Quality Account
2009 - 2010
June 2010
Quality Account
Part 1: Statement on Quality from Chief Executive
Calderstones Partnership is a specialist learning disability NHS Foundation Trust authorised
on the 1st April 2009 by Monitor the Independent Regulator for Foundation Trusts. We
provide to people both an on-site assessment and treatment service and a comprehensive
support and care programme in the community. Our commitment is to delivering high
quality person centred services to people with learning disabilities who have complex and
challenging needs. For those that require care in a secure environment the level of security
is based on the least restrictive option commensurate with the degree of risk to the service
user, staff and public.
In June 2009 the Trust Board approved its Clinical Quality Framework outlining how it will
deliver its commitment to improving service delivery and developing the quality agenda.
Throughout the year we have consulted with staff, service users and more recently
Governors to identify their priorities for improving service delivery.
In April 2009 the Governance Committee approved the Service Improvement Work
Programmes for the clinical directorates. The key priorities agreed and developed
throughout the past year have included:
The development of person centred approaches across the Trust to enhance service user
involvement in their treatment, care and support.
The promotion of the privacy and dignity agenda through a dedicated project
development plan.
The promotion of physical health improvement and health surveillance of service users
(in collaboration with primary and secondary healthcare services); in response to a
number of national enquiries that have reported inequitable access to healthcare and
evidence of increased morbidity within the learning disability population.
The development of a ‘Risk of Choking Screening Tool’ for use across Trust services and
an extensive training programme for staff in its use. This has been developed in
response to the research into people with a learning disability and the risk of premature
death through choking. The Trust has invested significant resources aimed at reducing
the likelihood of this occurrence.
The development of a model for the management of aggression which focuses upon deescalation and conflict resolution which has received British Institute of Learning
Disability (BILD) accreditation. The aim of this initiative is to improve patient safety.
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Building on the engagement process established with service users, staff and governors the
Trust Board has approved the key priorities for service improvement in 2010 – 2011, which
are as follows:
The continued development of person centred approaches and the privacy and dignity
agenda, given these agendas are national priorities for health service providers and key
features of the Department of Health’s ‘Valuing People Now’ strategy and the Care
Quality Commissions Strategic Plan for Learning Disability Services 2010 – 2015.
The promotion of patient safety , through a number of initiatives with the overall aim of
developing a proactive safety culture
The enhancement of the treatment and care pathway, which is part of the continuous
quality improvement process aimed at improving issues of clinical effectiveness, safety
and service user experience.
The trust is committed to creating an environment in which the people we care for are
listened to, and where staff are supported to provide the highest quality of care possible.
The overarching aim and challenge is to deliver the highest quality treatment, care and
support, always being mindful that the people we care for are the most important people in
our service.
T R Pearce
Chief Executive
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Part 2: Priorities for Improvement 2010 - 2011
2.1
The Trust has undertaken a number of consultation exercises to identify the
continuous quality improvement priorities that reflect what is important to service
users, staff and governors.
Using the three domains as outlined within High Quality Care for All as a framework,
the following priorities have been identified:
o Patient Experience: Development of the Person Centred Approaches and Privacy
and Dignity Agenda
o Patient Safety: The Promotion of Service User Safety
o Clinical Effectiveness: Enhancing the Treatment and Care Pathway
2.2
Priority 1: Development of the Person Centred Approaches and Privacy
and Dignity Agenda
Rationale
Person centred approaches and the privacy and dignity agenda are national priorities
for health service providers, and are key features of the Department of Health’s
‘Valuing People Now’ strategy and of the Care Quality Commissions Strategic Plan for
Learning Disability Services. Service user ‘rights’ as outlined within the NHS
Constitution are also supported as part of the Person Centred Approaches / Privacy
and Dignity agenda. Within the Trust the promotion of Person Centred Approaches
in addition to the Privacy and Dignity agenda serve to reinforce the Trust values and
principles.
Aim
The aim of Person Centred Approaches serves to promote the importance of the
service user experience by delivering individualised treatment and care, which is
underpinned by service user engagement and involvement.
Quality Initiatives
The development of Person Centred Approaches and the Privacy and Dignity agenda
will be delivered through the following initiatives:
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2.3

The continued roll out of person centred approaches training for direct care staff
and multi disciplinary teams.

To develop the underpinning knowledge and skill competencies of ward
managers and ward based co-ordinators to lead the implementation of person
centred meetings as part of the Care Programme Approach.

The development of one page profiles as an integrated part of informing the
person centred treatment and care plan.

To revise policies and procedures that impact on direct care, reviewing these
using person centred approaches, involving consultation with service users, and
clearly taking and account of the issue of privacy and dignity

To develop three service defined improvements arising from service user
consultation feedback including satisfaction surveys, user forums and complaint
analysis etc (CQUIN).
Priority 2: The Promotion of Service User Safety
Rationale
The Trust is committed to promoting and building a safety culture, a key element of
this work includes enhancing the capability of its risk analysis mechanisms relating to
clinical incidents. A number of potentially high risk but necessary clinical
interventions include the use of physical restraint, rapid tranquilisation and
seclusion. The Trust recognises the need to invest time and resources into ensuring
that ‘patient safety culture’ is a key element of the Trust’s continuous quality
improvement agenda.
A key component of building a safety culture is the need to ensure service user
safeguarding mechanisms are robust and understood by both service users and staff.
Aim
The primary aims of this initiative include preventing harm, reducing risk and
improving organisational learning.
Quality Initiatives
The development of a safety culture will be delivered through the following
initiatives.
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2.4

The benchmarking of the Trust against the National Patient Safety Agency (NPSA)
7 Steps to Patient Safety (Mental Health Services), and from which develop a
Trust wide action plan to develop service user safety improvement programme
monitored via the Trust’s Governance Committee.

To evaluate the service user experience with regard to being successfully deescalated from a conflict situation, and feeling safe using Essen Climate
Evaluation Scale (CQUIN). Understanding from the service user perspective ‘what
works, what doesn’t, what needs to change’.

The production of easy read information for service users about safeguarding,
what they can do to report safeguarding concerns, together with the Trust’s
responsibilities.

Development of patient safety metrics aimed at improving patient safety
mechanisms around injuries sustained through physical intervention, the
management of enhanced supervision, self injury, rapid tranquilisation and
medication prescribing errors.
Priority3: Enhancing the Treatment and Care Pathway
Rationale
The Trust has already undertaken initial development work on mapping the service
user’s treatment and care pathway. The treatment and care pathway as part of the
continuous quality improvement process should address the issues of clinical
effectiveness, service user safety and service user experience.
Aim
To ensure the treatment and care pathway is delivered in an as efficient and
effective way as possible to minimise delayed discharges arising from the Trust’s
service delivery mechanisms.
Quality Initiatives
Enhancing the treatment and care pathway will be delivered through the
following initiatives:
o The implementation of the Health of the Nation Outcome Scale (HONoS
secure) assessment process dependant on point of care pathway (CQUIN)
o The implementation of the HCR-20 as a clinical risk assessment tool for all
service users within onsite services where clinically indicated (CQUIN)
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o The development (with service users) of treatment, care and support
plans that are recovery/rehabilitation focussed (CQUIN)
o The provision of a minimum of 25 hours per week of service user
structured activity including a planned programme of treatment,
education, work and leisure(CQUIN)
Part 3: Review of Quality Performance (Provider Determination)
3.1
Review of Services
3.1.1 Statement of Assurance from the Board
During the reporting period 2009-2010 Calderstones Partnership NHS Foundation
Trust provided for people with a learning disability:
Specialist on-site in-patient assessment and treatment service, inclusive of secure
service provision
Specialist forensic outreach support services
Support and care packages in the community, including supporting people with
complex healthcare needs
Calderstones Partnership NHS Foundation Trust has reviewed all the data that is
available to them on the quality of care in the above NHS services (inclusive of social
care provision). The income generated by the NHS services reviewed in the reporting
period 2009 – 2010 represents 100 percent of the total income generated from the
provision of NHS services by Calderstones Partnership NHS Foundation Trust for the
reporting period 2009 – 2010
3.1.2 Participation in Clinical Audits
During 2009 – 2010 the Trust has not been involved in any national clinical audits and
there was a nil return for the required Trust response to the National Confidential
Inquiry into Suicide and Homicide by People with Mental Illness (CISH) covered NHS
services that Calderstones Partnership NHS Foundation Trust provides.
The reports of local 16 clinical audits were reviewed by the provider in 2009 – 2010
and Calderstones Partnership NHS Foundation Trust intends to take action to
improve the quality of healthcare provided [See Appendix A for list of clinical audit
topics and brief synopsis].
All of the Trust’s clinical audits are presented to and reviewed by the multidisciplinary
Clinical Audit Committee. The reports are also presented to the Governance
Committee as a subcommittee of the Trust Board and provide the assurance that
quality issues are being addressed at Board level. The Trust encourages all services
to be quality focussed and as such encourages all clinical areas and disciplines to
participate in the review of services through the clinical audit.
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3.1.3 Participation in Clinical Research
The number of patients receiving NHS services provided or sub contracted by
Calderstones Partnership NHS Foundation Trust in 2009 - 2010 that were recruited
during that period to participate in research approved by a research ethics
committee was fifty seven.
This increasing level of participation in clinical research demonstrates Calderstones
Partnership NHS Foundation Trust commitment to improving the quality of care we
offer and to making our contribution to wider health improvement.
Calderstones Partnership NHS Foundation Trust was involved in conducting six
clinical research studies. The Trust completed 100% of these studies as designed
within the agreed time and to the agreed recruitment target. The Trust used national
systems to manage the studies in proportion to risk. Of the six studies given
permission to start, six were given permission by an authorised person less than 30
days from receipt of a valid complete application. Six of the studies were established
and managed under national model agreements and none of the six eligible research
involved used a Research Passport. In 2009-2010 the National Institute for Health
Research (NIHR) supported two of these studies through its research networks.
In the last three years, six publications have resulted from our involvement in NIHR
research, helping to improve patient outcomes and experience across the NHS.
3.1.4 Goals Agreed with Commissioners – The Use of CQUIN Payment Framework
A proportion of Calderstones Partnership NHS Foundation Trust income in
2009 - 2010 was conditional on achieving quality improvement and innovation
goals agreed between Calderstones NHS Partnership NHS Foundation Trust
and Specialised Commissioning NHS North West NHS.
Further details of the agreed goals for 2009 – 2010 and for the following 12 month
period are available on request from the Director of Finance
3.1.5 Statements from the Care Quality Commission
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Calderstones NHS Partnership NHS Foundation Trust is required to register with the
Care Quality Commission and its current registration status is registered to carry out
the following regulated activities:
Treatment of disease, disorder or injury
Assessment or medical treatment for persons detained under the Mental
Health Act 1983
Accommodation for persons who require nursing or personal care
Calderstones NHS Partnership NHS Foundation Trust is registered without conditions.
Calderstones NHS Partnership NHS Foundation Trust is not subject to periodic reviews
by the CQC.
Calderstones NHS Partnership NHS Foundation Trust has not participated in any
special reviews or investigations by the CQC during the reporting periods
3.1.6 Data Quality
NHS Number and General Medical Practice Code Validity
Calderstones Partnership NHS Foundation Trust submitted records during 2009 2010 to the Secondary Uses Service for inclusion in the Hospital Episode Statistics
which are included in the latest published data. The percentage of records in the
published data which included the patient’s valid NHS number was 100% for
admitted patient care
3.1.7 Information Governance Toolkit attainment levels
Calderstones Partnership NHS Foundation Trust score for 2009 - 2010 for Information
Quality and Records Management, assessed using the Information Governance
Toolkit was 83% based upon the score 40/ 48 (total of 63 items on the Information
Governance Toolkit of which 48 are applicable to learning disability services)
3.1.8 Clinical coding error rate
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Calderstones Partnership NHS Foundation Trust was not subject to the Payment by
Results clinical coding audit during 2009 – 2010 by the Audit Commission.
3.1.9 Performance against key national priorities and National Core Standards
Department of Health Operating Framework
o With regard to cleanliness the Trust PEAT score is “acceptable” for the
reporting period 2009 – 2010. The Trust is not required to report on HCAI
given the nature of the service provided (i.e. specialist learning disability
tertiary service).
o The 18 week referral treatment pledge is not applicable given the nature
of the service provided.
o With regards to reducing health inequalities and improving health the
Trust has developed a “Health Improvement and Health Surveillance
Strategy “. This has been delivered through a annual health action plan
and subject to monitoring and evaluation through the Trust’s Governance
Committee (see section 3.2.3)
o The Trust has maintained its annual User satisfaction Survey and regular
User Forum meetings, in addition to which 10 patient experience metrics
have been developed by the Trust (see section 3.2.6)
o With reference to emergency preparedness the Trust has developed a
Pandemic Influenza Contingency Plan. This has been developed by the
Trust emergency planning group in addition to which desk top exercises to
test the plan’s robustness have been undertaken and identify areas for
further improvement.
Standards for Better Health
For the period 2009 – 2010 the Trust declared full compliance with all the
applicable Standards for Better health core standards.
Targets and National Core Standards (Mental Health Indicators)
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Whilst Calderstones Partnership NHS Foundation Trust as a specialist learning
disability trust is not required to report on Mental Health Indicators, it does
however, report to Monitor on a quarterly basis “minimising delayed discharges”.
For the period 2009 – 2010 the Trust reported 5.12% delayed discharges.
3.1.10 Statements from primary care trusts, Local Involvement Networks and Overview
and Scrutiny Committees
The Trust has provided an opportunity to the Local Involvement Network (Lancashire LINk) to
comment on the Trust’s Quality Account 2009 -2010, prior to its publication. The Lancashire
LINk has stated that:
“In view of the relatively short timescale that the quality account process has allowed in its
first year for responses from other bodies (such as the LINk), the Lancashire LINk Board has
agreed that it will not be commenting on this year’s quality account submissions from its
relevant NHS trusts”
The Trust’s local service user involvement group (Calderstones Involvement) has been
provided with a presentation update and an opportunity to comment on the Trust’s Quality
Account 2009 -2010.
“The group acknowledged the opportunity to review and comment on this report and
supported the commitment to service improvement for the 2010 – 2011 period”.
The Trust has provided an opportunity to the Lancashire Overview and Scrutiny Committee
(OSC)) to comment on the Trust’s Quality Account 2009 -2010, prior to its publication. The
OSC have reported that the Committee has undergone a number of changes recently which
have resulted in its work load being re planned. As a consequence the OSC is not in a
position to provide comment at this stage on the Trusts Quality Account 2009 – 2010.
The lead commissioning PCT (NHS East Lancashire)have reviewed the Trusts Quality Account 2009 –
2010. “Based on advice from colleagues in North West Specialised Commissioning Team,
NHS East Lancashire as lead commissioner accepts the report of Calderstones Quality
Account 2009-2010”.
3.2
Review of Quality 2009 - 2010
3.2.1 Person Centred Approaches
“Person centred approaches are not another thing for services to do; it is what they
must do. It is not another job – it is the job” M Glynn et al 2008
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As part of the NHS commitment to developing the quality of services through person
centeredness the Trust has invested time and resources in early implementation
initiatives which have enabled staff to begin to use ‘Person Centred Approaches’ in
the treatment care and support planning processes.
The principle of ‘person centred approaches’ reinforces the Trust commitment to
respect and valuing the unique contribution of each individual. This approach has
begun to provide staff with the underpinning knowledge and skills to work in a
person centred manner.
The benefits to service users include being quickly engaged in their assessment and
early treatment and care planning and more appropriately identifying individual
needs and what is important to the service user. It has enabled service users to
contribute to and inform risk assessments, and the development of management
and support plans. Person centred approaches has demonstrated at an early stage
that service users are increasingly motivated to take an active role in engaging in
their treatment and care planning activity.
The key deliverables from this quality initiative have been:
The appointment of a lead facilitator and co-facilitator to support staff in
developing and delivering person centred approaches
Provided staff with 7 days training on using person centred planning tools
The development of the ‘1 page profiles’ which have allowed service users to
communicate what is important to them and how best to support them on their
care pathway
Developing and delivering positive and productive team meetings
Training in person centred clinical supervision
Involving service users in risk assessment and positive risk taking
In an attempt to begin to measure the impact and progress with person centred
approaches we have developed a metric as part of the service user experience
domain that asks for service users feedback on their opportunity to be involved in
the treatment, care and support planning. There is evidence to indicate that service
users report a high level of satisfaction with their level of involvement in the
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treatment, care and support planning process. There has been a small increase in
satisfaction levels from 08-09 at 91% and 93% in 09-10. This compares favourably to
the national comparative data of 54% (aggregate score - sourced from the “National
NHS patient survey programme: Mental health acute inpatient service users survey
2009”. There is no direct comparative data for inpatient learning disability services)
3.2.2 Privacy and Dignity
Dignity in care is based upon the principle that being treated with dignity is a basic
human right, not an optional extra. We believe that healthcare services must be
compassionate, person centered, as well as efficient, and are willing to try to do
something to achieve this
In accordance with the Department of Health’s priority to eliminate mixed sex
accommodation and promote the privacy and dignity agenda within healthcare
provision the Trust has developed a number of initiatives to drive this agenda within
the Trust. In year the Trust has been supported with additional funding by the
Department of Health to develop this work
A primary objective of this project has been to promote the privacy and dignity
agenda within service user treatment and care plans and throughout the care
pathway. The primary objectives from this project plan have been to ensure:
Service user experiences and contributions regarding privacy and dignity inform
Trust wide induction and values training initiatives
An increase in awareness and empathy from staff to the privacy and dignity
needs of service users
A review of the Trust’s clinical practices/procedures where privacy and dignity
may be challenged or compromised; and the engagement and contribution of
service users and clinicians in this review process
The development of a Trust wide ‘Privacy and Dignity Challenge’ Charter,
engaging service users, staff and partners in identifying key privacy and dignity
practice standards that the Trust will commit to promoting and delivering
consistently across all services
The delivery of specialist gender training with a focus on privacy and dignity for
women within secure services
Through the delivery of the Essence of Care benchmark service users’ right to
privacy is respected at all times.
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Ensuring that service users are treated with dignity and respect whilst being cared
for by the Trust, is very important. In response to which a metric has been developed
to capture information about their perceptions of services and Trust progress in
improving the experience of service users. Data has been collected over the last two
consecutive years. There has been a decrease in satisfaction 08-09 was 88% and 0910 was 80%, however the figure compares favourably with the national figure of 73%
(aggregate score - sourced from the “National NHS patient survey programme:
Mental health acute inpatient service users survey 2009”)
Whilst the project work on developing the privacy and dignity may not have yet fully
realised the potential benefits it is nonetheless apparent that there is clear scope to
improve the Trust performance in this domain. As a consequence of which the issue
of continuing to promote privacy and dignity will remain a significant feature of the
Trust’s Continuous Quality Improvement Programme for 2010 – 2011.
3.2.3 Health Improvement and Health Surveillance
“The health and strength of a society can be measured by how well it cares for its
most vulnerable members. For a variety of reasons, including the way society
behaves towards them, adults and children with learning disabilities, especially those
with severe disability and the most complex needs are some of the most vulnerable
members of our society today. They also have significantly worse health than
others.” Healthcare for All: Sir Jonathon Michael 2008
Most people with learning disabilities have greater health needs than the rest of the
population. They are more likely to experience mental illness and are more prone to
chronic health problems, epilepsy, and physical and sensory disabilities. As life
expectancy increases age-related diseases such as stroke, heart disease, chronic
respiratory disease and cancer are likely to be of particular concern. There is an
above average death rate among younger people with learning disabilities (Valuing
People 2001).
The Trust as a provider of specialist healthcare to people with learning disabilities is
well placed to encourage and facilitate access to healthier life styles. The Trust also
recognises that it has a responsibility for ensuring that the service users’ general
physical health needs are met, by developing links with health professionals,
promoting staff competence in basic health issues and implementing health
promotion initiatives
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The intention of the Trust’s health promotion initiatives are to increase the ability of
service users to make healthy choices, their knowledge about preventing illness and
access to health screening programmes
Information gathered by the Trust on the health of service users highlights high rates
of smoking, excessive weight gain and obesity. The Trust is committed to providing
and facilitating access to the same standard of healthcare that is available to the
general population. This is achieved through the development of a Trust wide
Health Promotion Strategy which is underpinned by an annual work programme.
The deliverables that have contributed to improving the physical health of service
users are:
A weekly weight management clinic facilitated by a qualified dietician with
weight information collected and analysed with a reduction of people in the
seriously obese category
Monthly recording of weights and quarterly reports
A project to review the nutritional content and quality of the food provided
100% of clients registered for national screening programmes and subject to
routine recall as required
All service users diagnosed with diabetes access the national retinopathy
screening programme
A diabetic clinic facilitated within Calderstones by the local PCT
Smoking cessation opportunities through a trained facilitator
In response to NICE guidance all service users prescribed antipsychotic
medication undergo an Electric Cardio gram (ECG)
3.2.4 The development of a ‘Risk of Choking Screening Tool’
Swallowing difficulties are more common in people with learning disabilities. If not
managed safely, this may lead to respiratory tract infections, a leading cause of early
death for people with learning disability
Recent analysis of incident reports by NPSA have highlighted choking incidents both
near miss and fatal for adults with learning disabilities. With increasing awareness
through staff training and risk assessment there has been increased reporting of
choking and near miss choking incidents through the Trust’s risk management
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system. The potential for catastrophic outcomes, trauma and stress of these
incidents is clear for the service user and for staff.
In response to this patient safety agenda the Trust has actively supported the clinical
research into the risk of choking and potential for premature death. And as a
consequence work has been undertaken to produce a ‘Risk of Choking Screening
Tool’.
This screening tool has been subject to initial pilot in both inpatient and community
services. As a consequence of which revisions to the tool have been made. The
outcomes to date form this work has included:
Risk of Choking Screening Tool training workshops for nursing and support staff
A protocol for initial screening and as appropriate referral to Speech and Language
Therapy Services
Completion of assessment tool with across on site and community services
As part of monitoring Trust performance in relation to patient safety and managing
the risk of choking a metric has been developed. The metric monitors compliance
with the completion of the Risk of Choking Screening Tool for all new inpatients. The
initial clinical audit for the 2008 – 2009 period reported a compliance rate of 38%.
This level of compliance was deemed highly unsatisfactory and a multidisciplinary
task group was convened by the Clinical Audit Committee to address this issue. A
comprehensive action plan was developed and the results for 2009 – 2010 show
100% compliance with the use Risk of Choking Screening Tool, which is a significant
improvement on the previous year.
The objective for 2010 -2011 is to achieve 100% compliance with this metric based
upon completion of the screening tool within 2 weeks of admission.
3.2.5 Management of Aggression
Within the Trust’s secure inpatient services the effective clinical management of
violence and aggression is a key priority both in terms of patient and staff safety.
The National Patient Safety Agency also highlighted the issue of physical intervention
of people with learning disability as a national priority as evidence suggests that:
‘50% of people with learning disability and challenging behaviour will be restrained
at some point in their life.’ BILD, 2004
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The Trust has developed a model for the management of aggression which focuses
upon de-escalation and conflict resolution which has received British Institute of
Learning Disability (BILD) accreditation. The aim of this initiative is to improve
patient safety.
The Trust’s accredited training (BILD) on managing aggression and violence focuses
upon the aetiology behind aggressive and/or violent behaviour. The principles of the
accredited training include; the issue of person centred approaches, adopting the
least restrictive option, emphasis on safety and the avoidance of positional asphyxia,
and the avoidance of pain as a means of obtaining compliance. In addition the
training now incorporates the Local Security Management Service (LSMS) Conflict
Resolution curriculum.
The Trust also has a specialist nurse acting in a consultative role – providing
assistance to MDT clinicians regarding the most appropriate conflict management
techniques for service users with special needs e.g. autism, mentally ill, obese,
asthma. The training of physical breakaway and intervention techniques are in
keeping with nationally recognised best practice and emphasise the issue of physical
safety for both individual service users and staff.
All incidents are monitored via a monthly clinical incident report. The analysis of this
electronically based data produces trend reporting that can also report on numbers
of incidents, accidents and injuries incurred by service, ward or even by individual
name. The Trust’s clinical risk management group (a multi-disciplinary group of
senior clinicians) meet on a monthly basis to review the clinical risk report.
It has been recognised that further analysis of incident data is required to improve
patient safety and in response a metric has been developed to try and establish if
the Trust’s initiative to effectively manage aggression and violence within the clinical
environment. The metric focuses upon injuries received by both staff and service
users during the physical intervention process. For the periods 2008 – 2009 injuries
rates during physical intervention for service users were 2% and staff 4%. In 2009 –
2010 it was 1.7% for service users and 5% for staff. Whilst these figures look positive
the Trust is committed to continuing to monitor this information and aim to reduce
further the frequency of injury through the ongoing commitment to staff training,
senior nurse specialist advice and monthly analysis of incident data.
3.2.6 Service User Satisfaction
We believe that listening to service users is a central component of delivering a
quality focused service. Understanding the service from the service user perspective,
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knowing what works and what doesn’t is integral to our quality strategy. Listening to
service users we have identified the key elements underpinning service user
satisfaction. Our service users have told us what is important to them. These key
elements of the care process have been measured through service user satisfaction
surveys and improvements made to continue improving the level of satisfaction with
services:
Patient Experience Metric
09-10
Results
08-09
Results
National
Comparative
Data *
1. Having enough activities available for them to do during
weekdays
72%
69%
44.5%
59%
57%
30%
85%
87%
72.5%
Having enough activities available for them to do during
the weekends
Service user activities have included a number of
developments throughout the 2009 – 2010 period
examples of which include:
Enhancing the 1:1 support provision for service users
to increase access to Adult Learning Services
The development of partnership arrangements with
outside agencies to provide specialist tutor provision
delivering special interest activities requested by
service users
The delivery of work experience opportunities within
the horticultural retail department
The development of ‘Eco arts’ using recyclable
materials to produce pieces of art work and also a
nationally recognised recycling course
Outdoor country leisure activities have included the
use of the dry stone walling and living willow
sculptures
2. Living in an environment that is clean and tidy
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Patient Experience Metric
09-10
Results
08-09
Results
National
Comparative
Data *
76%
79%
65%
82%
83%
56.5%
87%
75%
48%
There is now a formal inspection of all kitchens
completed by Matrons with Ward Managers every 3
months to ensure that infection control and cleanliness
standards are being maintained.
In addition there is also a service user involved with the
wider hospital environment checks advising domestic
service about standards of cleanliness from a service user
perspective
There has been no significant variation in the levels of
satisfaction but compare favourably to the national data
3. Feeling safe where they are living
There has been extensive consultation through
Psychological Treatment Services and Psycho-educational
Services with service users around feeling safe and
particularly the issue of bullying. This has resulted in a
the development of a structured programme for service
users to access with regards to feeling safe and
recognising and responding to issues of bullying, which
will be delivered in April 2010. In addition there has also
been an ‘easy read’ booklet developed for services users
about bullying.
4. Having their rights explained to them in a way that they
can understand
For all people detained under the Mental Health Act 1983
there is a statutory requirement to read people their
rights every 12 months or upon renewal of section. The
Trust has a minimum standard of reading rights every 3
months or more frequently if required to ensure that
service users are kept fully aware of their rights whilst
detained.
5. How to make a complaint
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Patient Experience Metric
09-10
Results
08-09
Results
National
Comparative
Data *
93%
91%
74%
80%
91%
64.5%
The Trust’s complaint procedure has been updated in line
with the new NHS statutory requirements. The Trust
continues to produce quarterly reports based upon the
analysis of complaint data. Feedback from service users
compares favourably with the national feedback with
being given information and supported to make a
complaint.
6. Involvement in their treatment and care
Service users are actively supported by the
multidisciplinary team to be involved in the preparation
and planning of their treatment and care pathway,
ensuring that there is a person centred focus
underpinning the Care Programme Approach.
The respective case manager takes responsibility for
ensuring that the service users treatment and care plan is
produced in a format that is easy for them to understand
7. Maintaining contact with family and friends
The Trust is mindful of the need to support service users
and their families in being able to maintain contact with
each other, given that the hospital provide care to people
across the North West Region which in turn may need
families to travel some distance.
Services have worked with service users to produce
significant events calendars to enable them to remain
engaged with important family dates/events.
The Trust remains committed to providing flexible visiting
arrangements and accessible facilities where needed.
* National comparative data based upon aggregate score - sourced from the “National NHS patient survey
programme: Mental health acute inpatient service users survey 2009”
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3.3
Development of Quality Dashboard
The Trust recognises that good quality information is a driver of performance
amongst clinical teams and helps to ensure the right services and best possible care
is provided to patients. A key element of providing good quality information is to
ensure that clinicians delivering the service receive regular feedback on performance
The Trust has developed the Quality Dashboard in collaboration with the clinicians,
which provides clinicians with the relevant and timely information they need to
inform daily decisions that improve quality of care for people using services.
The Quality Dashboard largely reflects the critical junctures of the service users care
pathway. For example, the multidisciplinary treatment and care plan process,
assessment of risk, access to therapies, access to meaningful occupation and leisure
and the monitoring of patient safety incidents.
There is an ongoing commitment to further develop metrics to improve the
efficiency and effectiveness of care pathway for people using services, in addition to
which is the need to develop ‘patient reported outcome measures’ in the longer
term.
3.4 Quality Overview 2009 – 2010
National Performance Indicators (Care Quality Commission: Learning Disabilities)
Metric:
All service users have a
treatment care plan in an
accessible format
Delayed transfers of care - a
clinical decision by the MDT has
been made that the service user
is ready for transfer and it is safe
to do so
All service users will have an
annual health check
Data quality on ethnic group
09-10 Results
08-09 Results
National
Comparative
Data
National
Target
Local
Improvement
Target for
2010 - 11
76%
70%
None
100%
100%
CQC LD
Performance
Indicators
5.12%
7.32%
None
<7%
Less than
7%
82%
59%
None
100%
100%
CQC LD
Performance
Indicators
100%
100%
98%
100%
100%
CQC LD
20
Performance
Indicators
(100% compliance requirement
for ethnic coding category).
Clinical Effectiveness
Metric:
All new admissions to the Trust
have received a risk of choking
screening assessment
All service users will have a
comprehensive multi
disciplinary treatment and care
plan by week 12 of the care
pathway
09-10 Results
08-09 Results
National
Comparative
Data
National
Target
Local
Improvement
Target for
10 - 11
100%
38%
None
None
100%
58%
35%
None
None
70%
Based on wk
12 of CP
(National
Standard)
Based on wk
12 of CP
(National
Standard)
73%
63%
Based on wk
14 of CP
(Trust
Standard)
Based on wk
14 of CP
(Trust
Standard)
98%
98%
None
None
100%
09-10 Results
08-09 Results
National
Comparative
Data
National
Target
Local
Improvement
Target for
10 - 11
Reduction of injuries sustained
by service users as a result of
physical intervention
1.7%
2%
None
None
Less than
2%
Reduction of injuries sustained
by staff as a result of physical
intervention
5%
4%
None
None
Less than
5%
All service users will have a
review of their current risk
profile by the MDT at least every
six months
Patient Safety
Metric:
21
All service users who self injure
(clinically assessed as high risk)
will have an advanced support
plan
100%
27%
None
None
100%
6%
3%
2%
2%
2%
09-10 Results
08-09 Results
National
Comparative
Data
National
Target
Local
Improvement
Target for
10 - 11
Score for service users who
reported that the flat they reside
on was clean
85%
87%
72.5%
None
90%
Score for service users who
reported that they were
involved as much as they
wanted to be about their care
and treatment
93%
91%
54%
None
93%
Score for service users who
reported there were enough
activities available for them to
do during the day on week days
Monday to Friday
72%
69%
44.5%
None
80%
Score for service users who
reported there were enough
activities available for them to
undertake during the evening
and / or weekends
59%
57%
30%
None
70%
Score for service users who felt
they were treated with respect
and dignity
80%
88%
73%
None
90%
Reduction in inpatient
medication prescribing errors
Patient Experience
Metric:
22
09-10 Results
08-09 Results
National
Comparative
Data
National
Target
Local
Improvement
Target for
10 - 11
Score for service users who
reported that when they were
detained, their rights were
explained to them in a way they
could understand
82%
83%
56.5%
None
90%
Score for service users reporting
‘Feeling Safe’
76%
79%
65%
None
80%
Score for service users knowing
how to make a complaint
87%
75%
48%
None
90%
Service user score for
involvement with treatment and
care plan
93%
91%
74%
None
95%
Score for service users reporting
the Trust helped them to keep
in touch with family or friends
80%
91%
64.5%
None
90%
Metric:
23
Appendix A – Clinical Audit Projects 2009 – 2010
1.
Project Title
Synopsis of Findings and Actions
Medicine Management
Review of medication administration record against the standards as outlined within the Clinical Negligence Scheme for
Trusts (CNST) for the prescribing, dispensing and administration of medicines at ward level. This was a re-audit from
the previous year.
The audit discovered issues with:
Registered nurses checking medicines and receipting same when they were delivered to the ward
Doctors undertaking regular monthly reviews of medicine
Doctors and nurses clearly marking medicines as discontinued
However, there has been significant improvement on the audit the previous year particularly with regards to
compliance form the medical staff. There is an action plan in place to address areas of non compliance and a re-audit
scheduled for 2010 – 2011
2.
Recording of medicines
within Electronic Patient
Record (EPR)
There is a local requirement that doctors maintain a record of the prescribed medicines within the EPR to enable an
accurate drug history to be maintained.
This was a re-audit from the previous year and showed a slight improvement from 63% compliance to 70% compliance.
Medical officers have been reminded again regarding the importance of an electronic record, the system has been
reviewed to improve the process and it will be re-audited again 2010 – 2011.
3.
Hand Washing
This was a mandatory requirement from the Safer Practice Notice on Hand Washing from the National Patient safety
Agency (NPSA). The audit reviewed the presence of hand washing facilities in clinical areas and ward areas.
There was 100% compliance within clinical areas but there was an issue with access to paper towel dispensers within
ward areas.
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4.
Project Title
Synopsis of Findings and Actions
Colour Coding – Infection
Control
This was addressed after the audit and 100% compliance was achieved across clinical and ward areas
The purpose of the audit was to assess compliance with the National Patient Safety Agency (NPSA) requirements in the
colour coding of Hospital cleaning materials and equipment. Colour coding of Hospital cleaning materials and
equipment ensures that these items are not used in multiple areas, therefore reducing the risk of cross infection.
Overall compliance was good with the exception of coloured aprons; however, guidance suggests that white disposable
aprons can be used across all areas.
The procedure has been amended accordingly
5.
Dysphagia
This was an audit of practice against the Trust procedure on managing the risk of choking and dysphagia. This is a
patient safety priority for people with a learning disability as they are at greater risk than the general population of
choking and/or dysphagia.
The audit focussed upon compliance with the Trust’s ‘Risk of Choking Screening Tool’.
There were issues found with:
A delay in completion within the assessment period
The competency of staff to complete the assessment
Integration into the MDT process
Annual review of the screening tool
An action plan has been formulated to address these compliance issues and is being monitored and tracked through an
MDT working group.
A re-audit is scheduled for 2010 – 2011
6.
Medical Devices:
Integration into Treatment
This is an audit that is required through Standards for Better Health (DH 2004) and audited the requirement to detail
the medical device an individual used into any treatment and care plan, risk management plan and/or support plan
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Project Title
Synopsis of Findings and Actions
Care and Support Plans
7.
Technology Appraisal (TA)
66: Bipolar Disorder
Overall there was very good compliance with the exception of one network which has since been addressed
This was an audit against the prescribing guidelines as outlined in TA66, which is required by Standards for Better
Health (DH 2004).
Overall there was good compliance, however there needs to be an improvement in the discussion and recording of side
effects with the clients. There is an action plan in place to address areas of non compliance
8.
Technology Appraisal (TA)
76: Epilepsy – Newer Drugs
This was an audit against the prescribing guidelines as outlined in TA76, which is required by Standards for Better
Health (DH 2004).
Overall there was good compliance, however there needs to be an improvement in the recording of ICD 10 diagnosis of
Epilepsy.
There is an action plan in place to address areas of non compliance
9.
Technology Appraisal The
Appropriate use of
Zolpidem, Zaleplon and
Zopiclone (NICE
Technology Appraisal
Guidance 77)
The purpose of the audit is to assess compliance with the requirements of the technology appraisal particularly in
respect of mono therapy and sleep hygiene.
There were issues about the long term use of hypnotic medication and the lack of sleep hygiene plans as a first level
intervention for people with insomnia.
There is an action plan in place to address areas of non compliance and a re-audit scheduled for 2010 – 2011
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10.
Project Title
Synopsis of Findings and Actions
Decision Making – Mental
Capacity Act
The purpose of this audit was to survey which decisions community service users have been identified as needing
support with and if the recording of the support requirements are line with the Procedure C5.1a Planning and
Supporting Process.
Overall compliance is good with regards to recording support for decision making
11.
Mental Health Act Rights
information
This was an audit how often detained clients have their legal rights read under the 1983 Mental health Act and whether
services where compliant with the Trust standard of every 3 months, which is greater that the statutory requirement of
every 12 months or upon renewal of section.
The audit demonstrated that there was considerable need for improvement both in recording of rights information
being read and with meeting Trust standards of every three months. There has been a significant effort from services
to address these deficits and implement a system that maintains Trust standards
There is an action plan in place to address areas of non compliance and a re-audit scheduled for 2010 – 2011
12.
Deprivation of Liberty –
assessment of decision
making
The purpose of the audit was to assess whether any of the Trust’s clients have been deprived of their liberty and
if this action has been taken using the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (MCA DOLS).
This was a case study audit reviewing evidence of people who were informal being subjected to restrictive practices, in
particular physical intervention and limited access to the community.
The results of the audit were based upon the professional judgement of a psychiatrist and the overall results were
favourable , however, there is an issue with access to community outings which warrants a further ‘case study’ for the
those individuals.
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13.
Project Title
Synopsis of Findings and Actions
Multidisciplinary team
decision Making regarding
discharge from Mental
Health Act section
The audit was to evaluate the multidisciplinary team (MDT) decision making process to remove people from their
Mental Health Act section.
The audit was a case study of all people who had been removed from their section within the previous year and
whether this decision making was compliant with the Trust’s Clinical Practice Standards with regards to reviewing
treatment and care.
The audit demonstrated the need for improvement in the recording of MDT decision making processes and in particular
with regards to consultation with external stakeholders.
14.
Controlled Drugs –
Compliance with Trust
procedure
The purpose of the audit was to monitor compliance of the Trust with Procedure 24.9 (On-site), Controlled Drugs dated
1st March 2008 and section 14 of Procedure 24.2 (Community), Medicines dated 1st September 2009, which are aligned
to the recommendations from The Shipman Inquiry (DH 2005)
There is limited use of controlled drugs by the Trust but there is a mandatory requirement to audit practice.
The audit concluded that there were concerns about the record keeping requirements with regards to the management
of controlled drugs, which has been immediately rectified along with plans that all nurses know how to appraise
themselves on how to management controlled drugs on the ward if they are ever prescribed
There is an action plan in place to address areas of non compliance and a re-audit scheduled for 2010 – 2011
15.
Treatment and Care
Planning – Access to
Accessible Treatment and
Care Planning (MSU)
The purpose of the audit was assess whether clients were receiving a copy of a user friendly treatment and
care plan which has been developed with the client and taken by the client to any meeting which involve
changes or review of treatment and care.
The audit was conducted with the clients residing within medium secure services.
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Project Title
Synopsis of Findings and Actions
Overall results were positive in respect of clients receiving a copy of their treatment and care plan, however,
there needs to be an improvement in record keeping for providing a verbal explanation of the content.
There is an action plan in place to address areas of non compliance and a re-audit scheduled for 2010 – 2011
16.
Care pathway for people
with a personality disorder
This was an audit of all clients residing at the Medium secure unit at Gisburn Lodge and reviewed the risk
assessment process and the identification of treatment outcomes
The results were favourable; however, there were issues with the identification of treatment outcomes.
There is an action plan in place to address areas of non compliance and a re-audit scheduled for 2010 – 2011
29