVERVIEW OF SERVICES IN NORTH SOMERSET
During 2009/10 AWP received 3,822 referrals for people registered to GPs in the North
Somerset area. Of these, the majority of service users were supported in the community,
however where necessary, some people were admitted into hospital for a period of
inpatient care. The total number of community based contacts and the total number of
inpatient admissions were as follows:
•
73,729 community contacts
•
364 inpatient admissions.
Services are provided at two inpatient sites at the Long Fox Unit and Elmham Way, as
shown on the map above, and at community sites across the area.
1.2 HOW WE HAVE MEASURED OUR SERVICE QUALITY IN NORTH SOMERSET
The table below represents local information, where it is available, for those indicators
that are presented in the main Quality Accounts under the heading Part 3.1 ‘How we
have measured our service quality’.
Please note for several of the indicators presented in the main Quality Accounts we
do not have localised data available. We have therefore excluded these from the
table opposite.
APPENDIX A INFORMATION BY PCT AND LOCAL AUTHORITY AREA
PATIENT EXPERIENCE – HOW WE DID IN NORTH SOMERSET
Indicator
% of service
users seen
for their first
appointment
within six
weeks of their
referral
% of service
users who
have received
a written
copy of their
care plan
Data source
Electronic
Patient
Record –
Mental
Health
Information
System (MHIS)
MHIS
Trust
wide
08/09
Trust
wide
09/10
90%
(June
2009)
99%
96%
North Somerset 09/10
%
98.9%
92%
95%
National
comparator
Numerator/
denominator
282 / 285
(for last
quarter)
NHS South
West target is
100%
2581 / 2706
CPA policy
requires that
100% of
patients have
a copy of
their jointly
agreed care
plan
EFFECTIVENESS – HOW WE DID IN NORTH SOMERSET
Indicator
% of carers of
new service
users who
have received
an assessment
Data source
Electronic
Patient
Record Mental
Health
Information
System (MHIS)
Trust
wide
08/09
Trust
wide
09/10
16%
(June
2009)
58%
North Somerset 09/10
%
Numerator/
denominator
76%
274 / 360
National
comparator
National
target 100%
% of service
users seen
during the
year who
have received
a review
MHIS
70%
74%
75%
2042 / 2706
CPA policy
requires 100%
of people
have an
annual review
as a minimum
Re-admission
rates
MHIS
4%
4%
5%
14 / 291
< 5% is
national
upper quartile
30/31
2. BRISTOL
KEY:
Adults of Working Age SBU
Older People’s SBU
Specialised and Secure Services SBU
1
2
Specialist Drug and Alcohol Services SBU
11
Multiple SBUs operate at this site
i
12
8
Inpatient facility
Bristol
3
1
i
Brentry site
7
Stokescroft
2
i
Southmead
8
Colston Fort
Grove Road
9
3
i
i
10
Petherton Resource Centre
5
Speedwell Centre
11
HMP Bristol
6
Brookland Hall
12
i
4
7
Callington Road
Lodge Causeway
4
6
5
9
10
Blackberry Hill Hospital
2.1 OVERVIEW OF SERVICES IN BRISTOL
During 2009/10 AWP received 9,262 referrals for people registered to GPs in the Bristol
area. Of those accepted into the service, the majority were supported in the community,
however where necessary, some people were admitted into hospital for a period of
inpatient care. The total number of community based contacts and the total number of
inpatient admissions were as follows:
•
232,631 community contacts
•
996 inpatient admissions.
Services are provided at five inpatient sites, as shown on the map above, including
Southmead Hospital and Callington Road Hospital and at community sites across the city.
2.2 HOW WE HAVE MEASURED OUR SERVICE QUALITY IN BRISTOL
The table below represents local information, where it is available, for those indicators
that are presented in the main Quality Accounts under the heading Part 3.1 ‘How we
have measured our service quality’.
Please note for several of the indicators presented in the main Quality Accounts we
do not have localised data available. We have therefore excluded these from the
table opposite.
APPENDIX A INFORMATION BY PCT AND LOCAL AUTHORITY AREA
PATIENT EXPERIENCE – HOW WE DID IN BRISTOL
Indicator
% of service
users seen
for their first
appointment
within six
weeks of their
referral
% of service
users who
have received
a written
copy of their
care plan
Data source
Electronic
Patient
Record Mental
Health
Information
System (MHIS)
MHIS
Trust
wide
08/09
Trust
wide
09/10
90%
(June
2009)
99%
96%
92%
Bristol 09/10
%
100%
91%
National
comparator
Numerator/
denominator
755 / 755
(for last
quarter)
NHS South
West target is
100%
7151 / 7894
CPA policy
requires that
100% of
patients have
a copy of
their jointly
agreed care
plan
EFFECTIVENESS – HOW WE DID IN BRISTOL
Indicator
% of carers of
new service
users who
have received
an assessment
Data source
Electronic
Patient
Record Mental
Health
Information
System (MHIS)
Trust
wide
08/09
Trust
wide
09/10
16%
(June
2009)
58%
Bristol 09/10
%
Numerator/
denominator
75%
428 / 568
National
comparator
National
target 100%
% of service
users seen
during the
year who
have received
a review
MHIS
70%
74%
78%
5346 / 6894
CPA policy
requires 100%
of people
have an
annual review
as a minimum
Re-admission
rates
MHIS
4%
4%
4%
28 / 785
< 5% is
national
upper quartile
32/33
3. SOUTH GLOUCESTERSHIRE
KEY:
Adults of Working Age SBU
Older People’s SBU
Specialised and Secure Services SBU
Specialist Drug and Alcohol Services SBU
1
2
Multiple SBUs operate at this site
i
Inpatient facility
South Gloucestershire
3
1
Thornbury Hospital
2
The Elms
3
Yate CMHT and contact centre
4
i
Whittucks Road
4
3.1 OVERVIEW OF SERVICES IN SOUTH GLOUCESTERSHIRE
During 2009/10 AWP received 3,290 referrals for people registered to GPs in the South
Gloucestershire area. Of those accepted into service, the majority were supported in the
community, however where necessary, some people were admitted into hospital for a
period of inpatient care. The total number of community based contacts and the total
number of inpatient admissions were as follows:
•
73,581 community contacts
•
263 inpatient admissions.
Services are provided at one inpatient site in Hanham as shown on the map above, as
well as from community sites across the area. South Gloucestershire patients are also
provided with services from locations in the neighbouring area of Bristol with inpatient
services at Callington Road Hospital, Southmead Hospital and Blackberry Hill Hospital.
3.2 HOW WE HAVE MEASURED OUR SERVICE QUALITY IN SOUTH
GLOUCESTERSHIRE
The table below represents local information, where it is available, for those indicators
that are presented in the main Quality Accounts under the heading Part 3.1 ‘How we
have measured our service quality’.
Please note for several of the indicators presented in the main Quality Accounts we
do not have localised data available. We have therefore excluded these from the
table opposite.
APPENDIX A INFORMATION BY PCT AND LOCAL AUTHORITY AREA
PATIENT EXPERIENCE – HOW WE DID IN SOUTH GLOUCESTERSHIRE
Indicator
% of service
users seen
for their first
appointment
within six
weeks of their
referral
% of service
users who
have received
a written
copy of their
care plan
Data source
Electronic
Patient
Record Mental
Health
Information
System (MHIS)
MHIS
Trust
wide
08/09
Trust
wide
09/10
90%
(June
2009)
99%
96%
92%
South Gloucs 09/10
%
99%
97%
National
comparator
Numerator/
denominator
289 / 291
(for last
quarter)
NHS South
West target is
100%
2164 / 2234
CPA policy
requires that
100% of
patients have
a copy of
their jointly
agreed care
plan
EFFECTIVENESS – HOW WE DID IN SOUTH GLOUCESTERSHIRE
Indicator
% of carers of
new service
users who
have received
an assessment
Data source
Electronic
Patient
Record Mental
Health
Information
System (MHIS)
Trust
wide
08/09
Trust
wide
09/10
16%
(June
2009)
58%
South Gloucs 09/10
%
Numerator/
denominator
77%
161 / 210
National
comparator
National
target 100%
% of service
users seen
during the
year who
have received
a review
MHIS
70%
74%
79%
1735 / 2195
CPA policy
requires 100%
of people
have an
annual review
as a minimum
Re-admission
rates
MHIS
4%
4%
7%
16 / 244
< 5% is
national
upper quartile
34/35
4. BATH & NORTH EAST SOMERSET (B&NES)
KEY:
Adults of Working Age SBU
Older People’s SBU
Specialised and Secure Services SBU
4
Specialist Drug and Alcohol Services SBU
Multiple SBUs operate at this site
i
1
Inpatient facility
i
Rock Hall
3
The Swallows
i
1
St Martins Hospital
2
4
2
BANES
3
Hillview Lodge
4.1 OVERVIEW OF SERVICES IN B&NES
During 2009/10 AWP received 2,811 referrals for people registered to GPs in the B&NES
area. Of these, the majority of service users were supported in the community, however
where necessary, some people were admitted into hospital for a period of inpatient
care. The total number of community based contacts and the total number of inpatient
admissions were as follows:
•
81,128 community contacts
•
326 inpatient admissions.
Services are provided at two main inpatient sites at St Martins Hospital and Hillview
Lodge, as shown on the map above, as well as at community sites across the area.
4.2 HOW WE HAVE MEASURED OUR SERVICE QUALITY IN B&NES
The table below represents local information, where it is available, for those indicators
that are presented in the main Quality Accounts under the heading Part 3.1 ‘How we
have measured our service quality’.
Please note for several of the indicators presented in the main Quality Accounts we
do not have localised data available. We have therefore excluded these from the
table opposite.
APPENDIX A INFORMATION BY PCT AND LOCAL AUTHORITY AREA
PATIENT EXPERIENCE – HOW WE DID IN B&NES
Indicator
% of service
users seen
for their first
appointment
within six
weeks of their
referral
% of service
users who
have received
a written
copy of their
care plan
Data source
Electronic
Patient
Record Mental
Health
Information
System (MHIS)
MHIS
Trust
wide
08/09
Trust
wide
09/10
90%
(June
2009)
99%
96%
92%
B&NES 09/10
%
97%
89%
National
comparator
Numerator/
denominator
390 / 401
(for last
quarter)
NHS South
West target is
100%
2962 / 3317
CPA policy
requires that
100% of
patients have
a copy of
their jointly
agreed care
plan
EFFECTIVENESS – HOW WE DID IN B&NES
Indicator
% of carers of
new service
users who
have received
an assessment
Data source
Electronic
Patient
Record Mental
Health
Information
System (MHIS)
Trust
wide
08/09
Trust
wide
09/10
16%
(June
2009)
58%
B&NES 09/10
%
Numerator/
denominator
31%
185 / 594
National
comparator
National
target 100%
% of service
users seen
during the
year who
have received
a review
MHIS
70%
74%
75%
2504 / 3317
CPA policy
requires 100%
of people
have an
annual review
as a minimum
Re-admission
rates
MHIS
4%
4%
0.34%
1 / 294
< 5% is
national
upper quartile
36/37
5. SWINDON
KEY:
Adults of Working Age SBU
Older People’s SBU
Specialised and Secure Services SBU
Specialist Drug and Alcohol Services SBU
4
Multiple SBUs operate at this site
i
Inpatient facility
Swindon
1
West Swindon Health Centre
2
The Mall
3
i
Victoria Centre
4
i
Sandalwood Court
5
i
Windswept
6
1
2
3
6
5
Whitbourne House
5.1 OVERVIEW OF SERVICES IN SWINDON
During 2009/10 AWP received 2,057 referrals for people registered to GPs in the Swindon
area. Of these, the majority of service users were supported in the community, however
where necessary, some people were admitted into hospital for a period of inpatient
care. The total number of community based contacts and the total number of inpatient
admissions were as follows:
•
72,170 community contacts
•
289 inpatient admissions.
Services are provided at three main inpatient sites including Victoria Hospital and
Sandalwood Court, as shown on the map above, as well as at community sites across
the area.
5.2 HOW WE HAVE MEASURED OUR SERVICE QUALITY IN SWINDON
The table below represents local information, where it is available, for those indicators
that are presented in the main Quality Accounts under the heading Part 3.1 ‘How we
have measured our service quality’.
Please note for several of the indicators presented in the main Quality Accounts we
do not have localised data available. We have therefore excluded these from the
table opposite.
APPENDIX A INFORMATION BY PCT AND LOCAL AUTHORITY AREA
PATIENT EXPERIENCE – HOW WE DID IN SWINDON
Indicator
% of service
users seen
for their first
appointment
within six
weeks of their
referral
% of service
users who
have received
a written
copy of their
care plan
Data source
Electronic
Patient
Record Mental
Health
Information
System (MHIS)
MHIS
Trust
wide
08/09
Trust
wide
09/10
90%
(June
2009)
99%
96%
92%
Swindon 09/10
%
98%
94%
National
comparator
Numerator/
denominator
257 / 262
(for last
quarter)
2740 / 2917
NHS South
West target
is 100%
CPA policy
requires that
100% of
patients have
a copy of
their jointly
agreed care
plan
EFFECTIVENESS – HOW WE DID IN SWINDON
Indicator
% of carers of
new service
users who
have received
an assessment
Data source
Electronic
Patient
Record Mental
Health
Information
System (MHIS)
Trust
wide
08/09
Trust
wide
09/10
16%
(June
2009)
58%
Swindon 09/10
%
Numerator/
denominator
67%
73 / 109
National
comparator
National
target 100%
% of service
users seen
during the
year who
have received
a review
MHIS
70%
74%
71%
2081 / 2917
CPA policy
requires 100%
of people
have an
annual review
as a minimum
Re-admission
rates
MHIS
4%
4%
2%
5 / 223
< 5% is
national
upper quartile
38/39
6. WILTSHIRE
KEY:
Adults of Working Age SBU
Older People’s SBU
Specialised and Secure Services SBU
6
Specialist Drug and Alcohol Services SBU
Multiple SBUs operate at this site
i
1
4
4 3
7
Inpatient facility
i
i
Fountain Way
5
2
Shearwater Lodge
6
Bewley House
3
Red Gables
7
Court Mills House
4
i
Green Lane
1
2
5
Wiltshire
2
1
Charterhouse
6.1 OVERVIEW OF SERVICES IN WILTSHIRE
During 2009/10 AWP received 7,289 referrals for people registered to GPs in the Wiltshire
area. Of those accepted into the service, the majority were supported in the community,
however where necessary, some people were admitted into hospital for a period of
inpatient care. The total number of community based contacts and the total number of
inpatient admissions were as follows:
•
156,792 community contacts
•
626 inpatient admissions.
Services are provided at three main inpatient sites at Fountain Way, Charter House and
Green Lane Hospital, as shown on the map above, as well as at community sites across
the area.
6.2 HOW WE HAVE MEASURED OUR SERVICE QUALITY IN WILTSHIRE
The table below represents local information, where it is available, for those indicators
that are presented in the main Quality Accounts under the heading Part 3.1 ‘How we
have measured our service quality’.
Please note for several of the indicators presented in the main Quality Accounts we
do not have localised data available. We have therefore excluded these from the
table opposite.
APPENDIX A INFORMATION BY PCT AND LOCAL AUTHORITY AREA
PATIENT EXPERIENCE – HOW WE DID IN WILTSHIRE
Indicator
% of service
users seen
for their first
appointment
within six
weeks of their
referral
% of service
users who
have received
a written
copy of their
care plan
Data source
Electronic
Patient
Record Mental
Health
Information
System (MHIS)
MHIS
Trust
wide
08/09
Trust
wide
09/10
90%
(June
2009)
99%
96%
92%
Wiltshire 09/10
%
98%
90%
National
comparator
Numerator/
denominator
725 / 740
(for last
quarter)
NHS South
West target is
100%
6905 / 7666
CPA policy
requires that
100% of
patients have
a copy of
their jointly
agreed care
plan
EFFECTIVENESS – HOW WE DID IN WILTSHIRE
Indicator
% of carers of
new service
users who
have received
an assessment
Data source
Electronic
Patient
Record Mental
Health
Information
System (MHIS)
Trust
wide
08/09
Trust
wide
09/10
16%
(June
2009)
58%
Wiltshire 09/10
%
Numerator/
denominator
49%
360 / 734
National
comparator
National
target 100%
% of service
users seen
during the
year who
have received
a review
MHIS
70%
74%
68%
5195 / 7666
CPA policy
requires 100%
of people
have an
annual review
as a minimum
Re-admission
rates
MHIS
4%
4%
2%
10 / 534
< 5% is
national
upper quartile
40/41
APPENDIX B
EXTERNAL ASSURANCES AND COMMENTS
Published verbatim below are the statements received from the associated organisation.
In the light of the comments received and as indicated on page 27, changes have been
made to this document and where this has not been possible, the suggestions will be
considered when we produce the 2010/11 Quality Accounts.
1. NHS SOUTH GLOUCESTERSHIRE, OUR LEAD PCT COMMISSIONER
“The following statement has been developed in our lead commissioning role, and we
are grateful for contributions and suggestions from NHS associate commissioners and
other local partners and stakeholders.
NHS South Gloucestershire, as lead commissioner for the Avon and Wiltshire Mental
Health Partnership Trust (AWP), is delighted to have an opportunity to comment on the
Trust’s first annual quality accounts. This is an important new requirement for all NHS
organisations, which recognizes both the wish to respond positively to the feedback of
local patients, carers, partners and staff and also the increasing importance of driving,
demonstrating and celebrating ongoing improvements in service quality and patient
experience.
The document is well structured, and all partners found it easy to read. A number of
partners have reflected that it has been helpful in increasing their understanding of
the services provided by AWP to local people. I understand that, on the basis of early
feedback, you will be adding further information as appendices which will clarify how
the quoted targets are measured, and the number of patients to whom they relate.
Future consideration may also be given to adding pictures of local services and/or direct
feedback quotes from patients and staff.
The Trust has made considerable and positive progress over the last year. This includes:
•
Improved performance against core national NHS targets, supported by an enhanced
performance management programme and scorecard covering the breadth of
national and local targets
•
Meeting the registration requirements of the Care Quality Commission (CQC)
•
Achieving ‘fully met’ against Standards for Better Health requirements in 2009/10
•
Further progress against the CQC health check requirements, with a projected ‘good’
rating for quality of services in 2009/10 compared to a ‘fair’ rating in 2008/9
•
Improvements in practice following a CQC inspection relating to infection control
•
Excellent progress against national quality measures of adult inpatient care
•
Improving the timeliness of the reporting and learning from serious untoward
incidents.
For the first set of quality accounts, we recognize that the Trust has elected to focus
particularly on quality standards which reflect core services and support to patients
and their families, including the speed of access to services, care planning and support
to carers.
APPENDIX B EXTERNAL ASSURANCES AND COMMENTS
Looking ahead, we support the Trust’s aspirations to make further progress on the quality
of CPA, crisis care, carer support and user and carer engagement, and feel that you may
wish to give additional information on your planned actions in these areas. We are also
keen to continue to work with the Trust and the wider mental health community to
develop and report measures that reflect longer term patient satisfaction. These should
reflect both clinical and social outcomes, for example, an individual’s ability to maintain
or return to employment or to live independently. Given the essential role played by staff,
the Trust may also wish to consider quality measures associated with a well developed,
flexible and responsive workforce, including improved results against the NHS staff
satisfaction survey.
AWP’s first quality account provides an excellent baseline position and we look forward
to continuing to work alongside the Trust in meeting the quality aspirations of local
users, carers, partners and staff.”
2. LOCAL AUTHORITY OVERVIEW AND SCRUTINY COMMITTEES
“The six main Local Authority Overview and Scrutiny Committees (OSCs) that receive
services from AWP were invited to comment, on a voluntary basis, on these Quality
Accounts.
Bath and North East Somerset, Swindon, South Gloucestershire, North Somerset, and
Bristol Local Authority OSCs have responded to this invitation, and a collation of their
responses is shown below. Wiltshire OSC chose not to comment this year, but have
co-ordinated the response below:
1. To make the Quality Accounts more informative AWP are asked to note the points
below. They are a collation of suggestions from all the contributing OSCs.
Include information on:
a) Proposals and timescales for addressing the listed priorities.
b) Compliments and complaints received, including type and area of complaint
c) N
umerators and denominators. Include data with percentages in section 3, to show
patient numbers being treated
d) National Targets: background and detail of targets, possibly as an annex.
e) L ocal data: ‘Local Authority specific’ figures. Include in Section 3, or appendices for
each LA.
f) S
afeguarding: new section in relation to the care of Adults of Working Age and
Older People.
g) Inpatient hydration and nourishment – commentary on how this issue is addressed.
h) Data linking the QA to the care pathway, ideally in schematic form.
i) Trust wide data on numbers of patients treated and services.
2. In addition to the above, individual OSCs also wished to make the following Comments
a) B
ath & North East Somerset Council, Healthier Communities and Older People
Overview and Scrutiny Panel has seen a massive improvement in the way AWP engage
with us as a Local Authority OSC, which has been maintained over the last three
years. AWP are open to constructive criticism, take the panel’s views seriously, and are
open and honest when issues arise for them. The Assistant CEO has been particularly
instrumental in fostering and maintaining excellent relationships with us, showing a
42/43
willingness to respond swiftly and frankly to any issues or queries we might have.
As a panel, we have been given access to local AWP sites, and have been fully engaged
in AWP’s plans for Foundation Trust status. We look forward to a continuing good
relationship with AWP.
b) N
orth Somerset Council Health Overview and Scrutiny Panel has had the opportunity
to be a critical friend to AWP and advise them of concerns. They came to this Panel on
five occasions during the past municipal year, consulting on a range of issues including:
•
Temporary use of decant facility for single sex.
•
Consultation on AWP’s plans for Foundation Trust status,
•
Proposed changes to secondary care mental health services.
•
Security Arrangements at Juniper Court, Long Fox Site, Weston-super-Mare;
•
Update on Shaping the Future of Secondary mental health care in North Somerset.
c) S
windon Borough Council Health Overview and Scrutiny Committee Chair and a
representative on behalf of the Local Involvement Network and Service User Network,
Swindon (SUNS), met to consider the QA.
It was difficult to consider whether it was representative across the whole of the Trust.
Services in Swindon had been failing and have been under scrutiny over the past
year. Following implementation of a Rapid Improvement Plan, services have indeed
improved and continue to do so. There is however no mention of the improvement
plan, or indeed the successes that have arisen from it.
They felt unable to comment on if there were significant omissions of issues of concern
as this was the first year of Quality Accounts.”
3. LOCAL INVOLVEMENT NETWORKS (LINks)
“Statements have been received by Wiltshire Involvement Network (WIN) from two LINks
for onward submission to AWP, subject to a 500 word limit.
EXTRACT FROM SOUTH GLOUCESTERSHIRE LINk STATEMENT FOR THE AWP
QUALITY ACCOUNT
AWP has much to be proud of as it works towards foundation status later on this year,
their focus for 2010/11 clearly demonstrated commitment to improving patient / service
user and carers experience compared to their own self assessment 2009/10.
AWP strengths are rooted in their capacity for involvement, which is demonstrated with
their Community Engagement Strategy and when it involves service users and carers in
design / co-production of services to promote opportunities and personal recovery.
South Gloucestershire Local Involvement Network would recommend to the Department
of Health (DOH) and the National Quality Board (NQB) the following:
1.For 2010/11 Quality Accounts (QA) submission that providers arrange for LINks, OSCs
and other interested parties pre QA submission where open discussion and QA can
support Trusts draft QA assurance to be relied on.
APPENDIX B EXTERNAL ASSURANCES AND COMMENTS
2.In most areas where mental health trusts operate there will be a lead PCT
Commissioner for Mental Health services, consideration should be given as to how
each of the other PCT’s services has been commissioned on behalf of the lead PCT
commissioner as each service level agreement will look different.
3.DOH and NQB to consider using each of the Strategic Health Authorities’ development
centre’s to develop Action Learning Sets to progress towards better understanding
of Quality Accounts from the data received for 2009/10 in readiness for 2010/11
submissions.
Finally lessons from the past will show that taking a piecemeal approach to Quality
Accounts will yield little progress for the first couple of years if it is not understood,
such was the case for Standards for Better Health (Healthcare Commission) and Annual
Health Check (Healthcare Commission) with respect to third party comments. There is
still discussion to be had nationally on taking Quality Accounts forward.
EXTRACT FROM BRISTOL LINk STATEMENT
The Quality Account should be created using a quality standard such as the BS5750
Quality Data Standard to define what is meant by quality within the document. This
would ensure that it is clear and objective about what the trust is measuring against
with regard to quality.
The Quality Account data appears disjointed and it is difficult to identify what the
%s are.
The priorities written with the Chief Executives introduction are not reflected in the
Quality Account document.
The LINk find it difficult to judge the review of quality performance in the Quality
Account when they do not know how many staff, clinicians, service users, carers and key
stakeholders have been consulted.
From issues that the LINk has heard, we understand there are still delays in responsiveness
to treatment although the LINk believe that the Trust has gone some way to improve the
care and service to users.
The Bristol LINk listed 10 omissions from the Quality Account, which the word count does
not permit us to reproduce, but WIN has passed the entirety of both LINKs’ submissions
to AWP.”
44/45
APPENDIX C
FURTHER INFORMATION ON MEASURES AND
PERFORMANCE TARGETS
This appendix explains the terms and sets out the calculation methods used to achieve
the figures listed in :
•
3.1 ‘How we have measured our service quality: Trust level’ Tables 1, 2 and 3
•
3.2 ‘How we are measured nationally’ Table 4.
3.1 ‘HOW WE HAVE MEASURED OUR SERVICE QUALITY:
TRUST LEVEL’
TABLE 1 PATIENT EXPERIENCE – HOW WE DID
Indicator
% of service
users seen
for their first
appointment
within six
weeks of their
referral
% of service
users who
have received
a written copy
of their care
plan
Definitely
treated
with dignity
and respect
by their
healthcare
professional
Data source
Electronic
Patient
Record –
Mental Health
Information
System (MHIS)
MHIS
Community
Mental Health
Survey 2009
Definition
Numerator
Denominator
Data period
The
numerator
divided by the
denominator
expressed as
a%
Number of
service users
seen for
their first
appointment
within six
weeks of the
Trust receiving
the referral
from the
GP or other
source
Number of
service users
referred to
the Trust to
have been
seen for a first
appointment
1 January to
31 March 2010
(Quarterly)
The
numerator
divided by the
denominator
expressed as
a%
The number
of service
users in the
care of the
Trust for
whom a copy
of their care
plan had been
uploaded
to their
electronic
patient record
The number
of service
users in the
care of the
Trust
1 April 2009
to 31 March
2010
The
numerator
divided by the
denominator
expressed as
a%
The number
of people
answering ‘yes
definitely’ to
the question
“Did the
person treat
you with
respect and
dignity?”
The total
number
of people
responding to
the question
“Did the
person treat
you with
respect and
dignity?”
Survey
conducted
April to July
2009
APPENDIX C FURTHER INFORMATION ON MEASURES AND PERFORMANCE TARGETS
TABLE 2 SAFETY – HOW WE DID
Indicator
Data source
Definition
Numerator
Denominator
Data period
Benchmark
position for
reporting
patient safety
incidents to
the National
Patient Safety
Agency
The number
of incidents
National
reported per
Patient Safety 1,000 bed days
Agency Report compared to
20 March 2010 other NHS
Mental Health
Trusts
In the period AWP reported
1 April to 30
19.4 incidents per 1000 bed
September
days against the national mean
2009
of 18.7
Serious
Untoward
Incidents
(SUIs)
reported
to the Lead
Commissioner
and Strategic
Health
Authority
within 24
hours
Strategic
Executive
Information
Management
System (STEIS)
Internal
performance
monitoring
The number
of SUIs
reported
via STEIS to
NHS South
West within
24 hours of
the incident
taking place
During your
most recent
stay did you
feel safe?
National NHS
Inpatient
Survey Report
2009
Sickness
absence data
cumulative
average over
past three
months
Internal
Electronic
Staff Record
(ESR) sickness
absence
monitoring
The
numerator
divided by the
denominator
expressed as
a%
The number
of SUIs
reported via
STEIS to NHS
South West
The Trust is given a statistically weighted score
by the CQC out of 100 based on how the
following question was answered:
“During your most recent stay did you feel
safe?”
Calculation is automatically made via input to
the national ESR database on the number of
sick days lost, head count of sick staff and head
count of all staff. Formulae not available.
1 April 2009
to 31 March
2010
Survey
conducted
April to June
2009
1 December
2009 to 28
February 2010
46/47
TABLE 3 EFFECTIVENESS – HOW WE DID
Indicator
Physical
health checks
for inpatients
within seven
days of
admission
% of carers of
new service
users who
have received
an assessment
% of service
users seen
during the
year who have
received a
review
Re-admission
Rates
Data source
Definition
Numerator
Denominator
Data period
Adult services
inpatient
audit
The
numerator
divided by the
denominator
expressed as
a%
The number
inpatients
who received
a physical
health check
within seven
days of
admission
The number
of inpatients
admitted
1 April 2009
to 31 March
2010
MHIS
The
numerator
divided by the
denominator
expressed as
a%
The number
of identified
carers who
received an
assessment of
their needs
The number
of carers
identified by
services
1 April 2009
to 31 March
2010
MHIS
The
numerator
divided by the
denominator
expressed as
a%
The number
of service
users seen
during the
year who
have received
a review of
their care and
treatment in
the last 12
months
The number
of service
users seen
during the
year
1 April 2009
to 31 March
2010
MHIS
The
numerator
divided by the
denominator
expressed as
a%
The total
number or readmissions
The total
number of
discharges
1 April 2009
to 31 March
2010
3.2 HOW WE ARE MEASURED NATIONALLY
TABLE 4 – PERFORMANCE AGAINST NATIONAL TARGETS AND STANDARDS
Further information on the CQC national targets set out in the first section of Table 4 is
available directly from the CQC website at the following link:
http://www.cqc.org.uk/_db/_documents/Download_national_priority_indicators_for_
mental_health_trusts.pdf
APPENDIX C FURTHER INFORMATION ON MEASURES AND PERFORMANCE TARGETS
Other national standards
and targets
Further information
Compliance to Department
of Health standards for
eliminating mixed sex
accommodation
Seventeen principles to support the Department of Health
Delivering Same Sex Accommodation initiative have been
developed to ensure each organisation delivers the highest
standards of privacy and dignity within all areas of a hospital,
other trusts and providers. Further information at the following
link: www.dh.gov.uk/en/Healthcare/Samesexaccommodation/
index.htm
Compliance with Hygiene
Code and CQC Regulation for
Infection Control
Providers of services are required to comply with the
requirements of Regulation 12 of the Health and Social Care
Act 2008 (Regulated Activities) Regulations 2010 with regard
to the Code of Practice for health and adult social care on the
prevention and control of infections and related guidance.
Reduction in Clostridium
Difficile
NHS trusts are required to demonstrate year on year reductions
in the incidence of the hospital communicated and acquired
infection Clostridium Difficile.
National Health Service
Litigation Authority Risk
Management Standards
Level 1
The standards are designed to address organisational, clinical,
and non-clinical/health and safety risks. There are three levels
of achievement that dictate the amount of discount the NHS
organisation receives against their insurance premiums with the
Clinical Negligence Scheme for Trusts. Level 1 being the lowest
level. Further information at the following link: www.nhsla.com
Standard for under 18
admission to adult inpatient
wards
The Government made a commitment that by April 2010 no one
under the age of 18 will be admitted on to an adult psychiatric
ward inappropriately. This is supported by a new duty under the
Mental Health Act 1983 that came into force on 1 April 2010
where “the patient’s environment in the hospital is suitable
having regard to his age (subject to his needs)”.
Number receiving assertive
outreach services and teams
meeting required standards
Number of crisis resolution
home treatment episodes
delivered and teams meeting
required standards
Number of people who are
taken on to the caseload
of early intervention teams
and teams meeting required
standards
Care Quality Commission Core
Standards for Better Health
These three targets were set for mental health trusts as part
of the implementation of the National Service Framework for
Mental Health in 1999. Three specialist services must be provided
in each local area:
• Assertive outreach
• Crisis resolution
• Early intervention.
Each PCT area has targets for new assessments, caseload and
activity. In addition, teams have to meet minimum quality
standards as set out by the Department of Health.
The Core Standards for Better Health were set by the
Department of Health in 2005 to monitor the service quality and
safety of NHS trusts. The standards set out the minimum level of
service patients and service users have a right to expect. As the
independent regulator for the NHS, the Care Quality Commission
has the role of assessing performance against these standards.
With the introduction of the Health and Social Care Act 2008
and the Health and Social Care Act (Registration Requirements)
Regulations 2009, Standards for Better Health for the NHS are
being replaced by registration requirements – essential common
quality standards across the health and social care sector.
48/49
APPENDIX D
GLOSSARY OF TERMS
ASSERTIVE OUTREACH
A service designed to meet the needs of individuals with severe mental health problems
and complex needs who have difficulty engaging with services and often require repeat
admission to hospital. For example, may have a poor response to treatment, unstable
accommodation or be homeless, drug or alcohol dependent.
CARE PROGRAMME APPROACH (CPA)
The process that providers of mental health care use to co-ordinate the care, treatment
and support for people who have mental health needs.
CARE QUALITY COMMISSION (CQC)
The CQC is the independent regulator of health and adult social care services in England.
It also protects the interests of people whose rights are restricted under the Mental
Health Act.
CLINICAL AUDITS
A systematic process for setting and monitoring standards of clinical care. ‘Guidelines’
define what the best clinical practice should be, ‘audit’ investigates whether best practice
is being carried out and makes recommendations for improvement.
CLOSTRIDIUM DIFFICILE
Clostridium Difficile is a bacterial infection that most commonly occurs in people who
have recently had a course of antibiotics and are in hospital. Symptoms can range from
mild diarrhoea to a serious inflammation of the bowel.
COMMISSIONING FOR QUALITY AND INNOVATION (CQUIN)
A payment framework that has been a part of the NHS contract from 2009/10. It
allows all local health communities to develop their own schemes to encourage quality
improvement and recognise innovation by making a proportion of provider income
conditional on locally agreed goals.
CRISIS CARE
Delivered by the Trust’s Crisis Resolution Home Treatment (CRHT) teams. This is a shortterm, community, intensive service, commonly for adults (16 years and over) with severe
mental illness such as schizophrenia, manic depressive disorders and severe depressive
disorder. Crisis care is provided to those in acute psychiatric crisis of such severity that,
without the involvement of a CRHT team, admission to hospital would be necessary.
EARLY INTERVENTION
These teams work with service users and their families to provide expert assessment,
treatment and support at an early stage in their psychosis, with a view to being able to
minimise its impact on their lives and avoid longer term need for mental health services.
Typically service users are aged 14 to 35, this will be their first episode of psychosis and
they will receive up to three years’ support.
FOUNDATION TRUST
Foundation Trusts are a new type of NHS organisation with greater local accountability and
freedom to manage themselves. They remain within the NHS overall, and provide the same
services as traditional trusts, but are more free to set local goals. Staff and members of the
public can join their Boards or become members and have a direct say in how they are run.
APPENDIX D GLOSSARY OF TERMS
HOSPITAL EPISODE STATISTICS (HES)
HES is a national data source that contains details of all admissions to NHS hospitals in
England. It includes private patients treated in NHS hospitals, patients who were resident
outside of England and care delivered by treatment centres (including those in the
independent sector) funded by the NHS. HES also contains details of all NHS outpatient
appointments in England.
INFORMATION GOVERNANCE TOOLKIT
An online tool that enables organisations to measure their performance against
information governance standards.
There are several elements of law and policy from which information governance
standards are derived. It encompasses legal requirements, central guidance and best
practice in information handling, including:
•
The common law duty of confidentiality
•
Data Protection Act 1998
•
Information Security
•
Information Quality
•
Records Management
•
Freedom of Information Act 2000.
LOCAL INVOLVEMENT NETWORK (LINk)
A LINk is a network of local people, organisations and groups from across the community
that want to make care services better. There is one for every local authority area.
Their aim is to provide a stronger voice for local people in the planning, design,
commissioning and provision of health and social care services.
NATIONAL PATIENT SAFETY AGENCY (NPSA)
The NPSA leads and contributes to improved, safe patient care by informing, supporting
and influencing the health sector.
They manage a national safety reporting system receiving confidential reports of patient
safety incidents from healthcare staff across England and Wales. Clinicians and safety
experts analyse these reports to identify common risks to patients and opportunities to
improve patient safety.
NATIONAL INSTITUTE OF HEALTH AND CLINICAL EXCELLENCE (NICE)
NICE provides guidance, sets quality standards and manages a national database to
improve people’s health and prevent and treat ill health.
NICE makes recommendations to the NHS on:
•
New and existing medicines, treatments and procedures
•
Treating and caring for people with specific diseases and conditions
•
How to improve people’s health and prevent illness and disease.
NIHR FLEXIBILITY AND SUSTAINABILITY FUNDING (NIHR FSF)
NIHR FSF is a research funding stream designed to help research-active NHS organisations
attract, develop and retain high-quality research, clinical and support staff by supporting
the salaries of their Faculty members and associated workforce in a flexible manner.
MEDICINES RECONCILIATION
The aim of medicines reconciliation on hospital admission is to ensure that medicines
prescribed on admission correspond to those that the patient was taking before
admission. Details to be recorded include the name of the medicine(s), dosage, frequency,
and route of administration.
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MENTAL HEALTH INFORMATION SYSTEM (MHIS)
Electronic computer based system for the recording of service user clinical and
care records.
MENTAL HEALTH MINIMUM DATA SET (MHMDS)
The MHMDS is a mandatory data return for all NHS providers of specialist adult mental
health services. Data from the Trust’s electronic patient records, relating to admissions,
appointments, CPA, and some basic demographic information is submitted to the
Department of Health on an anonymised basis throughout the year.
OVERVIEW AND SCRUTINY COMMITTEE (OSC)
Each local authority is required to have an OSC to scrutinise public services outside its
own organisation in particular health. It has statutory powers to call in witnesses from
local NHS bodies, and make recommendations that NHS organisations must consider
as part of their decision-making processes. Similarly there is a requirement on NHS
organisations to consult with health overview and scrutiny committees when considering
substantial developments or variations to services.
PATIENT ADVICE AND LIAISON SERVICE (PALS)
PALS is an impartial service designed to ensure that the NHS listens to patients, their
relatives, carers and friends, and answers their questions and resolves their concerns as
quickly as possible.
PALS also helps the NHS to improve services by listening to what matters to patients and
their loved ones and making changes, when appropriate.
QUALITY AND HEALTHCARE GOVERNANCE SYSTEM
In AWP this is a combination of structures and processes from Board to frontline that
ensures quality standards are being maintained, including:
•
Ensuring required standards are achieved
•
Investigating and taking action on sub-standard performance
•
Planning and driving continuous improvement
•
Identifying, sharing and ensuring delivery of best-practice
•
Identifying and managing risks to quality of care.
QUANTITATIVE AND QUALITATIVE RESEARCH
Qualitative research is used to explore and understand people’s beliefs, experiences,
attitudes, behaviour and interactions. It generates non-numerical data, eg a patient’s
description of their pain rather than a measure of pain.
Quantitative research generates numerical data or data that can be converted into
numbers, for example experiments, questionnaires and psychometric tests provide
information which is easy to analyse statistically and, if the research has been designed
and conducted well, provides reliable information.
RiO
RiO is the name of a new electronic patient record and case management system that will
largely replace paper records. RiO will ensure that clinical staff have accurate, up to date
and secure information available around the clock. It will provide real-time information
for assessment, care management, progress notes and bed management. RiO will be fully
implemented across all AWP services by April 2011.
APPENDIX D GLOSSARY OF TERMS
REGULATORY FRAMEWORK
A framework or system of rules and requirements that are set out by law in statutory
legislation.
SAFEGUARDING
A term used in conjunction with measures that are taken to protect, safeguard and
promote the health and welfare of children and vulnerable people; ensuring they live
free from harm, abuse and neglect.
SCORECARDS
Fully named The Balanced Scorecard this is a performance management tool that sets out
in tabular form, in a single place, all of the targets and standards the Trust must meet
and how we are doing against them. It is reported monthly to Board, PCTs and local
authorities, and internally to our operational services. It enables everyone to see what
our performance is and to target improvements where they are needed. It is supported
by weekly internal reports that break performance down to team and ward level.
SERIOUS UNTOWARD OR ADVERSE INCIDENT (SUI)
Any event or circumstance arising that could have or did lead to serious unintended or
unexpected harm, loss or damage.
Essentially serious adverse incidents are those which cause (or have the potential to
cause) the most harm either to individuals (staff, service users, visitors, contractors,
others) or to the organisation. These include unexpected deaths; injuries causing major
and permanent physical or psychological harm; large-scale theft or fraud; outbreak of
Legionnaires disease; major fire or flood; etc.
STANDARDS FOR BETTER HEALTH
Standards set by the Department of Health that describe the minimum level of service
patients and service users have a right to expect.
STRATEGIC BUSINESS UNITS (SBU)
This is a term adopted by AWP to describe the way the organisation has structured the
management of its main operational services and areas of business. Each SBU is led by a
service director and clinical director.
STRATEGIC EXECUTIVE INFORMATION SYSTEM (STEIS)
A system for collecting weekly management information from the NHS. We use this
system to report all Serious Untoward Incidents (SUIs).
STRATEGIC HEALTH AUTHORITY (SHA)
The role of the SHA is to ensure the NHS in the south west is run effectively and that NHS
services, staff and organisations are developed to meet the needs of the future. SHAs are
a key link between the Department of Health and the local NHS.
The South West Strategic Health Authority has three main roles:
1. The strategic leadership of the NHS in south west England
2. The development of NHS organisations and NHS staff in the south west
3. Ensuring the local NHS operates effectively and delivers improved health and
healthcare performance.
The South West Strategic Health Authority oversees the performance of 14 primary
care trusts.
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CONTACT US WITH YOUR FEEDBACK OR FOR
FURTHER INFORMATION AT:
Email: Communications@awp.nhs.uk
Telephone: 01249 468000
Or write to:
Quality Accounts Communications Team
Avon and Wiltshire Mental Health Partnership NHS Trust
Jenner House, Langley Park Estate, Chippenham, SN15 IGG