QUALITY AND ACCOUNT
FOR
2009-10
JE/RP
April 2010
CONTENTS
Page
1.0
Introduction
1
2.0
Statement from Chief Executive
4
3.0
Priorities for Improvement and Statement of Assurance from the
15
Board
3.1 Priorities for Improvement 2010/11
15
3.2 Statement of Assurance from the Board
18
Statements from :
•
NHS Bournemouth & Poole
•
Bournemouth Borough Council Overview and Scrutiny
Committee
•
Borough of Poole Health and Social Care Overview and
Scrutiny Committee
•
Dorset County Council Overview and Scrutiny Committee
Appendix
A
Statement from LINks
B
Partnership Endorsement - Dorset Community Services
C
1.0
1.1
INTRODUCTION
This is the first formal Quality Account published by Dorset HealthCare NHS
Foundation Trust.
Our Quality Account incorporates suggestions and
comments obtained from consulting with a wide range of stakeholders during
July 2009 on the initial draft Quality Account. The Trust Quality Account
covers all services provided by the Trust, i.e.
1.2
•
Children & Young People’s Services
•
Adult Mental Health Services
•
Primary Care (Psychological Therapies)
•
Older Peoples Mental Health
•
Services for People with a Learning Disability
•
Drug and Alcohol Addiction Services
•
Community Brain Injury Services
•
Community Dental Services
Lord Darzi’s review ‘High Quality Care for All’ has rightly made Quality one of
the key principles of the National Health Service. The Department of Health
has since introduced ‘Quality Accounts’ as a mechanism for public reporting
on Quality covering the areas outlined in Figure 1 below, as a means to
giving a whole picture of the quality of care a service user receives. As a
Trust we recognise that the areas outlined in figure 1, alongside patient
outcomes will give the Board an overall picture to ensure that we are giving
a quality service.
Page 1 of 36
Areas covered within the Quality Account
Clinical
Effectiveness
Figure 1
1.3
As a Trust we pride ourselves on offering high quality cost effective
treatment and care for individuals.
We welcome the introduction of the
Quality Account as a way of conveying the quality of care that we provide.
Quality is at the very heart of all we do and is a key guiding principle of the
Council of Governors and the Board of Directors. This is enshrined in our
Vision Statement:
‘To provide services with which we ourselves would happily be treated and
which we would recommend to our family and friends.’
1.4
We believe that the introduction of a Quality Account provides an ideal
opportunity to highlight how we have improved services and our plans to
continue to do so over the coming year.
The structure of this Quality
Account is in line with the guidance published and inevitably only provides a
summary of the initiatives and arrangements that go into providing the high
quality service delivered by our dedicated and motivated staff.
Page 2 of 36
1.5
We hope that the Account will be both helpful and informative for our
Services Users, Carers, Staff, Commissioners and partner organisations.
Page 3 of 36
2.0
STATEMENT FROM CHIEF EXECUTIVE
2.1
I am delighted to have the opportunity to summarise the Trusts view on the
quality of its services during 2009/10, but before doing so, I would like to
thank the staff for their hard work, dedication and commitment, without
whom we would be unable to deliver high quality services to our service
users and carers.
2.2
The Trust has consistently been recognised as a high performing Trust,
having been rated Excellent for ‘Quality of Service’ in the most recent
assessment by the Care Quality Commission (2008/09).
2.3
This is the fourth year running that the Trust has achieved an ‘Excellent’
rating for the Quality of its services, which encompasses the safety of
patients, cleanliness and waiting times.
We are delighted to have
maintained our ‘Excellent’ rating, as the overall number of mental health
trusts achieving this has more than halved, from 64% to 30%, compared to
twelve months ago.
2.4
Nonetheless, we also recognise that this is only one measure of the quality
of services we provide and throughout the year we have looked at a range
of indicators to provide assurance as to the quality of our services, including
service user and carer feedback.
2.5
This has been achieved by regular reports to the Board including:
•
Monthly Quality Report
•
Quarterly Infection Control Report
•
Annual Clinical Effectiveness and Clinical Audit Report
•
Monthly Chief Executive Report
•
Six-monthly Patient Safety Report
•
Annual Compliments and Complaints Report including lessons learnt
Page 4 of 36
•
Annual Safeguarding Children Report
And
•
Quarterly Mental Health Act Hospital Managers Information Report
•
Six-monthly National Patient Safety Agency (NPSA) National
Reporting & Learning Service Cluster Report
•
External reviews and accreditations
•
Listening to Service user and carer feedback whether through
compliments, comments, surveys or complaints
•
Announced and unannounced visits to ward and units by the Non
Executive Directors
•
Establishing a Quality & Clinical Governance sub committee of the
Board.
•
Establishing a Human Resources and Staff Development sub
committee of the Board.
2.6
As a Trust we recognise the importance of individuals being able to get help
at the time that they need it and being able to access services in a timely
manner.
I am pleased to report that in 2009/10 that the Trust met or
exceeded all its waiting time targets including those for outpatient
appointments, access to psychological therapies, inpatient detoxification
and stabilisation, specialist prescribing, structured day care and alcohol
assessment. We also met all the targets set by Monitor, which are detailed
later in this report.
2.7
One of the most important indicators of the quality of our services is direct
service user and carer feedback.
In the latest national mental health
survey, covering people who had recently used the Trust’s acute mental
health inpatient services, the Trust scored well in terms of its staff,
Page 5 of 36
admissions, activities and attention to physical health as follows.
•
87% reported that their physical health was taken into consideration,
as well as their mental wellbeing
•
83% of service users reported that staff made them feel welcome on
the ward
•
Two thirds of respondents felt their psychiatrists and nurses listened
to them and treated them with dignity and respect
•
A higher than average score was achieved for activities provided on
the ward during weekdays, evenings and weekends
•
A higher than average score was achieved for care in the process of
leaving hospital, including crisis support and out of hours services
As with all feedback from service users we have also used the results to
identify areas for improvement and developed an action plan to achieve this.
2.8
We are always keen to benchmark our services against national standards
and recognise good practice to ensure that we continue to provide the best
services that we can, details of which are covered in this report. I am also
please to report that the Trust was accredited with Trust wide ‘Practice
Development Unit’ (PDU) status by Bournemouth University in 2009. Dorset
HealthCare NHS Foundation Trust is the first and only Trust working with
Bournemouth University to have achieved this. The process of accreditation
assists clinical teams to deliver effective, high quality care for service users.
2.9
We were pleased to participate in the review of dementia services across
the South West in 2009/10. The review aimed to assess the strengths and
areas for development in dementia services against the recommendations
of the National Dementia Strategy. The review also sought to find areas of
good practice in Dementia services that could be shared across the South
Page 6 of 36
West Region and we were pleased that the was Trust were cited in the
Dorset and Bournemouth & Poole reviews which related to age equality,
privacy and dignity, falls reduction work and the high quality of information
that we provide to service users and carers.
2.10 During 2009/10 the Trust was also selected as only one of ten sites
nationally to be part of the Kings Fund’s Enhancing the Healing
Environment programme for that year.
This programme is specifically
looking at enhancing the environment in one of our inpatient wards for
service users with Dementia by the use of colour, light and texture as a way
of promoting independence and dignity for our service users.
2.11 As a Trust we are proud to be leading the ‘Time to Change’ programme
locally, which has bought together a team of people across the statutory
agencies, service user and carer forums, the third sector and voluntary
organisations. Time to Change is a groundbreaking and exciting national
awareness campaign which aims to end discrimination faced by people who
experience mental health problems.
2.12 We are delighted that a number of our staff and services were also
recognised for the quality of their services The Trust’s ‘Assertive Outreach
Team’, with colleagues from the local acute hospital, were presented with a
Highly Commended Mental Health Nursing Award at the Nursing Times
Awards in London for their work to help service users with Hepatitis C. The
Learning Disability Intensive Support and Crisis Resolution Service in West
Dorset was shortlisted and came amongst the last six from approximately
ninety applications for the Health Service Journal Mental Health Innovation
Award.
A Trust Occupational Therapist for Learning Disabilities was one of six
Page 7 of 36
winners at the South West Regional final of the Allied Health Professionals
Leadership Challenge. The Trust’s Crisis and Home Treatment team won
the ‘Patient Safety’ award at NHS Dorset’s Health and Social Care Awards.
The team was recognised for its work on its ‘Zoning Policy’ which focuses
on the level of intervention required to safely care for service users in the
community.
2.13 We have also participated in the Productive Ward initiative. This is an NHS
Institute project to enable ward staff to increase the time spent on direct
patient care. Reviews of ward practices took place to identify where
improvements could be made to enable staff time to be freed to spend with
service users. The project included service user involvement to identify
additional activities which they would like to see made available with extra
staff time.
2.14 As a Trust we place patient safety high on our agenda and recognise the
importance of reporting and reviewing all incidents to improve services
locally. The Trust reports patient safety incidents anonymously to the
National Patient Safety Agency (NPSA) on a regular basis. The NPSA
produces detailed reports twice a year which compare Dorset HealthCare’s
incidents with other similar trusts’ data. The latest report for the period April
to September 2009 shows that
•
the Trust remains a high reporting trust (in general the higher the
rate of reported incidents, the stronger the reporting culture is
felt to be within that organisation).
•
the Trust consistently reports incidents on a monthly basis to the
NPSA in line with their Data Quality Standards
•
the overall degree of harm (risk grade) to service users as a
Page 8 of 36
result of incidents is in line with other similar trusts.
•
the Trust has increased reporting of medication incidents.
The Trust had previously identified that it was under-reporting medication
incidents and this is a positive outcome following the action taken to
improve reporting
2.15 Like all NHS Trusts we also have a focus on infection control and prevention
and during 2009/10 our infection control programme was developed to
ensure best practice and to ensure that the Trust achieves compliance with
the Health Act (2006) Code of Practice for the Prevention and Control of
Health Care Associated Infections (revised 2008) and other national
standards. I can confirm that the overall objectives within the annual
programme have been achieved and that there have been no cases of
MRSA Bacteraemia or Clostridium Difficile within the Trust. We are also
compliant with current national standards for decontamination of reusable
surgical instruments used in the Community Dental Service.
2.16 During 2009/10 the Trust received in excess of 500 written compliments.
However, whilst the Trust always endeavours to provide high quality
services, inevitable given the 186,589 treatments that we carried out last
year, there are sadly some occasions when we do not meet the standards
that we would have liked. During 2009/10, the Trust received 53 written
complaints, which represents 0.028% of treatments given. All except ten
complaints were responded to within the agreed timescales. Delays on the
ten responses were due to the complexity of the response or due to staff
absences. All of our complaints have been thoroughly investigated and
carefully considered to identify areas in which we can improve the services
which we provide.
Page 9 of 36
2.17 During August 2009, the Trust was made aware that NHS Bournemouth &
Poole (PCT) had received anonymous concerns about the local health
community in respect of Older People’s Services from an independent
organisation. Whilst the concerns were not specific to a service or Trust, we
worked closely with the PCT to see if there were any learning points and to
provide assurance about the quality and safeguarding arrangements within
the Trust. Having worked closely with the PCT and the Alzheimer’s Society
on this, we are pleased to report that both the PCT and the Alzheimer’s
Society, following visits, have given positive feedback.
2.18 The Trust places an emphasis on the safeguarding of vulnerable adults and
children.
We have worked closely with NHS Bournemouth & Poole to
improve the timeliness and openness in which we report appropriate
incidents to the PCT to provide assurance that immediate and appropriate
action has been taken and to share any lessons learned which may inform
others to improve services both locally and nationally.
Sadly, during
2009/10, there was some negative publicity concerning two support workers
who had been dismissed from Kings Park Hospital following inappropriate
behaviour towards a service user.
The Trust is confident that it took
immediate and swift action in this case. We reported the incident to the
Police and supported them towards a prosecution of the two individuals
concerned. We take very seriously our duty to protect our service users and
set clear expectations about the standards which we expect from our staff.
Following the incident the PCT and Trust have again worked together to
reaffirm that appropriate safeguards are in place. The Trust remains
committed to continually keeping safeguarding and the dignity and
independence of patients under review in an aim to continually improve
Page 10 of 36
services.
2.19 The Trust has also welcomed the PCT’s audit on Safeguarding within our
Learning Disability Homes as a tool for highlighting good practice that can
be rolled out across units. The audit has also provided assurance in that it
reported no significant concerns and where appropriate action plans have
been put in place to further improve services.
2.20 During
2009/10
the
Trust
reviewed
its
position
against
the
recommendations made by Health Care Commissions in its report following
investigations into Mid Staffordshire NHS Foundation Trust (published in
March 2009) to ensure that the Trust’s own governance procedures and
arrangements for monitoring the quality of care were robust. The Trust will
also be reviewing and producing an action plan in response to the
recommendations of the Francis Inquiry Report into Mid Staffordshire NHS
Foundation Trust (published in February 2010) that was subsequently
commissioned by the Department of Health.
2.21 From April 2010, the Trust has established a Lead Director for Quality, who
will be proactive in developing the quality agenda, outcomes, patient safety
and capturing service users’ and carers’ experiences across all services and
at all levels within the Trust. This post will also take a lead in improving
clinical coding across the Trust as this has been identified as an area for
improvement and will work closely with the PCT to further enhance the
Trust’s Quality and Clinical Governance arrangements and collaborative
working with the PCT.
2.22 During 2009/10 the Trust Board reaffirmed that its top priority was to have
Service Users and Carers involved at all levels within the Trust and across
services. The Nurse Executive is the designated lead Director to take this
Page 11 of 36
forward and will also give priority to further enhancing service user and
carer involvement during 2010/11.
We see this as key to ensuring high
quality services and continuous improvement.
2.23 To deliver high quality services we also recognise and value the skills and
dedication of our staff, many of whom have been invited to speak at
conferences or have published articles nationally. This has included for
example, International Eating Disorders Conference on Recovery from
Eating
Disorders,
International
Network
for
Psychiatric
Research
Conference on Voice Hearing Research, International Hepatitis C
Conference on Serious Mental Health Problems and Hepatitis C and
National Forum for Assertive Outreach. We continued to support staff in
maintaining
their
expertise
and
skills
through
the
delivery
of
a
comprehensive training programme of both mandatory and additional
training and recognise the importance of time to reflect on their skills and
development through annual appraisals. In 2009/10 92% of eligible staff
received an annual appraisal.
2.24 Although the focus of our quality account is inevitably on the services that
provide direct patient care it should also be recognised that Quality of
Service also involves “non-clinical services” such as finance, estates,
catering and cleaning etc which are vital in ensuring the total service user
and carer experience is satisfactory.
2.25 The Trust has been rated as ‘Excellent’ in terms of financial management in
the recent Care Quality Commission ratings (2008/9). Coupled with our
‘Excellent ‘ rating for quality of service this places us in the top 10% of all
392 NHS Trusts in England with a ‘Double Excellent’ rating and in the top
four Trusts (out of 40) in the South West Region. And the only Trust to have
Page 12 of 36
maintained its double excellent status from last year.
2.26 We have submitted our annual NHS Information Governance Toolkit for
2009/10 and have retained our ‘Green’ status, with a score of 90%
compliance
2.27 Every year the Trust also participates in the Patient Environment Action
Team assessments which look at the quality of the environment, privacy
and dignity, cleanliness and catering. All the Trust services have previously
achieved a good or excellent rating and we expect this to be maintained in
the 2009/10 scores which are due to be published in late June 2010.
2.28 During 2009/10, we continued to make improvements in the provision of
same sex accommodation and having completed the Department of Health
self declaration can confirm that we are virtually compliant with the national
‘Delivering Same Sex Accommodation Standards’. At the end of March
2010, we placed a declaration concerning Same Sex Accommodation on
our website.
We are committed to an ambitious estates modernisation
programme that will also help to enhance facilities for our service users
including the provision of single en suite rooms for those individuals who
have an inpatient stay.
2.29 I believe that the services which the Trust has provided during 2009/10 have
continued to be of a high standard and we remain committed to continual
improvement. The Board has received assurance of this through a variety of
means including internal monitoring, external ratings, accreditations,
inspections, reviews and above all service user and carer feedback.
2.30 The Council of Governors, Board of Directors, our senior managers, clinical
leaders and I are committed to delivering an ambitious programme of
continuous quality improvement during 2010/11.
Page 13 of 36
2.31 I recommend this Quality Report and Account to you, which to the best of
my knowledge is a complete and accurate record as seen by the Trust.
Date:07th June 2010
Signed :
Roger Browning
Chief Executive
Page 14 of 36
3.
PRIORITIES FOR IMPROVEMENT AND STATEMENTS OF
ASSURANCE FROM THE BOARD
3.1
Priorities for Quality Improvement – 2010/11
3.1.1 The Trust has given careful consideration to its priorities for 2010/11, to
ensure that this has a real and genuine impact on improving services and
the service users’/carers’ experience. Key priorities identified for 2010/11
are:
3.1.2 Patient reported outcome measures
To develop and implement patient reported outcome measures which are
meaningful for service users and carers and which support the Trust’s
‘Recovery Approach’ and service user choice and engagement.
In 2009,
the Trust piloted the use of clinical outcome measures in two of its
Community Mental Health Teams. This included the use of Health of the
Nation Outcome Scales, Patient Identified Problems and Euroqol (a quality
of life outcome scale).
In September 2009 a Trust wide event was held
involving Senior Clinicians, together with Governors and managers to
discuss progress and the outcome of the pilot, including service user
feedback on the outcomes measures gained via the pilot. Views were also
gained as to what outcome measure would be appropriate to roll out
across the Trust during 2010/11.
In line with the Trusts ‘Recovery Approach’ there was consensus on the
rollout of the Recovery Star, Patient Reported Goals and continued use of
HoNoS. The roll out and implementation of these outcome measures will
be monitored on a number of levels:
1) At an individual service user and care coordinator level, as part of
Page 15 of 36
routine reviews of care;
2) At individual team level with the development of a team level
‘Quality Account’;
3) At the Trust Management Group on a quarterly basis via the
Quality Report;
4) At Board level via the Quality Report.
3.1.3 Service user and carer involvement and experience.
The Trust is committed to engaging with its service users and carers both
to inform the delivery of patient / carer focussed services and to improve
the service user / carer experience by putting their needs at the heart of
our quality programme.
Following a group set up to include Governors, Service Users, Carers and
representatives from Bournemouth University, a Service User and Carer
Involvement workshop was held in December 2009. The workshop which
was extremely well attended by service users and carers, representatives
from Dorset Mental Health Forum, South West Eating Disorders Service,
East Dorset Mental Health Carers Forum, Poole Mental Health Forum and
Rethink. Some of the key issues arising were:
•
The development of a database of individuals detailing the areas
they would be interested in participating in within the Trust;
•
Involvement with Trust new staff Induction;
•
Assisting in the training of staff and interviews;
•
Developing Peer support roles, such as contributing to care in
inpatient settings, creating an awareness of what is going on
already; so scoping what we are doing and using that to plan the
next steps.
Page 16 of 36
Building on the feedback from this workshop a smaller group of service
users, carers, Governors and the Trust Nurse Executive was established
and will take a lead role in 2010/11 on producing and implementing a
detailed action plan with key measurable milestones. Progress will be
monitored quarterly by the Trust Management Group and details included
in the Trust quality report to the Board.
To ensure that Service user and carer experience is also at the heart of
our services we will also be systematically rolling out a programme of
service user and carer surveys across all service areas within the Trust.
Surveys will be reviewed over the year to ensure that core elements of the
surveys in each service are specifically aimed at capturing the service
user/ carer experience. These will inform individual service action plans
and the overarching Trust wide plan.
The results on individual service surveys and action plans will be reported
and monitored by the Service Directorate Management Group and also
reported on a rolling basis to the Trust Board.
3.1.4 Recovery Model
The evidence for Recovery is overwhelmingly clear and the Trust together
with service users and carers is committed to ensure it is developed in all
areas of our service.
Recovery can be defined as ‘A deeply personal, unique process of changing one's attitudes, values,
feelings, goals, skills and roles. It is a way of living a satisfying, hopeful
life, even with the limitations caused by illness.
Recovery involves
developing new meaning and purpose in one’s life as one grows beyond
the catastrophic mental illness’… (Anthony 1993, from the Sainsbury
Page 17 of 36
Centre 2008: Making Recovery a Reality).
Following the Trust’s new partnership with Dorset Mental Health Forum,
the Trust is in the process of establishing a Wellbeing and Recovery
Partnership Board. This Board will steer the development of Wellbeing and
Recovery as it is used to transform the way in which services are provided
across the Trust.
The intention of the Wellbeing and Recovery Partnership Board will be to
identify particular areas in which to prioritise work and ensure that baseline
views of service users and carers are captured and that their views are reaudited, following the completion of the transformation work.
This will
ensure the Wellbeing and Recovery Partnership Board is able to measure
both its impact and effectiveness.
The Trust is also working with the local councils, PCTs, and service users
to set up a more robust service user led organisation locally by
establishing a new Bournemouth and Poole Mental Health Network.
3.2
Statements of Assurance from the Board
3.2.1 Information on the Review of Services
In line with the Monitor guidance for quality accounts for Foundation Trusts
we can confirm that during 2009/10 Dorset HealthCare NHS Foundation
Trust provided eight NHS services as follows:
•
Children & Young People’s Services
•
Adult Mental Health Services
•
Primary Care Services ( psychological therapies)
•
Older Peoples Mental Health
•
Services for People with a Learning Disability
Page 18 of 36
•
Drug and Alcohol Addiction Services
•
Community Brain Injury Services
•
Community Dental Services
The Board has reviewed a wide range of data on the Quality of care in
these services. This has included the following information:
1. Information Relating to Quality
Monthly Quality Report to the Board
Monthly Chief Executive Report to the Board
Quarterly Mental Health Act Hospital Managers Information Report
Annual Compliments and Complaints Report including lessons learnt
Announced and unannounced visits to ward and units by the Non
Executive Directors
National Service User Survey Results
Staff Survey Results
Evidence Portfolios gathered in relation to Standards for Better Health
2. Information relating to Patient Safety
Monthly Quality Report to the Board
Quarterly Infection Control Report to the Board
Six-monthly Patient Safety Report to the Board
Annual Safeguarding Children Report
Six-monthly National Patient Safety Agency (NPSA) National Reporting
& Learning Service Cluster Report
Evidence Portfolios gathered in relation to Standards for Better Health
3. Information relating to clinical effectiveness
Monthly Quality Report to the Board
Page 19 of 36
Annual Clinical Effectiveness and Clinical Audit Report to the Board
External accreditations
Evidence Portfolios gathered in relation to Standards for Better Health
The income generated by the NHS services reviewed in 2009/10
represents 92.7 per cent of the total income generated from the provision
of NHS services by Dorset HealthCare NHS Foundation Trust for 2009/10.
3.2.2 Information on participation in Clinical Audits and National Confidential
Enquiries
During 2009/10 there have been two national clinical audits and one
national
confidential
enquiry
covering
NHS
services
that
Dorset
HealthCare NHS Foundation Trust provides.
During 2009/10 Dorset HealthCare NHS Foundation Trust participated in
0% and 100% of the national clinical audits and national confidential
enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquires that Dorset
HealthCare NHS Foundation Trust was eligible to participate in during
2009/10 are as follows:
•
NAPTAD anxiety and depression ( piloted in 2009/10)
•
POMH prescribing topics in mental health services
•
National Confidential Inquiry into Suicide and Homicide by people
with mental illness.
3.2.3 The national clinical audits and national confidential enquiries that Dorset
HealthCare NHS Foundation Trust participated in during 2009/10 are as
follows:
•
National Confidential Inquiry into Suicide and Homicide by people
with mental illness.
Page 20 of 36
The national clinical audits and national confidential enquiries that Dorset
HealthCare NHS Foundation Trust participated in and for which data
collection was completed during 2009/10, are listed below alongside the
number of cases submitted to each audit or enquiry as a percentage of the
number of registered cases required by the terms of that audit or enquiry.
•
National Confidential Inquiry into Suicide and Homicide by people with
mental illness. The number of cases within this inquiry was 7 (100%).
Non of the reports of two national clinical audits were reviewed by Dorset
HealthCare NHS Foundation Trust in 2009/10 due to the fact that the
outcome of the NAPTAD anxiety and depression pilot have not yet been
published and the results of any of the POMH prescribing topics in mental
health services are not publically available and are only available to
members of POMH.
Dorset HealthCare NHS Foundation Trust will be considering membership
to POMH to improve the quality of healthcare provided.
The reports of 21 local clinical audits were reviewed by the provider in
2009/10 and Dorset HealthCare NHS Foundation Trust. The Trust has
identified 54 action points which will be monitored to ensure
implementation. The action points from the local audits carried out within
the Trust during 2009/10 can broadly be categorised under the following
headings:
•
Dissemination of audit results
•
Staff education/training
•
Improving provision of information to service users
•
Improving ongoing checking processes to ensure good practice is
maintained, e.g. discussion at ward rounds
Page 21 of 36
•
Improving recording in clinical records through checklists or
redesign of forms
•
Review service user access to services
•
Ensuring comprehensive clinical assessments take place in a timely
way
3.2.4 Information on Participation in Clinical Research
The number of patients receiving NHS services provided by Dorset
HealthCare NHS Foundation Trust that were recruited during that period to
participate in research approved by a research ethics committee was 85.
3.2.5 Information on the use of the Commissioning for Quality and Innovation
Framework (CQUIN)
A proportion of Dorset HealthCare NHS Foundation Trust’s income in
2009/10 was conditional upon achieving Quality improvement and
innovation goals agreed between Dorset HealthCare NHS Foundation
Trust and any person or body they entered into a contract, agreement or
arrangement with for the provision of NHS services, through the
Commissioning for Quality and Innovation payment framework. Further
details of the agreed goals for 2009/10 and for the following twelve month
period are available on request from the Director of Quality for Dorset
HealthCare NHS Foundation Trust.
3.2.6 Information Relating to Registration with the Care Quality Commission
(CQC) and periodic/special reviews.
Dorset HealthCare NHS Foundation Trust is required to register with the
Care Quality Commission and its current registration status is ‘Registered
without Conditions’.
The Care Quality Commission has not taken enforcement action against
Page 22 of 36
Dorset HealthCare NHS Foundation Trust during 2009/10.
Dorset HealthCare NHS Foundation Trust has is subject to periodic review
by the Care Quality Commission and the last review was in October 2009.
The CQC’s assessment of Dorset HealthCare NHS Foundation Trust
following the review was :
‘The Trust’s administration of the Mental Health Act continues, in most
instances, to be of a high standard – particularly at St Ann’s Hospital’.
‘The relationship between Mental Health Act Commissioners and senior
managers of the Trust has remained constructive throughout the reporting
period. The Mental Health Act office has been actively involved in each
visit and has sought to rectify any problem areas, where possible during
the course of the visit, and, otherwise, within a very short period of time.’
‘The Trust hosts regular multi-agency meetings and the Mental Health Act
Commissioner was able to join one of these meetings during the reporting
period. This was an invaluable opportunity to discuss issues arising from
visits and it is intended that this will be repeated on occasions in the
future.’
Recommendations for Action
1.
Section 2 and Section 3. Work should continue with doctors
and AMHPs (via the multi-agency meetings) to improve the
quality of completion of the statutory forms, especially
concerning the grounds for detention.
2.
Section 17A. The impact of CTOs should be monitored and the
Mental Health Act Commissioner will work with the Trust to find
ways to improve access to the Mental Health Act Commissioner
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and to SOADs.
3.
Section 58. The Trust should continue with its work in seeking
improvement in clinical practice in accordance with the Mental
Health Act and the Code of Practice and in line with the
evidence base on decision making and consent.
4.
Section 130A. The Trust should ensure that information for
detained patients regarding their statutory right to advocacy
services (IMHA) is ‘user friendly’ and visible on all ward notice
boards where patients are detained, and that patients are
routinely reminded of this right and of how they may access
these services.
5.
Section 133. The Trust should seek to improve compliance with
this section and to find ways of recording such compliance.
6.
The Trust should continue to work towards improving privacy
and dignity for patients, giving particular priority to facilities in the
Trust’s remaining mixed sex wards.
Dorset HealthCare NHS Foundation Trust intends to take the following
actions to address the points made by the CQC’s assessment and made
the following progress by the 31st march 2010 in taking such action :
Response to issues identified in Care Quality Commission Annual
Statement for Dorset HealthCare NHS Trust November 2008 –
October 2009
RECOMMENDATION
SECTION
RESPONSE
LEAD
OFFICER(S)/
TARGET
COMPLETED
DATE FOR
COMPLETION
1
The
Trust
should
continue with
doctors
and
AMHPS via the
multi-agency
meetings)
to
Sections
2&3
The second audit
of section papers
to be circulated to
all section 12
approved doctors
within the Trust
CDW / 15 Feb
2010
Completed
Page 24 of 36
improve
the
quality
of
completion of
the
statutory
forms,
especially
concerning the
grounds
for
detention
2
.
3
.
The impact of
CTOs should
be monitored
and the Mental
Health
Act
Commissioner
will work with
the Trust to find
ways
to
improve access
to the Mental
Health
Act
Commissioner
and SOADs
The
Trust
should
continue with
its
work
seeking
improvement in
clinical practice
in accordance
with the Mental
Health Act and
the Code of
Practice and in
line with the
evidence base
on
decision
making
and
consent.
Section
17A
Section
58
Completed
The audit to
circulated to
section
approved GPs
information
be
all
12
for
KC / 15 Feb
2010
The audit to
taken
to
Mental Health
Multi-Agency
Group for
AMHP leads
note.
be
the
Act
CDW / 17 Mar
2010
Completed
the
to
Further audit of
this area to be
undertaken
in
August 2010
Mental
Health
Legislation
Manager to link in
with Rob Brown,
Mental Health Act
Commissioner to
review the impact
of CTOs and
discuss ways to
improve access
to the Mental
Health
Act
Commissioner
and SOADs
Qualified nursing
staff and other
professionals to
be
reminded
through
team
meetings and by
email about their
responsibility to
document
their
consultation with
the SOAD as a
statutory
consultee.
A
form was been
designed
and
rolled out to staff
a year ago to
address
this
issue.
Compliance
is
strictly monitored
by
the
MHA
Office.
August 2010
KC/RB / 17
Mar 2010
Ongoing
communica
tions taking
place
between
the Trust
and CQC
KC /15 Feb
2010
Completed
Completed
KC /15 Feb
2010
Qualified nursing
staff
to
be
reminded through
team
meetings
Page 25 of 36
and by email
about
their
responsibility for
checking that a
statutory
document
is
attached to the
prescription chart
and
that
the
treatment
authorised
on
that
form
matches
the
prescribed
medication.
This issue will be
picked up by the
ongoing consent
to
treatment
training which is
being rolled out to
all
units/homes/hosp
itals.
4
.
The
Trust
should ensure
that information
for
detained
patients
regarding their
statutory right
to
advocacy
services
(IMHA) is ‘user
friendly’
and
visible on all
ward
notice
boards where
patients
are
Section
130A
This
will
be
reviewed through
the Trust Consent
to
Treatment
auditing and will
be monitored via
the MAC, NAC
and
MHA
Hospital
Managers
Committee
Meeting
and
respective Trust
Management
Groups to ensure
compliance and
performance
in
order
to
strengthen
processes
and
documentation.
Mental
Health
Legislation
Manager to link in
with the current
Independent
Mental
Health
Advocates
to
review
information
leaflets
for
patients to ensure
they are user
friendly.
KC / Ongoing
KC/ Ongoing
KC/KM/JP-H /
28 Feb 2010
First draft
with the
IMHAs for
agreement.
KC /15 Feb
2010
Completed
Qualified nursing
Page 26 of 36
detained, and
that
patients
are
routinely
reminded
of
this right and of
how they may
access these
services.
5
.
6
.
The
Trust
should seek to
improve
compliance
with
this
section and to
find ways of
recording such
compliance.
The
Trust
should
continue
to
work towards
improving
privacy
and
dignity
for
patients, giving
particular
priority
to
facilities in the
Trust’s
remaining
mixed
sex
wards.
staff,
to
be
reminded through
team
meetings
and through an
email of their
responsibility to
ensure patients
are made aware
of
the
IMHA
service
when
giving rights.
Section
133
Ward Managers
will also be asked
to ensure that
IMHA posters are
on display in
prominent areas
of the ward, and
leaflets
are
readily
accessible.
Mental
Health
Legislation
Manager to link in
with South West
MHA
Administrators to
establish
other
Trust’s
policies
for
addressing
section 133.
Where areas of
good practice are
identified
consideration will
be
given
to
adopting practice
to
assist
in
improving
compliance with
section 133.
The
Trust
complies
with
Department
of
Health guidelines
on mixed sex
wards so use of
the term “mixed
sex”
in
this
context is slightly
misleading. We
do have some
sole same sex
wards but we
also have some
wards
where
there are male
and females but
with
separate
facilities
in
KC / 15 Feb
2010
Completed
KC /28 Feb
2010
Completed
KC / LW / 1
May 2010
KC /2 Feb
Hospital
Page 27 of 36
2010
accordance with
the
national
guidance.
Mental Health Act
Hospital
Managers will be
asked to review
this area as part
of their weekly
ward visits to
newly
detained
patients
and
unannounced
visits
and
feedback
any
concerns.
JB /
RBr /Ongoing
Managers
advised
01.02.10 –
Issue
ongoing
The Trust will
continue
with
redevelopment
plans to deliver fit
for
purpose,
modern
mental
health services.
Dorset HealthCare NHS Foundation Trust has not participated in any
special reviews or investigations by the CQC during the reporting period.
3.2.7 Information on Quality of Data
Dorset HealthCare NHS Foundation Trust submitted records during
2009/10 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 98.32%for
admitted patient care;
99.60% for outpatient care. Accident and
emergency care not applicable to this Trust.
-
which included the patient’s valid General Practitioner Registration
Code was 100% for admitted patient care; 99.89% for outpatient
care. Accident and emergency care not applicable to this Trust.
Dorset HealthCare NHS Foundation Trust score for 2009/2010 for the
Information Quality and Records Management assessed using the
Page 28 of 36
Information Governance Toolkit was 90%.
Dorset HealthCare NHS Foundation Trust was not subject to the
Payment by Results clinical coding audit during the reporting period by
the Audit Commission.
Page 29 of 36
APPENDIX A
STATEMENTS
NHS Bournemouth & Poole
‘NHS Bournemouth and Poole have been working closely with the trust
to gain greater assurance on the internal governance arrangements in
place to improve quality and provide a safe, clinically effective service
with increasing levels of patient satisfaction. The trust has responded to
the PCT’s requests and provided detailed information on all aspects of
clinical governance and quality monitoring and reporting. The PCT is
pleased to see that a Director of Quality has been appointed to lead on
quality and look forward to working closely with the trust in the coming
year.’
Bournemouth Borough Council Overview and Scrutiny Committee
The Committee have commented that:
‘We find that overall the QAs are representative and comprehensively
cover provision.
We are particularly pleased reference 2.10 that during 2009/10 the Trust
was selected as only one of ten sites nationally, to be part of the Kings
Fund’s Enhancing the Healing Environment programme for the year.
As this programme is specifically looking at enhancing the environment
in one of our inpatient wards for service users with Dementia by the use
of colour, light and texture as a way of promoting independence and
dignity for service users. I believe this same type of work is used to great
effect for service users with Disabilities.
Further interested in 2.12 the Team was recognised for its work on its
`Zoning Policy’ which focuses on the level of intervention required to
safely care for service users in the community, a paragraphed on what
the Zoning Policy was and a little detail on what it has achieved would
have been good.
The information contained is well presented, however we have regularly
pointed out that the use of plain English is vital as this assists fair
scrutiny. We are therefore pleased, to see a reduction in the use of
jargon in the document. We understand that medical terminology is
necessary, it would be helpful if less familiar terms, for example,’ clinical
coding’ are defined.
We have also discussed with the trust the need for numbers of patients
involved to be shown clearly when data is presented as it is on page 15.
We further understand that the monitoring of Performance Indicators
does need to use %s, however we believe it is also important to show
Page 30 of 36
the actual number of patients.
This is all part of local relevance on our visits to hospitals, we have
observed when talking to patients and nurses that dignified care and
person-centred care is at the heart of the Trusts work.
The Trust is very aware that a local top priority is sole same sex wards,
which the Health O/S Panel fully supports’ the section, page 26-29
shows responses to issues identified in CQC’s Annual Statement dates
for completion are shown. Item 6, page29, shows that the Trust’s priority
is to improving facilities on mixed sex wards. We would like to have seen
further information here including a date for implementation.
Finally on the section regarding consultation with other OSC’s in the
Department of Health’s guidance document, we already work closely
with other committees on matters where there is substantial activity. One
example is the Bournemouth, Dorset and Poole Joint Health Scrutiny
Panel on Campus Reprovision.
The scrutiny involved on people moving from hospital living has been
significant and lengthy discussions have, and are taking place.’
Borough of Poole Health and Social Care Overview and Scrutiny
Committee
No comments received
Dorset County Council Overview and Scrutiny Committee
‘At its meeting yesterday 20 May) the Dorset Health Scrutiny Committee
resolved that it would not be commenting on the Quality Accounts
submitted by Trusts this year.
The Committee has decided that over the coming year individual
members who act in a liaison capacity with individual Trusts will
endeavour to strengthen this role and develop their engagement so that
next year the Committee is better placed to comment. It is envisaged
that we will set up a task and finish group to look at the accounts next
year so that we can start the process earlier and not be tied into the
Committee timetable which may make the process easier and less
pressured for everyone.’
Page 31 of 36
APPENDIX B
LINks Comment for Dorset Healthcare FT Quality Account
2010
Bournemouth, Poole & Dorset LINks welcome this opportunity to comment on
their work with Dorset Healthcare Foundation Trust over the last year.
Public LINks Event
A joint Bournemouth & Poole LINks event took place in December 2009 which
over 50 local people attended. An afternoon workshop focused on mental
health issues. Here’s some of the feedback gathered at that event:
‘Talk about mental health more, it would help people feel less
alone if they knew how common it is’
‘Carers are a high risk category, they need preventative mental
health services’
The feedback gathered at this event prompted the LINks to make a
formal recommendation to NHS Bournemouth & Poole:
Publicise the Time to Change campaign to reduce the stigma of mental
illness.
Here’s NHS Bournemouth & Poole’s response to our recommendation:
NHS Bournemouth and Poole is currently consulting on its mental health
commissioning strategy. Once this consultation has closed and
recommendations agreed by the Trust Board, a full communication plan
will be produced which will, amongst other things, ensure that people are
aware of how to access services.
The full report of the day is available on our website:
http://www.makesachange.org.uk/cms/site/docs/LINks%20Event%2010
%2012%2009%20Report%20PDF%20Version.pdf
Joint Working
We have worked together on promotional events throughout the year,
including the LINk stand at Poole Park Festival in August 2009. LINk
representatives were invited to attend the interview panel for
Bournemouth & Poole Mental Health Network Tender in January 2010.
Page 32 of 36
LINk Development Officers and Trust representatives have regular
meetings to share information and the Trusts newsletter has run LINk
articles.
Poole LINk is currently working on an NHS Dentistry project and this
may involve some joint work with the Trust next year.
Dorset LINk has been working on a Dementia Review and the results
from this project will be shared with the Trust.
The LINks also look forward to monitoring enhanced service user and
carer involvement, mentioned as a priority in the Trusts Report under
reference: 2.19.
Page 33 of 36
Appendix C
Partnership Endorsement
Dorset Community Services, Dorset PCT have reviewed the Quality
account and have provided the following Statement of Endorsement
‘We have a history of working collaboratively with Dorset Healthcare
Foundation Trust (DHFT). We respect their ongoing commitment to
working in partnership for the benefit of the people we serve. That work
is underpinned by robust governance and a willingness to share best
practice. Dorset Healthcare Foundation Trusts quality agenda and
improvement plans are both challenging and user focussed.
Dorset Community Health Services and its Committee support and
endorse DHFT in their endeavours, and look forward to an ongoing
positive partnership.’
Tim Archer
Jan Owens
Chief Operating Officer
Chair
Dorset Community Health Services Dorset Community Health Services
Page 34 of 36