Greater Manchester West
Quality Account
2009-2010
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
All images taken from various events and
activities which Greater Manchester West
has taken part in during 2009 and 2010
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
Presented to Parliament pursuant to
Schedule 7, paragraph 25(4)(a) of the
National Health Service Act 2006.
Greater Manchester West Mental Health
NHS Foundation Trust
Quality Account for the financial year
April 2009 to March 2010
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
Important notes:
This Quality Account meets Monitor’s annual reporting
requirements for a Quality Report for 2009/10. This Account
incorporates the requirements of the NHS (Quality Accounts)
Regulations 2010 and Monitor’s additional annual reporting
requirements. This Quality Account will be submitted to
Monitor as part of GMW’s Annual Report and published
separately to meet Department of Health requirements.
This document is the full and comprehensive version of the
Trust’s Quality Account for 2009/10. A more user-friendly
summary of this Account will be published in July 2010 for
distribution to the Trust’s key stakeholders.
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
Table of Contents
PART 1:
Statement on Quality from the Chief Executive
p.06
PART 2: Priorities for Improvement and Statements of Assurance
from the Trust Board Relating to the Quality of Services Provided:
2.1 Priorities for Improvement
p.08
2.2 Review of Services
p.29
2.3 Participation in Clinical Audits and National Confidential Enquiries
p.31
2.4 Participation in Clinical Research
p.37
2.5 Commissioning for Quality and Innovation (CQUIN)
p.39
2.6 Registration with the Care Quality Commission (CQC)
p.44
2.7 Data Quality
p.46
2.8 Information Governance
p.47
2.9 Clinical Coding
p.49
PART 3: Review of Quality Performance
3.1 Quality Performance in 2009/10
p.50
3.2 Performance Against Key National Priorities and National Core Standards
p.54
ANNEXES:
Annex 1 Statements from Primary Care Trusts, Local Involvement Networks
p.55
and Overview and Scrutiny Committees
Annex 2 Review of Services
p.60
Annex 3 PEAT Self-Assessment Inspection Outcomes 2010
p.62
Annex 4 Glossary of Terms
p.63
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
PART 1
Statement on Quality
from the Chief
Executive
At Greater Manchester West Mental Health
NHS Foundation Trust we are committed to
continuously improving the quality of all the
services we provide. Taking into account the
range and diversity of services we provide, this is
no small feat. It is a challenge, however, that we
relish and we have established great foundations
to build on as we look to improve things further
in 2010/11.
The improvements delivered over the last year,
and described in this Quality Account, are
indicative of the efforts put in by staff across the
Trust. I would like to thank everyone who has
contributed in some way to delivering quality
improvements in 2009/10. Thanks to their
contribution, we have delivered achievements
against the priorities for improvement set in our
2008/09 Quality Report and secured the CQUIN
(Commissioning for Quality and Innovation)
income that was dependent on a number of
these priorities. These achievements include
improving the frequency of care plan reviews, the
information shared with service users and carers,
and the involvement of service users and carers
in decision making. We have also developed a
shared protocol for physical health, taken great
strides in improving the support provided by
GMW to people with learning disabilities and
made significant progress in improving the
efficiency of our primary care psychological
therapies services. There is still a long way to go
before waiting times for psychology meet our
view of acceptable levels. Our achievements in
2009/10 have, however, set a good foundation
for making further improvements this year.
As can be seen by our new priorities for
improvement, our focus in 2010/11 is firmly
on improving outcomes. From listening to the
feedback from our Quality Accounts involvement
and engagement process, we know that
outcomes are what really matter to our service
users. The improvements we have begun to make
to processes and outcomes over the last year, and
will continue to make next year, will support us in
achieving improved outcomes in future.
Next year, in particular, we are keen to develop
more creative approaches to gathering feedback
from our service users. We already participate
in the national patient surveys and have
implemented a number of improvements based
on the outcomes of these. We are now also
looking at ways of gathering real-time feedback
that will enable us to implement more timely
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
changes. We have had a taste of gathering this last
year, with our successful video diary room event
in Salford and the pilot of our patient experience
questionnaire. The plan now is to roll-out these
types of initiatives across the organisation and
ensure that our approaches to gathering feedback
are co-ordinated and embedded in our systems,
structures and culture. We will also continue to
have recovery at the heart of all of our operations
and will aim to roll-out the wider use of recovery
tools, improve access to therapeutic activities for
our service users and enhance the quality of our
physical environments through significant capital
investment.
To the best of my knowledge, the information
contained in this Quality Account is accurate
and representative of the quality of services we
provide. The Statement of Internal Control in the
Trust’s Annual Report for 2009/10 demonstrates
the steps taken to ensure that this Account is
fairly stated. External assurance on our Quality
Account is provided in the form of statements
from our lead Primary Care Trust commissioners
in Bolton, Salford and Trafford, Local Involvement
Networks (LINks) and Joint Scrutiny Committee.
These statements are published verbatim in Annex
1 of this Account.
I hope that this Quality Account provides a clear
and rounded picture for you of what quality
means at GMW. We have tried to describe
things as clearly and concisely as possible and
have provided a glossary of terms to support
your understanding. We will also be publishing
a more user-friendly, summary version of this
Account in July 2010. We recognise, however,
that quality is a complex area of work with many
over-lapping and equally important agendas. If
you have any questions on the content of this
Account please email communications@gmw.
nhs.uk.
Bev Humphrey
Chief Executive
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
PART 2
Priorities for
Improvement and
Statements of
Assurance from the
Trust Board Relating
to the Quality of
Services Provided
2.1 Priorities for Improvement
2.1.1 Performance
Against
Quality
Improvement Priorities in 2009/10
In 2008/09 all NHS Foundation Trusts were
required to produce a Quality Report for
Monitor. Monitor is the independent regulator
of NHS Foundation Trusts. The Quality Report
set the foundations for this Quality Account and
included the following priorities for improvement
in 2009/10:
Priority 1
Priority 2
Priority 3
Priority 4
Priority 5
Care Programme Approach (CPA)
Physical Health
Psychological Therapies Waiting Times
Learning Disabilities
Service User Survey
These priorities reflected issues identified
through the Trust’s annual business planning
processes for 2009/10 and feedback from the
2008 National Patient Survey. These priorities
also aligned with 4 of the 5 priorities agreed for
our Commissioning for Quality and Innovation
(CQUIN) scheme. Section 2.5 provides further
detail on CQUIN.
Through the hard work and commitment of our
staff, the Trust has achieved significant progress
against each of these priorities.
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
Achievements against 2009/10 Improvement Priorities:
Achievements against 2009/10 Improvement Priorities:
Priority for
Improvement in
2009/10
1
Care
Programme
Approach
(CPA)
Description
2008/09 Baseline Position
All service users on
CPA are reviewed
within 6 monthly
intervals
GMW’s standard was for CPA •
reviews within 12 months in
2008/09.
•
The Quality Report established a •
baseline of 68.9% of CPA reviews •
undertaken
within
6
monthly
intervals in 2008/09. Since this
calculation, data definitions and •
methods of measurement for CPA
reviews have been refined to ensure
all appropriate exclusions (e.g.
service users who are externally
care co-ordinated) are accounted •
for. Updates have also been made
to the Trust’s Integrated Clinical
Information System (ICIS) to enable •
more accurate data collection. The
baseline provided in the Quality
Report is therefore not directly
comparable to the 2009/10 year-end
position.
A 75% target was
subsequently agreed
for this indicator as
part of the Trust’s
CQUIN scheme for
2009/10
2
Physical
Priority
for
Health
Improvement in
2009/10
To develop a shared
Description
care agreement with
primary care services
to ensure that physical
health checks are
undertaken and that
relevant information
relating to a service
user’s physical health
is shared between
providers
3
To improve waiting
times for primary care
psychological therapies
and have no-one
waiting more than 18
weeks by December
2009
Psychological
Therapies
Waiting Times
Priority for
Improvement in
2009/10
Primary care
psychological therapies
Description
are currently provided
by the Trust in Salford
and Trafford
Achievements in 2009/10
Target of 75% of service users on CPA reviewed
within 6 monthly intervals exceeded – 80.3%
achieved
Improved compliance with the Trust’s CPA Policy
More up-to-date care plans
More proactive approaches to monitoring and
planning CPA reviews by team managers and care
co-ordinators
Improved communication and liaison between
services for service users whose case manager
and care co-ordinator (the individual responsible
for co-ordinating the CPA review within 6 months)
are in different services
Improved data quality - development of more
accurate data definitions and methods of
measurement
Changes to the ICIS to support more accurate data
capture and reporting
Physical Healthcare Policy in place
• Shared care protocol for the minimum standards
2008/09 Baseline Position
Achievements
required for in
the2009/10
provision of physical healthcare for
A number of Physical Healthcare
people on SMI (serious mental illness) registers
Advanced Practitioners appointed
developed and agreed with primary care trusts in
January 2010
• Agreed and operational arrangements in place for
the provision of physical healthcare services for
our secure services. Physical healthcare services
being provided by a Manchester-based GP 6
practice
• New Physical Healthcare Policy ratified in
December 2009, which establishes minimum
standards for the physical healthcare of service
users across all Trust directorates
• Rebecca Dawber, Advanced Practitioner in the
Trust’s Alcohol and Drugs Directorate, won the
Nursing Times Award for Mental Health Innovation
for the development of a tool that analyses the liver
function of people with severe alcohol dependency
• Physical health agreed as a CQUIN priority for
2010/11
Since the development of the Achievements:
Quality Report the Trust has taken
significant steps to improve the • Establishment of ’Psychology 18 Weeks Task and
quality of its data relating to
Finish Group’
psychological therapies and ensure • Development of new procedures for managing
all individuals waiting for services
cancellations and DNAs (did not attends) for
are appropriately captured and
psychological therapies
reported. For example, the baseline • Development of new referral management
position reported in the Quality
procedures
Report
only identified
individuals •Achievements
2008/09 Baseline
Position
Completion inof2009/10
job planning for psychological
waiting for therapy. The Trust Board
therapists to ensure the best possible levels of
has subsequently requested that the
productivity
waiting list position includes all • Increased use of therapeutic group work
patients waiting for assessment and • Clarification of care pathways and inclusion and
therapy to ensure that the Board
exclusion criteria for services
has a more realistic picture of • Start of negotiations with local Universities to
7
demand. On this basis, the baseline
introduce training placements for counsellors
position for numbers waiting more
within the Trust’s psychological therapies services
than 18 weeks for assessment and • Significant investment from Trafford PCT to
therapy at the end of 2008/09 is
establish a new complex needs service (Trafford
1,691.
Enhanced Service (TES)) to meet the needs of
service users who are too complex for the primary
care psychological therapy services but do not
meet the criteria for secondary care. TES will also
provide psychological therapy support for people
with Attention-Deficit Hyperactivity Disorder
(ADHD) and autistic spectrum disorders.
During 2009/10 over 4,100 service users were
assessed or given therapy by the Trust’s primary care
psychological
therapy services. This equates to over
Greater Manchester West Mental Health Foundation NHS Trust Quality Account
2009 / 2010
19,400 contacts and, on average, close to 5 contacts
per service user. At the end of 2009/10, the numbers
therapy to ensure that the Board
has a more realistic picture of •
demand. On this basis, the baseline
position for numbers waiting more
than 18 weeks for assessment and •
therapy at the end of 2008/09 is
1,691.
Achievements against 2009/10 Improvement Priorities:
Priority for
Improvement in
2009/10
1
Care
Programme
Approach
(CPA)
Priority for
Improvement in
2009/10
2
4
Physical
Health
Learning
Disabilities
Priority for
Improvement in
2009/10
Description
2008/09 Baseline Position
All service users on
CPA are reviewed
within 6 monthly
intervals
GMW’s standard was for CPA
reviews within 12 months in
2008/09.
A 75% target was
subsequently agreed
for this indicator as
part of the Trust’s
CQUIN scheme for
2009/10
Description
To develop a shared
care agreement with
primary care services
to ensure that physical
Development of an
agreed Green Light
Toolkit action plan in
each of the Trust’s
district services
(Bolton, Salford and
Trafford) and
engagement with
partners to progress
action plans.
The Green Light Toolkit
is a framework and
Description
self-audit toolkit for
improving the support
provided by mental
health services to
people with learning
disabilities.
The Quality Report established a
baseline of 68.9% of CPA reviews
undertaken
within
6
monthly
intervals in 2008/09. Since this
calculation, data definitions and
methods of measurement for CPA
reviews have
beenPosition
refined to ensure
2008/09
Baseline
all appropriate exclusions (e.g.
service users who are externally
care co-ordinated) are accounted
for. Updates have also been made
to the Trust’s Integrated Clinical
Information System (ICIS) to enable
more accurate data collection. The
baseline provided in the Quality
Report is therefore not directly
comparable to the 2009/10 year-end
position.
Physical Healthcare Policy in place
A number of Physical Healthcare
Advanced Practitioners appointed
The 2008/09 baseline position
against all 39 requirements for
Bolton, Salford and Trafford is
shown in the following charts.
Position is identified as red, amber
or green with red indicating not
achieved, amber indicating work in
progress and green indicating that
the situation is positive across the
health economy.
exclusion criteria for services
Start of negotiations with local Universities to
introduce training placements for counsellors
within the Trust’s psychological therapies services
Significant investment from Trafford PCT to
establish a new complex needs service (Trafford
Enhanced Service (TES)) to meet the needs of
service users who are too complex for the primary
care psychological therapy services but do not
meet the criteria for secondary care. TES will also
provide psychological therapy support for people
Achievements
in 2009/10
with Attention-Deficit
Hyperactivity Disorder
(ADHD) and autistic spectrum disorders.
•During
Target
of 75% over
of service
on CPA
reviewed
2009/10
4,100users
service
users
were
within or6 given
monthly
intervals
– 80.3%
assessed
therapy
by the exceeded
Trust’s primary
care
achieved therapy services. This equates to over
psychological
• Improved
compliance
with the Trust’s
CPA
Policy
19,400
contacts
and, on average,
close to
5 contacts
per
service
user. At care
the end
of 2009/10, the numbers
• More
up-to-date
plans
waiting
improvedapproaches
from the recalculated
2008/09
• Morehasproactive
to monitoring
and
baseline.
1,429
continue and
to care
wait
planning
CPApeople,
reviews however,
by team managers
more
than 18 weeks for assessment and therapy. The
co-ordinators
18
targetcommunication
was set internally
by the between
Trust to
• week
Improved
and liaison
demonstrate
our service
commitment
improving
to
services for
users towhose
case access
manager
Achievements
in 2009/10 (the
psychological
therapies.
The individual
target was
always
and care co-ordinator
responsible
recognised
as a major
forwithin
GMW,
but the
for co-ordinating
the challenge
CPA review
6 months)
scale
ofinthe
challenge
was not fully understood until inare
different
services
depth
and focused
work - on
our psychological
• Improved
data quality
development
of more
therapies
waiting
timesdefinitions
was underway.
work has
accurate
data
and This
methods
of
identified
a significant historical backlog of referrals
measurement
and
a mismatch
between
the more
capacity
of data
our
• Changes
to the ICIS
to support
accurate
8
psychological
capture andtherapies
reportingservices and the number of
new referrals received. Whilst there is much GMW can
do to improve the efficiency of our psychological
therapy services, it is clear that, in some areas,
resources are insufficient and commissioners will need
to invest to achieve the target. For these reasons,
psychological
remains
a priority
for
• Shared caretherapies
protocol for
the minimum
standards
improvement
forthethe
Trust in
(see Section
required for
provision
of 2010/11
physical healthcare
for
2.1.2people
below).on SMI (serious mental illness) registers
developed and agreed with primary care trusts in
• Action plan for achievement of all 39 Green Light
Toolkit requirements developed and in place in
each district service
• Position against all 39 Green Light Toolkit
requirements improved by the end of 2009/10 in 6
comparison to 2008/09 baseline in Bolton, Salford
and Trafford. See following charts. Examples of
areas where the most significant improvements
have been achieved include:
•
2008/09 Baseline Position
Local partnerships with primary care services –
clear agreement between mental health,
Achievements
2009/10 and primary care services
learning indisability
about roles and responsibilities and referral
routes for specialist support
• Local partnerships with people with learning
disabilities in terms of enabling their
contribution
and
support
to
service
configuration and plans related to mental health
9
support
• Sharing information and accessing care plans
between learning disability, primary care,
mental health services and other relevant
agencies
• Developing person-centred and whole life care
plans
• Workforce
planning,
including
staff
knowledgeable and competent in mental health
and learning disabilities being available to
provide support and the workforce reflecting
the diversity of the local population of people
with mental health problems who have a
learning disability
• Further improvements against the Green Light
Toolkit agreed as a CQUIN priority for 2010/11
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
10
10
Progress against the 39 Green Light Toolkit Requirements (March 2009 to March 2010):
Progress against the 39 Green Light Toolkit Requirements (March 2009 to March 2010):
GREEN
LIGHT
TOOLKIT
- SALFORD
DISTRICT
Progress
against
the 39
Green Light
Toolkit
Requirements (March 2009 to March GREEN
2010):
ACHIEVEMENTS
45
45
40
GREEN LIGHT TOOLKIT - SALFORD DISTRICT
ACHIEVEMENTS
35
45
35
45
30
40
30
40
Red
25
35
Am ber
20
30
15
25
20
30
Red
15
25
Green
5
15
5
0
45
40
25
35
Green
Am ber
10
20
0
10
GREEN
40
10
20
5
15
Salf ord March 09
0
10
Salf ord March 10
GREEN LIGHT TOOLKIT - BOLT ON DIST RICT
Salf ord MarchACHIEVEMENTS
09
Salf ord March 10
0
Traf f o
GREEN LIGHT TOOLKIT - BOLT ON DIST RICT
ACHIEVEMENTS
35
45
30
40
Red
25
35
Am ber
20
30
Green
15
25
Traf f o
5
The number of
‘green’ or achie
improved from t
The number of
and Trafford.
‘green’ or achie
improved from t
and Trafford.
Red
Am ber
10
20
Green
5
15
0
10
5
Bolton March 09
Bolton March 10
Bolton March 09
Bolton March 10
0
quirements (March 2009 to March 2010):
GREEN LIGHT TOOLKIT - TRAFFORD DISTRICT
ACHIEVEMENTS
RICT
45
40
35
30
Red
Am ber
Green
Red
25
Am ber
20
Green
15
10
5
0
Traf f ord March 09
Traf f ord March 10
CT
The number of Green Light Toolkit requirements reported as
‘green’
achieved
by the end
of 2009/10
hasorsignificantly
The number of Green
LightorToolkit
requirements
reported
as ‘green’
achieved by the end of 2009/10
improved from the 2008/09 baseline position in Bolton, Salford
has significantly improved from the 2008/09 baseline position in Bolton, Salford and Trafford.
and Trafford.
Greater
Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
Red
Am ber
11
Priority for
Improvement in
2009/10
5
Service User
Survey
Description
2008/09 Baseline Position
75% of service users
on CPA, or their carers,
have:
• Been
given
an
information pack
• Been
given
or
offered a copy of
their care plan
• Had
their
views
taken into account
when their care plan
is produced
• Had the side effects
of their medication
discussed
• Received or been
offered a carers
assessment
The 2008 Community Mental Health • Target of 75% exceeded in all areas
Survey highlighted opportunity for • More proactive approaches to monitoring and
improvement in each of the areas
planning CPA reviews by team managers and care
identified.
co-ordinators
• Increased involvement of service users and carers
As with the CPA 6-monthly review
in care planning
indicator,
the
Quality
Report • Improved data quality - development of more
included a 2008/09 baseline for all
accurate data definitions and methods of
areas of this priority. Since this
measurement
calculation, data definitions and • Changes to ICIS to support more accurate data
methods of measurement have
capture and reporting
been
refined
to
ensure
all
appropriate
exclusions
are The impact of these achievements is recognised in the
accounted for. Updates have also outcomes of the Trust’s 2010 Service User Survey.
been made to ICIS to enable more
accurate data collection. The
baseline provided in the Quality
Report is therefore not directly
comparable to the 2009/10 year-end
position.
This goal was agreed
with commissioners as
part of the 2009/10
CQUIN scheme,
following the
publication of the
Quality Report
Achievements in 2009/10
12
To ensure that these achievements are sustained
and further improved in 2010/11, more
challenging targets for Priorities 1, 2, 4 and 5 have
been incorporated into our PCT CQUIN scheme
for 2010/11 (also see Section 2.5). In terms of
improving access to primary care psychological
therapies (Priority 3), the Trust recognises that it
will need to overcome further challenges before
significant reductions in current waiting times
can be achieved. As such, psychological therapies
remains a priority for improvement for the Trust,
and our commissioners, in 2010/11.
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
12
2.1.2Priorities for Improvement
in 2010/11
GMW has undertaken a process of involvement
and engagement with key stakeholders to
establish views on priorities for improvement
in 2010/11 and the draft Quality Account.
Representatives from the following groups have
been invited, and had the opportunity to, give
their views:
• Local Involvement Networks (LINks) for
Bolton, Salford and Trafford
• Joint Overview and Scrutiny Committee for
Bolton, Salford and Trafford
• Bolton, Salford and Trafford Primary Care
Trusts (PCTs), North West Specialised
Commissioning Team and local authorities in
Bolton, Salford and Trafford via the Trust’s
Partnership Development Group
• Council of Governors, including representation
from service users and carers, staff, the general
public, PCT and local authority partners, and
other partner organisations
• Service users via local service users forums
and away days including:
o Young Persons Directorate Community
Forum
o Trafford Patients Council
o Ward Community Meetings in Salford
o Adult Forensic Mental Health Services
Directorate Away Day
o Bolton Patient Experience Meeting
o Video Diary Room event in Salford
• User Action Team (UAcT)
• Staff via the following forums:
o Specialist and District Services Network
Board Meetings
o Research Governance Group
o Professional Advisory Group
o Medicines Management Group
o Matrons Meeting
o Corporate Nursing Meeting
o Local directorate/service meetings and
away days
o Forward to Excellence U2 - a development
programme for over 50 of the Trust’s
clinical and non-clinical managers
o Executive Management Team
o Clinical and Social Care Governance
Committee (CSCGC)
o Trust Board
The Trust Board reviewed the views expressed
by these stakeholders at its meeting in April
2010 and agreed the following priorities for
improvement in 2010/11. These priorities all
reflect the three domains of quality set out in
‘High Quality Care for All’: patient experience,
effectiveness, safety. It is recognised that the
Trust was only mandated to select a minimum
of 3 priorities for improvement. The Trust has
identified 7 priorities in total, which demonstrates
the diversity of services provided by the Trust
and the Trust’s commitment to improving quality
wherever possible.
To ensure effective leadership for this significant
programme of work, the Trust will review existing
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
13
forums where quality is discussed in 2010/11
with a view to establishing a single quality forum.
This forum will be responsible for co-ordinating
a systematic approach to quality improvements
and overseeing progress against all of the
following improvement priorities. Practical steps
to achieve progress will continue to be led and
managed through existing operational forums.
It is expected that the quality forum will be
chaired by an executive director and include
representation from across the Trust’s clinical
and corporate services and from service users.
The 7 priorities for improvement in 2010/11
cover the following areas:
• Priority 1 - Improving access to primary care
psychological therapies
healthcare services for users of mental health
and substance misuse services
• Priority 7 - Improving the safety of the physical
environment by reducing all potential ligature
risks in inpatient settings to a minimum
A more detailed description of each of these
improvement priorities is provided below.
PRIORITY 1
Priority for Improvement:
Improving Access to
Psychological Therapies
Primary
Care
Quality Domain:
• Priority 2 - Developing and implementing
new approaches for gathering real-time
patient experience feedback
Patient Experience
• Priority 3 - Improving clinical outcomes
through the delivery of recovery-focussed
services
To improve access to the Trust’s primary care
psychological therapies services in Salford and
Trafford and work towards reducing the number
of services users waiting over 18 weeks.
• Priority 4 - Improving carer engagement and
involvement
• Priority 5 - Improving care planning and
ensuring care plans are up-to-date, reflect
need and enable recovery
• Priority 6 - Improving access to physical
Aim/Goal:
Description of Issue and Rationale for
Prioritising:
National Institute of Clinical Excellence (NICE)
guidelines evidence the effectiveness of primary
care psychological therapies in treating people with
mental health problems and bringing them closer
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
14
to recovery. Improving access to psychological
therapies is also identified as a national priority.
GMW has a historical backlog of referrals to
our psychological therapies services, which has
resulted in excessive waiting times for a significant
number of service users. Excessive waiting times
can impact on patient experience and outcomes
and be demoralising for staff working in the
services. There is also a tension between the
capacity of our psychological therapies services
and the number of new referrals received.
Significant progress has been made in 2009/10
to improve the efficiency and productivity of our
psychological therapies services and the quality of our
data capture and reporting. Prioritising psychological
therapies in 2010/11 will be an opportunity to build
on the progress made in 2009/10.
Current Status:
During 2009/10 over 4,100 service users were
assessed or given therapy by the Trust’s primary
care psychological therapy services. This equates
to over 19,400 contacts and, on average, close
to 5 contacts per service user. At the end of
2009/10, 1,429 people had been waiting
more than 18 weeks, from initial referral, for
assessment and treatment.
The Trust delivers high intensity IAPT (Improving
Access to Psychological Therapies) services,
providing complex psychological treatments, in
Salford and Trafford. Low intensity IAPT services,
providing briefer interventions, are currently
provided by the PCTs. IAPT aims to relieve distress
and transform lives by offering interventions and
treatment choice to individuals with depression
and anxiety disorders. IAPT also recognises the
importance of maintaining, or moving towards,
employment for individuals with mental health
problems. There is a national commitment to
including employment support functions in
every PCT that provides IAPT services.
Identified
2010/11:
Areas
for
Improvement
in
In the current economic climate, opportunity
for additional investment in services, to create
additional capacity, is limited. The following
improvements identified for 2010/11 will need
to be achieved within existing resources:
• Testing the impact of achievements delivered
in 2009/10 on access to psychological
therapies services
• Exploring options for managing referrals
to the service and/or generating additional
capacity
• Undertaking a service improvement initiative
to review and improve administrative
processes and arrangements for psychological
therapies
• Evaluating the effectiveness of job planning to
see if resources are used to optimum levels
• Developing service specification and pathways
– including pathways to specialist services – to
help manage demand
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
15
The Trust is also exploring opportunities for
integrating primary care psychological therapies
services and low intensity IAPT workers into
its service provision. The Trust will ensure that
sufficient resources are available to support this
integration.
Methods of Monitoring, Measuring and
Reporting Progress:
Referrals and waiting times for primary care
psychological therapies are captured in the
Trust’s Integrated Clinical Information System
(ICIS). Currently, progress, in terms of numbers
of referrals and waiting times, is monitored by
individual services, the ‘Psychology 18 Weeks
Task and Finish Group’ and the Trust Board.
The Trust Board receives monthly updates, via
the Board Performance Report, on long waiters.
Reports on other areas of progress made by the
‘Task and Finish Group’ are fed back to the Trust’s
Executive Management Team by the Director of
Nursing and Operations and Director of Service
and Business Development.
These methods of monitoring, measuring and
reporting progress have proved effective and
will continue for 2010/11.
Timescales for Achievement:
End of March 2011 for identified areas for
improvement
PRIORITY 2
Priority for Improvement:
Patient Experience Feedback
Quality Domain:
Patient Experience
Aim/Goal:
To develop and implement more effective and
creative approaches for gathering real-time
patient experience feedback and ensure service
users’ views are genuinely listened to.
Rationale for Prioritising:
Having in place effective and timely means for
gathering service user feedback is crucial to
understanding whether the Trust is achieving its
strategic vision and objectives. Real-time service
user feedback will provide insight into whether
the services provided are delivering outcomes that
are valued by our service users. This insight will be
a key driver for future quality improvements.
Current Status:
Approaches used routinely to gather patient
experience feedback include:
• National patient survey (community and
inpatient)
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
16
• Feedback from local service user forums
• Feedback from service user representatives,
including LINks, UAcT, governors
• Feedback from acute care forums
• Complaints, compliments and claims
• Enquiries received via the Customer Care
Team
• Local satisfaction questionnaires or comment
cards
• Incidents
In late 2009/10, the Trust developed and
launched a patient experience questionnaire
for use, in the first instance, in a number of its
inpatient services. The questionnaire is focused
on privacy and dignity, but also includes areas
for improvement identified in national surveys
and incidents. The questionnaire will be used to
capture real-time feedback from service users
during their inpatient stay. Responses to the
questionnaire will be analysed and improvement
priorities identified for local implementation.
The Trust has also recently held a ‘Big Brother’
style video diary room event in its Salford services.
The event was part of a pilot co-ordinated by
the North West Mental Health Improvement
Programme, which aimed to involve service
users, carers and their representatives in
planning, implementing and evaluating service
delivery by:
• Testing whether ‘Big Brother’ style video
diary rooms are an effective way of gathering
patient experience information
• Supporting service users and carers to
comment on their experience of a service
• Using information gathered from video
diary rooms to plan and implement service
improvements
Service users, carers and their representatives
from Salford were invited to take part in the
pilot by giving their views on services direct to a
camera in the video diary room. 37 people were
interviewed as part of the event, resulting in over
2 hours of video footage. Key themes around
communication, workforce and environment
were identified from the feedback received.
The feedback is now being translated into
meaningful actions for improvement in Salford.
Identified
2010/11:
Areas
for
Improvement
in
The Trust will continue to strengthen its current
methods of gathering patient experience
feedback in 2010/11. The Trust will aim to coordinate these existing methods, and any future
developments, into a systematic approach that
is embedded in the Trust’s systems, structures
and culture.
The Trust will also:
• Evaluate the effectiveness of the patient
experience questionnaire as a means of
gathering real-time feedback
• Based on the outcomes of evaluation,
consider rolling-out the patient experience
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
17
questionnaire across all Trust inpatient services
and in community services
• Evaluate the effectiveness of the video diary
room event and consider further events in
other Trust services
• Share findings with partners, particularly
commissioners, LINks and OSCs, with the
aim of identifying areas of good practice and
priorities for collaborative solutions
Methods of Monitoring,
Reporting Progress:
Measuring
and
The Trust’s Business Intelligence Team will analyse
and report on feedback captured via the new
patient experience questionnaires. This feedback
will be fed back to matrons in individual services
for local progress.
Feedback from the video diary event in Salford was
shared with key stakeholders, including service
users, staff, commissioners, governors and service
user representatives, at a Service Improvement
Workshop in early April. Ideas for improvement
were agreed at this Workshop. The Trust’s Council
of Governors have also received feedback from the
video diary event. Progress against the identified
actions for improvement will be measured,
monitored and reported on locally in Salford and
achievements communicated, where possible, to
individuals who participated in the event.
Timescales for Achievement:
PRIORITY 3
Priority for Improvement:
Recovery
Quality Domain:
Effectiveness
Aim/Goal:
To improve clinical outcomes through the delivery
of recovery-focussed services
Rationale for Prioritising:
The Trust’s over-arching vision – ‘improved lives
and optimistic futures for people affected by
mental health and substance misuse problems’ –
is focused on recovery and improving outcomes.
Outcomes are what really matters to our service
users.
The Trust’s ‘Nursing Strategy’ sets out the Trust’s
commitment to embedding the principles of the
recovery approach into every aspect of nursing
practice. For GMW, the recovery approach means
‘working towards aims that are meaningful to
service users, being positive about change and
promoting social inclusion for mental health
service users and carers’. The ‘Nursing Strategy’
also sets out goals for putting the values of the
recovery approach into practice.
End of March 2011
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
18
‘New Horizons: A Shared Vision for Mental
Health’ sets out the expectation that mental
health services will be focused on recovery.
Recovery is a personal and unique process for
each individual and as such should be defined in
discussion with the service user.
Monitor has established new targets for mental
health services in 2010/11, which include
improving outcomes for patients on CPA. Clinical
outcomes has also been agreed as a priority in
both of the Trust’s CQUIN schemes for 2010/11
(also see Section 2.5).
Current Status:
The Trust has an ‘Equality, Inclusion, Recovery
Strategy’, which aims to promote social
inclusion and the recovery model. The ‘Equality,
Inclusion, Recovery Strategy’ also incorporates
the Trust’s Single Equality Scheme and sets out
our arrangements for meeting statutory duties
in relation to race equality, disability equality
and gender equality as well as actions on age,
sexual orientation and spirituality.
Alongside this, the Trust has published a
handbook on personal recovery planning entitled
‘Taking Back Control: A Guide to Planning Your
Own Recovery’, which provides service users
with a guide through the recovery model. The
handbook is supported by a ‘Personal Recovery
Plan’ and ‘Advance Decisions’ recovery tool.
The Trust has also launched a Trust-wide
Recovery Collaborative to take forward the
recovery agenda.
To support its recovery focus, a number of the
Trust’s services use the Health of the Nation
Outcome Scale (HONOS) to measure the health
and social functioning of people with severe
mental illness. Similarly, our alcohol and drugs
directorate (A+DD) use Treatment Outcomes
Profiles or TOPs assessments, to measure the
effectiveness and impact of drug treatment care
plans.
Identified
2010/11:
Areas
for
Improvement
in
To enable improved clinical outcomes, the Trust
will work towards achieving the following
improvements in 2010/11:
• 75% of patients to have had a HONOS
assessment completed at their last CPA
review
• Use of appropriate version of HONOS for
secure and young people’s services to measure
outcomes – all service users with a length of
stay of more than 3 months to have a plan in
place by Quarter 4 2010/11
• To work towards achieving 80% completion
rates for all 3 Treatment Outcome Profiles
(TOPs) (assessment, care plan reviews,
assessments at planned discharge) in the
Trust’s substance misuse services
• Roll-out use of tools for recovery planning
and evaluate effectiveness
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
19
• Consider and implement options for improving
access to therapeutic activities in all services
• Establish a Recovery Collaborative and
Recovery Showcase Event
Methods of Monitoring, Measuring and
Reporting Progress:
those that form part of the Trust’s CQUIN
schemes for 2010/11 – i.e. HONOS and the use
of recovery tools – will be reported separately
in the performance reports to enable increased
focus. Quarterly progress reports will also be
provided to commissioners on these priorities.
Timescales for Achievement:
HONOS data is captured in ICIS. TOPs data is
recorded locally by our substance misuse services
and reported to the National Treatment Agency
(NTA) as part of the monthly National Drug
Treatment Monitoring System (NDTMS) returns.
TOPs data reported in Performance Reports is
based on published data from the NTA.
Data quality (completeness) of HONOS scores is
currently reported to individual services as part
of their Data Quality Reports and Performance
Reports and the Trust Board as part of the Board
Performance Report. Performance in the use
of TOPs is included in the Alcohol and Drug
Directorate’s Performance Report. Monitoring,
and the agreement of actions to improve
performance, takes place in local services and at
Network Board level.
An approach to recording levels of therapeutic
activity will need to be agreed for 2010/11. This
may be through ICIS or, alternatively, service may
consider undertaking audits or questionnaires to
enable a clearer understanding of their baseline
position and improvements made on that.
Of the above identified areas for improvement,
End of March 2011 for the specific actions
identified above. Improving clinical outcomes
through the delivery of recovery-focussed services
is not a priority for just one year. Recovery will
continue to be a priority for the Trust in future
years, as it has been in previous years.
PRIORITY 4
Priority for Improvement:
Involvement of Carers
Quality Domain:
Effectiveness
Aim/Goal:
To improve carer engagement and involvement
in the delivery of care and treatment for people
with mental health problems.
Rationale for Prioritising:
One of the Trust’s six strategic objectives is to
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
20
‘empower service users and carers to be involved
in their own care planning and recovery and that
of others’. An increasing number of individuals
are finding themselves taking on a caring role
at some point in their lives. To enable carers to
continue making their invaluable contribution,
the Trust must recognise and respond to their
distinct needs. The Trust is committed to
improving support for carers by ensuring that
their own health and well-being is maintained
and that they are not disadvantaged in any
way.
Following a review of complaints and incidents,
the Trust’s Bolton Mental Health Service launched
a project to address a number of key issues. One
of the issues identified as part of this project
was the need to improve carer involvement and
engagement. Building on the initial success of
this project, which included contribution to the
development of a Multi-Agency Carer Strategy
for Bolton (‘Supporting Carers in Bolton –
Everyone’s Responsibility’), Bolton was awarded
funding from the Department of Health in
2009/10 to operate as a National Carers
Demonstration Site. This funding is now being
used to deliver further planned improvements
for carers. The over-arching aims of the Carers
Demonstration Site project are to:
• Ensure that carers’ needs are assessed and
met
• To improve carer engagement and involvement
in care planning and review and in service
development, monitoring and evaluation
Other drivers for the inclusion of carers as an
improvement priority include:
• Publication of the National Carers Strategy in
June 2008
• Transforming social care agenda, including
the introduction of ‘Our Health Our Care Our
Say’ and personalised budgets
Current Status:
As described above, Bolton Mental Health
Service has been funded until March 2011 as
an identified National Carers Demonstration
Site. An over-arching Project Board has been
established to oversee this project. The Project
Board includes individuals with remit across
the Trust – for example, one of the Trust’s nonexecutive directors, the Network Director for the
Trust’s district services and the Deputy Director
of Nursing – as well as Bolton representatives. A
formal launch event for this project took place
in April 2010. Representatives from across the
Trust contributed to this event.
The Trust’s services in Bolton, Salford and Trafford
have all contributed to the development of
multi-agency carer strategies in their respective
areas.
The Trust’s Council of Governors includes active
carer representation.
Significant progress has been made as part of the
2009/10 CQUIN scheme in terms of improving
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
21
access to carers’ assessments. The target of 75%
of carers assessed or offered an assessment had
been exceeded at the end of 2009/10.
Identified Areas for Improvement in 2010/11:
Key actions identified as part of the National
Carers Demonstration Site Project in Bolton
include:
• Identifying Carers Champions in each service area
to improve services for, and links with, carers
• Commissioning Making Space to develop
a befriending project for carers, which will
increase the level of peer support, enable
improvements in carers’ emotional health
and well-being and reduce isolation
• Commissioning Barnardo’s to extend the
service already offered to young carers of
people with mental health problems and
provide monthly consultations to school
nurses and mental health professionals and
disseminate literature
• Increasing the number of carers offered oneoff direct payments to provide breaks from
their caring role
• Establishing a care pathway, which will
provide physical healthcare and well-being
assessments for carers identified via secondary
care mental health services. A physical health
practitioner has been appointed to support
the achievement of this action.
• Designing and delivering an induction
programme for new starters to raise awareness
of carers across the Trust.
• Designing and delivering a programme
of training for staff and carers, which will
ensure carers are seen as partners in care and
deliver a change in staff culture and practice.
Carers training will be mandatory for staff in
Bolton.
• Involving carers in discharge planning.
The Trust will be appointing a practice
development nurse with responsibility for
developing standards to improve engagement
and communication with carers throughout
the cared for person’s inpatient stay.
• Developing and undertaking two types
of questionnaires – Carers Satisfaction
Questionnaire and Staff Attitude Survey – and
analysing, and acting on, the outcomes of
these. The Staff Attitude Survey will be carried
out prior to, and following, the mandatory
training for staff to enable evaluation of its
impact.
These actions reflect views expressed by carers
in Bolton on their priorities.
The successes in Bolton will be shared more
widely across the Trust as follows, to enable
Trust-wide improvement in carer engagement
and involvement:
• Delivery of carers induction programme at
Trust-wide level
• Training – Considering ways of rollingout carers training in Salford and Trafford
services
• Discharge planning – Evaluation of the
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
22
effectiveness of the standards developed
by the discharge co-ordinator in advance of
wider roll-out across the Trust
Work is also ongoing to develop a Carers
Strategy and Carers Charter for application
across the Trust. The Carers Charter will clearly
set out what carers can expect from any member
of GMW staff, whilst the strategy will establish
key objectives and actions for achievement.
Methods of Monitoring, Measuring and
Reporting Progress:
Methods of monitoring, measuring and reporting
progress on actions identified as part of the
Carers Demonstration Site Project include:
• Quarterly progress reporting to the Carers
Demonstration Sites National Evaluation
Team and the Department of Health
• Ad hoc reporting to the National Evaluation
Team on new carers involved in the project
• Reports to the Bolton Carers Demonstration
Site Project Board (bi-monthly basis) and
Steering Group that sits below the Project
Board (monthly basis). Feedback from the
Project Board is fed up to the Trust’s Executive
Management Team via the Deputy Director
of Nursing and Network Director and to the
Trust Board via the non-executive member of
the Project Board
• Capture of staff and carer questionnaire
data in a bespoke Sharepoint system and
evaluation
• Establishment of a ‘carers area’ in ICIS to enable
recording and reporting of carers’ physical
healthcare and well-being assessments
• Undertaking contract monitoring meetings
with Making Space and Barnardo’s to ensure
the commitments and targets set out in their
respective contracts are delivered on
• Local evaluation of services will be fed into
the Project Board, Steering Group and
Department of Health
• Progress reported at the Strategic Local
Implementation Team in Bolton
• Progress reported at the Bolton Carers Impact
Group: a multi-agency strategic group with
responsibility for ensuring the delivery of the
multi-agency carers strategy in Bolton
Data relating to the carers assessment measure,
included in the 2009/10 CQUIN scheme, is captured
in ICIS. Robust data definitions and operational
guidance has been developed to support services
in capturing and recording this data. Progress is
reported as part of individual services monthly
Performance Reports, which are monitored locally
and in Network Board meetings, and in the Trust
Board’s Performance Report. Progress is also
reported to commissioners on a quarterly basis. A
‘stretch’ target of 85% has been agreed for access
to carers’ assessments in the 2010/11 CQUIN
scheme. This established approach to monitoring,
measuring and reporting progress against goal, as
described here, will continue in 2010/11.
Methods of monitoring, measuring and reporting
on other Trust-wide actions, for example the
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
23
Carers Charter and Strategy, will be outlined in
these documents.
Timescales for Achievement:
Timescales for the completion of the
identified areas for improvement in the Carers
Demonstration Site Project is end of March
2011. It is expected that the Carers Charters
and Carers Strategy will be in place prior to the
end of March 2011.
Timescales for achieving the carer’s assessment
CQUIN priority is also March 2011.
PRIORITY 5
Priority for Improvement:
Care Planning
Quality Domain:
Effectiveness
Aim/Goal:
To improve the Trust’s approaches to care planning
and ensure care plans are up-to-date, reflect need
and enable movement towards recovery
Rationale for Prioritising:
The Care Programme Approach (CPA) is
the cornerstone for the delivery of modern,
community-based mental health care which
meets health and social care needs. In ‘Putting
People First’ (2007) the government set out a
shared vision and commitment to transform
adult social care. Personalisation is at the heart
of this vision and is intended to form the basis
for community services provision. Personalisation
means every service user:
• Having choice and control over the shape of
their care and support
• Receiving support in the most appropriate
setting
• Accessing support easily and when they need
it
Direct payments and individualised budgets for
social care are crucial to delivering improved
choice and quality. The Trust is committed to
providing mental health service users with any
assistance needed to access these.
The Trust’s approach to delivering the
personalisation agenda will focus on working
with our council partners to transform social care
in mental health and to integrate Self-Directed
Support fully into CPA. Self-Directed Support is
critical to recovery and social inclusion. To achieve
this, the Trust will ensure the involvement of
service users and their carers in the assessment
of needs and in the development of care plans
that are person-centred, recovery-focussed and
enable people to live independent and valued
lives.
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
24
Current Status:
The Trust has an established CPA Policy, which
sets out how the Trust will meet national
guidance on care planning. CPA formed part
of the Trust’s CQUIN programme for 2009/10
and has been prioritised again for 2010/11
(see Section 2.5). As an outcome of CQUIN,
significant improvements have been made in
terms of the timing of CPA reviews, and the
information shared with service users and carers
and their involvement in decision-making.
The Care Programme Approach is not applicable
to the majority of service users in the Trust’s
Alcohol and Drugs (A+DD) services. All A+DD
service users receive a written, structured and
personalised care plan that is completed by the
service user in conjunction with the service user’s
key worker, clinicians and other agencies involved
in the provision of care. A+DD care plans are
used to identify improvements in personalised
care and treatment and are frequently reviewed
to ensure that changing needs are responded to
on an individual basis.
The Trust recognises that there is opportunity
for further improvements to be made in all areas
of care planning in 2010/11. Care co-ordinators
and key workers are central to delivering these
improvements and finding creative solutions to
meeting service users’ diverse needs.
Identified
2010/11:
Areas
for
Improvement
in
Identified areas for improvement include:
• 85% of service users on CPA reviewed within
6-monthly intervals – as per 2010/11 CQUIN
scheme
• As per 2010/11 CQUIN scheme, 85% of
service users on CPA, or their carers, have:
o Been given an information pack
o Attended or been invited to attend their
CPA review
o Been given or offered a copy of their care
plan
o Had their views taken into account when
their care plan is produced
o Had the side effects of their medication
discussed
o Received or been offered a carers
assessment
• Undertake an audit to evaluate the quality
of care plan documentation (both CPA and
A+DD care plans) with particular focus on:
o Recovery capital - Whether the actions
identified demonstrate that the care
plan assessment considered an individual’s
recovery capital
o Personalisation - Whether the actions
identified focus on meeting the needs of
individuals in ways that work best for them
o Usefulness of the care plan to service users
and carers
o Compliance with the CPA Policy, where
applicable
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
25
Methods of Monitoring, Measuring and
Reporting Progress:
Data relating to the CPA measures identified
for CQUIN is captured in ICIS. Robust data
definitions and operational guidance has been
developed to support services in capturing and
recording this data. Progress is reported as part
of individual services monthly Performance
Reports, which are monitored locally and in
Network Board meetings, and in the Trust
Board’s Performance Report. Progress is also
reported to commissioners on a quarterly basis.
This approach to monitoring, measuring and
reporting progress against the CQUIN CPA
indicators will continue in 2010/11.
Methods of monitoring, measuring and reporting
on the care plan documentation audit will be
defined in the audit tool.
Timescales for Achievement:
End of March 2011
PRIORITY 6
Priority for Improvement:
Physical Health Care
Quality Domain:
Safety
Aim/Goal:
To improve access to physical healthcare services
for users of mental health and substance misuse
services and reduce the risks associated with the
physical health of these service users
Rationale for Prioritising:
Individuals with mental health problems can
suffer significantly poorer health than the rest
of the general population. Evidence suggests
that individuals with mental health problems
are particularly vulnerable to the three major
causes of death in England – cardio-vascular
disease, cancer and respiratory disease. Physical
health may also be affected by self-neglect,
substance misuse and the effects of psychotropic
medication. Despite this, individuals with mental
health problems are found to have higher levels
of unmet physical health need and to receive
less effective treatment.
GMW is committed to the principle that users
of mental health and substance misuse services
should have access to the same quality of
physical health services as everyone else.
Current Status:
As outlined in Section 2.1.1 above, the Trust
currently has:
• A shared care protocol for the minimum
standards required for the provision of physical
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
26
healthcare for people on SMI (serious mental
illness) registers developed and agreed with
Primary Care Trusts in January 2010
• Arrangements in place for the provision of
physical healthcare services for our secure
services.
• A new Physical Healthcare Policy, ratified in
December 2009, which establishes minimum
standards for the physical healthcare of
service users across all Trust directorates
• A number of Advanced Practitioners, with a
specific remit around physical healthcare, in
post
Identified
2010/11:
Areas
for
Improvement
in
As part of its CQUIN priorities for 2010/11, the
Trust will undertake an Audit of compliance
against the minimum standards set out in the
Physical Healthcare Policy.
Methods of Monitoring,
Reporting Progress:
Measuring
and
Methods of measuring, monitoring and reporting
progress against this priority will be established
in an audit tool. Progress with the audit and its
outcomes will be shared with commissioners
on a quarterly basis and an action plan for
improvement (including timescales) agreed.
The audit outcomes and action plan will also be
shared with the Trust’s Physical Healthcare Group.
The Physical Healthcare Group provides reports
to the Clinical and Social Care Governance
Committee, on a bi-monthly basis, with regard
to the delivery of the Trust’s Physical Healthcare
Policy. The CSCGC is a formal committee of
the Trust Board with responsibility for advising
the Board on all clinical and non-clinical issues,
which affect patient care and services.
Timescales for Achievement:
End of March 2011
PRIORITY 7
Priority for Improvement:
Physical Environment
Quality Domain:
Safety
Aim/Goal:
To improve the safety of the physical environment
by reducing all potential ligature risks in the
Trust’s inpatient settings to a minimum
Rationale for Prioritising:
People with mental health problems are a high
risk group for suicide. Despite national declines
in inpatient suicide rates in the last ten years,
suicide remains the main cause of premature
death in people with mental illness.
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
27
Inpatient suicide using collapsible bed rails is
identified by the National Patient Safety Agency
(NPSA) as a never event. Never events are largely
preventable patient safety incidents that should
not occur if available preventative measures
have been implemented.
(high, medium or low) present in their inpatient
settings. These audits have considered patient
profile as well as clinical environment.
Current Status:
To reduce the risks identified in the ligature
audits, the Trust has committed to invest c£700k
in 2010/11. This investment follows significant
investment to reduce ligature risks in previous
years and is part of the Trust’s wider Capital
Programme for 2010/11 and. This year, the
Trust is planning to invest in excess of £7million
to improve physical environments and enable
service developments.
Following the launch of the National Suicide
Prevention Strategy in 2002, the Trust developed
a Suicide Prevention Toolkit for use by mental
health services. This Toolkit set out a framework
of eight standards to address the patient’s
experience of the care pathway from crisis
to admission. Significant changes have taken
place in mental health since the publication
of the Toolkit. As such, the Trust has recently
contributed to a piece of work led by the NPSA to
review and update the eight original standards.
The updated standards have been incorporated
into a new NPSA Toolkit (‘Preventing Suicide: A
Toolkit for Mental Health Services’) published in
November 2009. It includes audit procedures for
use by organisations to measure current practice
and identify areas for improvement.
To maintain patient safety, the Trust undertakes
regular audits to monitor and reduce dangers.
These audits are particularly focused on ligature
risks as hanging or strangulation is the most
common method of suicide in people with
mental illness. During February and March 2010,
services across the Trust have completed ligature
audits to determine the level of ligature risk
Identified
2010/11:
Areas
for
Improvement
in
Currently, the following areas are identified for
investment to reduce ligature risks in 2010/11:
•
•
•
•
Meadowbrook, Salford
Maple House, Bolton
Moorside, Trafford
Grasmere Ward, Adult Forensic Services,
Prestwich
• Kingsley and Lowry Ward, Adult Forensic
Services, Prestwich
These areas have been prioritised based on the
outcomes of the ligature audits.
Methods of Monitoring, Measuring and
Reporting Progress:
The Trust has an established Ligature Audit
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
28
Group, which comprises both corporate and
clinical services representatives. The Ligature
Audit Group is responsible for monitoring, coordinating and prioritising the outcomes of
ligature audits to enable capital investment to
reduce ligature risks.
Timescales for Achievement:
Capital works to reduce ligature risks in the
above areas will be complete by the end of
March 2011.
2.2 Review of Services
During 2009/10 GMW provided and/or subcontracted 46 NHS services. The services
provided are listed in Annex 2.
Where possible, GMW has reviewed all the data
available to them on the quality of care in 46 of
these services.
The income generated by the NHS services
reviewed in 2009/10 represents 100% of the
total income generated from the provision of
NHS services by GMW for 2009/10.
In addition to covering all services provided by the
Trust, the data reviewed to develop this Quality
Account has also covered the three dimensions
of quality (effectiveness, safety and patient
experience). This ensures that this Account is
a rounded reflection of the quality of services
provided and will hopefully enable readers to
gain a clear and balanced understanding of
what quality means to GMW.
The Trust’s robust business and clinical
information systems have supported the capture
of this diverse data. These systems include the
Trust’s integrated clinical information system
(ICIS), finance and contract monitoring systems
and integrated risk management software
(DATIX). ICIS supports the planning and delivery
of services by providing a record of the service
user’s ‘journey’ from referral to outcome and
ensuring that all information collected through
assessment, care planning and treatment is
captured. ICIS is used by clinical and administrative
staff across the Trust and effectively meets the
Trust’s diverse information needs. DATIX is used
to record, monitor and report, both internally and
externally, risk and performance management
across the Trust. Datix integrates a number of
modules, including incidents, risk management
and safety alert bulletins, into one system in
order to improve efficiency, provide tighter
management control and provided assurance
via qualitative and quantitative reports.
As outlined in Section 2.7, the Trust recognises
that high quality data is essential to planning
and delivering quality improvements. There is
always opportunity to review and improve the
quality, completeness, accuracy, timeliness and
validity of data.
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 2010
29
Currently, the Trust’s Business Intelligence and
Performance Team produce a confidential Data
Quality Report for each service on a routine basis.
The Data Quality Report includes demographic
and administrative data taken directly from
individual service users’ health care records.
Services monitor and act on the Data Quality
Report to improve the quality of service user
data. Assurance on data quality is subsequently
provided on a monthly basis to services as part
of their individual Performance Reports and the
Trust Board as part of the Board’s Performance
Report. Work is ongoing to review and improve
the content, structure and function of the Data
Quality Report, individual services’ Performance
Reports and the Board’s Performance Report.
This is with the aim of:
• Better supporting staff responsible for data
capture and reporting
• Ensuring consistency between internal and
external reporting requirements in terms of
data definitions and data sources
• Ensuring data relating to all key performance
indicators is captured, clearly presented and
positioned so as to be a focus of the reports
• Improving understanding and linking data
quality more clearly to the Trust’s corporate
objectives
• Further embedding data quality, and the wider
performance agenda, into the organisation’s
day to day operations
• Providing feedback to staff and service users
Staff from across the Trust will be involved in this
work, to ensure that performance reports, and
the performance indicators reported in them,
are relevant, able to demonstrate outcomes
and locally owned. The Trust may also consider
undertaking an audit of data quality to enable
improved understanding of the accuracy and
validity of data as well as just the completeness
and timeliness.
The Trust will also be working with its
commissioners to produce a Data Quality
Improvement Plan as part of its work-plan to
transfer contracts to the new Standard Contract
for Mental Health and Learning Disability
Services. This Improvement Plan will identify
gaps in the completeness of data available to
monitor performance against the contract and
agree steps to remedy this over the lifetime of
the contract.
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201030
2.3 Participation in Clinical
Audits and National
Confidential Enquiries
The Trust uses clinical audit, and participation
in national confidential enquiries, as a driver for
improvements in quality. The Trust aims to ensure
that all clinical professional groups participate in
clinical audit.
During 2009/10 one national clinical audit and
one national confidential enquiry covered NHS
services that GMW provides.
During 2009/10 GMW participated in 100%
of the national clinical audits and 100% of the
national confidential enquiries which it was
eligible to participate in.
The national clinical audits and national
confidential enquiry that GMW was eligible to
participate in during 2009/10 are as follows.
Clinical Audits:
• Prescribing Observatory for Mental Health
(POMH) Programme of Audits on Prescribing
Topics in Mental Health
National Confidential Enquiries:
• National Confidential Inquiry (NCI) into
Suicide and Homicide by People with Mental
Illness (NCI/NCISH)
The national clinical audits and national
confidential enquiries that GMW participated in
during 2009/10 are as follows:
Clinical Audits:
• Programme of Audits on Prescribing Topics in
Mental Health (POMH) – From this programme
of audits, the Trust has chosen to participate
in an audit on medicines reconciliation and an
audit on the use of anti-psychotic medication
in people with learning disabilities.
The Trust is unable to report participation in the
National Audit of Psychological Therapies for
Anxiety and Dementia as this audit was not active in
2009/10. The Trust’s National Standards and Audit
Group also reviewed in detail the terms and scope of
a National Audit of Dementia and National Audit on
Falls and Bone Health. The National Standards and
Audit Group is responsible for determining which
audits the Trust is eligible to, and should, participate
in. Both Audits were primarily focused on the care
provided in general hospitals and, as such, the Trust
did not participate in either nationally. The National
Standards and Audit Group did, however, recognise
the applicability of the audit topics to mental
health services. The Trust has therefore undertaken
two local dementia audits in 2009/10, looking at
compliance with NICE guidelines and dementia
quality standards. The outcomes of these audits
are reported below. The Trust has also adapted
the national falls audit tool to mental health with
the intention of undertaking a local audit of falls in
2010/11.
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201031
The Trust is unable to report participation in the National Audit of Psychological
Therapies for Anxiety and Dementia as this audit was not active in 2009/10. The
Trust’s
National Standards
National
Confidential
Enquiries:and Audit Group also reviewed in detail the terms and
scope of a National Audit of Dementia and National Audit on Falls and Bone Health.
The National Standards and Audit Group is responsible for determining which audits
• National
Confidential Inquiry (NCI) into
the Trust is eligible to, and should, participate in. Both Audits were primarily focused
Suicide
and
Homicide
by in
People
with
Mentaland, as such, the Trust did not participate in
on the care
provided
general
hospitals
Illnesseither
(NCI/NCISH)
– As
as participating
nationally.
Thewell
National
Standards and Audit Group did, however, recognise
in thisthe
enquiry,
the
Trust
has
also
undertaken
a health services. The Trust has therefore
applicability of the audit topics
to mental
undertaken
two local
audits
in 2009/10, looking at compliance with NICE
prevention
of suicide
auditdementia
in 2009/10
in line
guidelines
and
dementia
quality
standards.
The outcomes of these audits are
with the recommendations of this enquiry.
reported below. The Trust has also adapted the national falls audit tool to mental
health with
the intention
a local audit of falls in 2010/11.
The national
clinical
auditsof undertaking
and national
confidential
enquiries that GMW participated
National Confidential Enquiries:
in, and for which data collection was completed
during 2009/10,
are Confidential
listed belowInquiry
alongside
• National
(NCI) into Suicide and Homicide by People with
the number ofMental
cases Illness
submitted
to
each
audit
(NCI/NCISH) – As well as participating in this enquiry, the Trust
also undertaken
prevention
or enquiry as has
a percentage
of thea number
of of suicide audit in 2009/10 in line with the
recommendations
this enquiry.
registered cases
required by theofterms
of that
audit or enquiry.
The national clinical audits and national confidential enquiries that GMW 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 Clinical Audit
POMH
Programme of
Audits on
Prescribing
Topics in
Mental Health
Number
of Ward
Areas
Audited
Total
Sample
Frame
Required
Medicines Reconciliation
Completed May 2009
7
Use of Antipsychotic
Medication in People
with a Learning Disability
Completed Sept 2009
1
5
service
users
per
area
Total = 35
Sample
frame of 43
service
users
chosen
National Confidential Enquiry
National Confidential
Inquiry (NCI) into
Suicide and Homicide
by People with
Mental Illness
(NCI/NCISH)
Suicide
Homicide
Actual
Number
of Service
Users
Audited
31
86%
42
98%
Questionnaires Questionnaires
Sent to GMW
Completed &
Returned
27
21
10
9
%
%
78%
90%
To note: four further suicide questionnaires were
also sent to the Trust as part of 33
this National
Confidential Inquiry. These questionnaires
turned out to be unrelated to the Inquiry so are
excluded from the above figures.
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201032
To of
note:
furtherclinical
suicideaudits
questionnaires
were also sent to the Trust as part of this
The reports
twofour
national
were
National Confidential Inquiry. These questionnaires turned out to be unrelated to the
reviewed Inquiry
by the so
provider
in 2009/10 and GMW
are excluded from the above figures.
intends to take the following actions to improve
the quality
ofnote:
healthcare
provided:
The
reports
two
national
audits were
2009/10
To
fouroffurther
suicideclinical
questionnaires
werereviewed
also sentby
to the
the provider
Trust as in
part
of this
and GMW
intends to Inquiry.
take theThese
following
actions to improve
thetoquality
of healthcare
National
Confidential
questionnaires
turned out
be unrelated
to the
provided:
Inquiry
so are excluded from the above figures.
National
Clinical
Titleclinical auditsKey
Actions
The reports
of twoAudit
national
were
reviewed by the provider in 2009/10
POMH
Trust policy
developed
and approved.
POMH
and GMW intends
to take theMedicines
following actions
to improve
the quality
of healthcare
Reconciliation
Review prescription documentation.
Programme
provided:
of Audits on
Completed May 2009
Prescribing
POMH
of
Development
National
Clinical
AuditUse
Title
Key Actions of monitoring form to improve
Topics
in
Antipsychotic
recording
of side effects
of medication,
POMH
Medicines the
Trust
policy developed
and approved.
POMH
Mental
weight
changes, documentation.
blood
pressure
Medication
in People
Reconciliation
Review prescription
Programme
Health
assessment and blood glucose and lipids
with
a Learning
of
Audits on
Completed
May 2009
in the clinical record
Disability
Prescribing
Development
of monitoring form to improve
POMH
Use of
Completed Sept 2009
Topics in
Antipsychotic
the recording of side effects of medication,
Mental
weight
changes,
blood
pressure
Medication in People
Health
The reports of 25
local
clinical audits were
reviewed by
theblood
provider
in 2009/10
and
assessment
and
glucose
and lipids
with
a Learning
GMW intends to
take the following actions
toclinical
improve
the quality of healthcare
in the
record
Disability
The reports of 25 local clinical audits were
provided:
Completed Sept 2009
reviewed by the provider in 2009/10 and GMW
intends to
the following
actions
to improve
Local Clinical
Audit
Actions
The reports
of 25 local
clinicalKey
audits
were reviewed
bytake
the provider
in 2009/10
and
the
quality
of
healthcare
provided:
GMWTitle
intends to take the following actions to improve the quality of healthcare
1
Physical Healthcare
provided:
1
2
2
3
3
Services should review the equipment they have
against the Trust Physical Healthcare Policy list of
and purchase the outstanding items.
Completed
April 2009
Local Clinical
Audit equipment
Key Actions
All inpatient physical health checks should be carried
Title
out within should
24 hoursreview
of admission.
If this is not
possible
Physical Healthcare
Services
the equipment
they
have
the reasons
why should
be Healthcare
documentedPolicy
in ICISlist(the
against
the Trust
Physical
of
Trust’s Integrated
Clinicalthe
Information
System).
and purchase
outstanding
items.
Completed April 2009 equipment
investigations
stipulated
the Trust
policy
should
All inpatient
physical
health in
checks
should
be carried
take
place
as
part
of
the
physical
health
check.
out within 24 hours of admission. If this is not possible
the reasons why
shouldscreen
be documented
in ICIS
(the
Health and Safety:
Trust-wide
display
equipment
training
Trust’s Integrated
Clinical Information System).
Display Screen
programme
to be developed
Equipment (DSE)
All investigations
in the ofTrust
policy Screen
should
staff to be stipulated
made aware
Display
take
place as
part of the physical health check.
Equipment
policy
Completed
2009
Health
and July
Safety:
Trust-wide display screen equipment training
Audit
of Screen
the Absent
AWOL policy
section
3.2 to be reinforced with staff.
Display
programme
to be
developed
Equipment
(DSE)
Without Leave
Assurances
be sent
Specialist
All staff toto be
madeto aware
of Services
Display Network
Screen
(AWOL) policy
Lead
in relation
to risk assessments i.e. risk
Equipment
policy
assessments must be subject to regular review and
Completed July 2009
updating
by the
clinical
Completed
Dec
2009
Audit of the Absent
AWOL policy
section
3.2 team
to bewhenever
reinforcedthe
withservice
staff.
user’s condition
risk to
profile
changes
(this includes
Without Leave
Assurances
to beorsent
Specialist
Services
Network
following
incident to
of escape,
absconsion, AWOL
or
(AWOL) policy
Lead
in anrelation
risk assessments
i.e. risk
going missing).must be subject to regular review and
assessments
AWOL policy
section
3.4 team
to bewhenever
reinforcedthe
withservice
staff.
updating
by the
clinical
Completed Dec 2009
Assurances
to
be
sent
to
Specialist
Services
Network
user’s condition or risk profile changes (this includes
Lead in anrelation
the requirement
each
following
incident to
of escape,
absconsion, for
AWOL
or
assessment
to be clearly documented in ICIS.
going
missing).
be be
reinforced
withwith
staff.staff.
AWOL policy
policy section
section6.2
3.4to to
reinforced
Network
Assurances to
to be
besent
senttotoSpecialist
SpecialistServices
Services
Network
relation
to service
usersrequirement
who escape, for
go each
Lead inin
relation
to the
assessment to be clearly documented in ICIS.
AWOL policy section 6.2 to be reinforced with staff.
Assurances to be sent to Specialist Services Network34
Lead in relation to service users who escape, go
34
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201033
Local Clinical Audit Key Actions
Title
AWOL or abscond i.e. if the police are informed staff
should complete the notification of absent patient proforma in appendix 3 of the AWOL policy.
4
Safeguarding Children
audit
Completed June 2009
5
Audit of National
Institute for Clinical
Excellence (NICE)
Implementation
Completed June 2009
6
7
NICE guidelines for
Anxiety/Obsessive
Compulsive Disorder
(OCD)/Post Traumatic
Stress Disorder
(PTSD)
Completed March
2010
Awareness of the
Mental Capacity Act
(MCA) 2005 and the
Code of Practice
Completed June 2009
8
Infection Prevention
Completed March
2010
9
10
NICE Guidelines on
the Management of
Bipolar Disorder:
Lithium Monitoring
Clinical Records: 10
Golden Rules –
All staff to be made aware of the local procedures
regarding Child Protection concerns.
All staff to be made aware of the Trust Safeguarding
Children policy
All staff to be made aware of the scheme of delegation
in their service regarding reporting of child welfare
concerns.
All child visiting areas to be risk assessed
Continue raising awareness of NICE throughout the
Trust
Promote the outcome of the Trust NICE
Implementation and Audit Group meetings in the Trust
newsletter/Lessons Learned publications.
Consider how NICE can be best promoted throughout
the Trust.
When clinicians become aware that a service user may
require additional cognitive behavioural therapy (CBT)
sessions, this should be raised within Clinical
Supervision and service managers alerted.
Clinicians to be provided with information on local
service availability to support effective signposting.
Information materials on mental capacity act (MCA) to
be made available for service users and carers
Information on IMCA (Independent Mental Capacity
Advocate) providers and how to access them via Trust
website and Trust Governance newsletter
A Trust-wide training needs analysis of MCA training to
be undertaken to ensure all relevant staff undergo MCA
training
Audit tool to be revised prior to future audits.
Quarterly hand washing technique audit implemented
To increase infection prevention audit to bi-annually for
inpatient areas
To educate link workers on completion of audit tools
e.g. isolation facilities
Report with audit lead for action planning
Report with audit lead for action planning
35
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201034
Local Clinical Audit Key Actions
Title
Nursing Records,
Progress notes
11
Safeguarding Adults
Completed November
2009
12
Oxygen Safety in
Hospitals
(NPSA/2009/RRR006)
Completed Nov 2009
13
Ligature Audit
14
Safe and appropriate
care for under 18s
admitted to adult
wards
Audit of NICE
guidelines for
Dementia
15
Completed April 2009
16
17
18
Audit of Dementia
Quality Standards
Completed March
2010
Chapter 21– leave
arrangements for
service users
(formerly Section 17)
Care Programme
Approach (CPA)
Completed May 2009
Safeguarding information to be displayed in areas
where the public have access
Inclusion of safeguarding adults training in local
induction arrangements. Development of e-learning
training package to be provided on Staffnet
All managers to be aware of local training course,
training needs to be included in personal development
plans and staff appropriately nominated onto courses
Medical gasses policy to be developed
NPSA/2009/RRR006 and briefing sheets available to
all relevant staff
Where the use of oxygen cylinders is unavoidable
robust systems are in place to ensure reliable and
adequate supplies of oxygen including checking and
stocktaking of cylinders
The risk of confusing oxygen and medical compressed
air are assessed and action plans developed
Pulse oximetry to be available in all locations where
oxygen is used.
Report with audit lead for action planning
Report with audit lead and Joint Child Safeguarding
Group for action planning
Develop standards with in the Trust and with partner
agencies that include the management of challenging
behaviour and medication use
Develop protocols with PCTs on the management of
challenging behaviours and medication use for people
in residential care
Report with audit for action planning
Report with audit lead for action planning
All service users to have an initial risk assessment &
risk management plan recorded in ICIS
Staff to ensure that lone worker information is recorded
Ensure that service users have access to a written or
printed copy of their care plan
Decisions about care and treatment are taken involving
the service user. This must be recorded in ICIS
Where an advocate is involved, decisions about the
care of treatment of the service user must involve the
36
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201035
Local Clinical Audit Key Actions
Title
advocate. This must be recorded in ICIS
All care plans to include crisis plan and emergency
numbers for the service user
19
Audit relating to NICE
guidelines for
Schizophrenia
(Specialist services)
Completed Jan 2010
20
Audit relating to NICE
guidelines for
Schizophrenia (District
services)
Completed Jan 2010
21
Audit of Rapid
Tranquillisation
Completed July 2009
22
Audit of Compliance
with the Trust’s
Observation policy
Completed April 2009
23
Self Injury Audit
Completed June 2009
24
Prevention of Suicide
Staff to record in ICIS that CBT has been considered
for all service users and the rationale for why it is not
appropriate recorded
Medical staff to record the rationale for not prescribing
Clozapine to service users with treatment resistant
schizophrenia
Staff made aware that advance decisions and
statements are to be recorded in the care plan
Scope the number of service users who have an
identified carer and ascertain the number of carers that
would welcome the opportunity to undertake family
intervention
Baseline family therapy skills within all community
based services
Psychological therapies to develop operational protocol
for the delivery of CBT
The rationale for prescribing combined antipsychotic
medication to be documented in the clinical record
Develop care plan for the monitoring of physical
observations following administration of rapid
tranquillisation
Prescribers reminded to prescribe Procylidine IM in
conjunction with Haloperidol IM
Audit lead to review the observation recording sheet to
develop a standard recording sheet across the Trust
Staff need to record in ICIS whether or not the service
user is able to engage in therapeutic activities during
observation
Staff to ensure that all the observation recording forms
are signed for at each period of observation. If, for any
reason, it is not possible to observe the service user by
the member of staff allocated to observation, the
reason why this has occurred should be recorded on
the observation recording form and signed
All recording sheets for level 1 and 2 observations to
be scanned onto ICIS as part of the care record
The Trust’s self-injury toolkit to be re-printed and widely
circulated
Consideration to be given to specific training to be
developed and made available for self-injury
Directorates to develop and implement actions to
address any deficits identified in the audit, with
particular reference to ensuring comprehensive
psychosocial assessments and effective and
comprehensive risk management plans
Provide updates/information and monitor referrals for
service users referred to NPI group for psychological
37
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201036
Local Clinical Audit Key Actions
Title
Completed June 2009 interventions related to service users at risk of
suicide/self harm
Provide updates and report on arrangements for
ensuring that families/carers of service users at risk of
suicide/self harm are kept appropriately informed
Dual diagnosis policy implemented
25
Thematic Review of
Post Incident Reviews
(PIRs)
Completed June 2009
Report presented to the following: Network Boards,
Trust post incident review panel, Professional Advisory
Group, Risk Management Strategy Group,
Clinical & Social Care Governance Committee
As a result of this audit, further audits are planned for
2010/11 on audit of clinical supervision and audit of
record keeping (medical notes)
All and
national
localaudit
clinical
auditarereports are reviewed by the Trust’s NICE
All national
localand
clinical
reports
2.4
inisClinical
Implementation and Audit Group, which meets
on aParticipation
bi-monthly basis and
chaired
reviewed by
by the
Trust’s
NICE
Implementation
and
the Trust’s Medical Director, Dr Steve Colgan.
The
outcomes
of
discussion
at the
Research
Audit Group,
meets on aand
bi-monthly
basis are fed up to the Trust’s Clinical and Social
NICEwhich
Implementation
Audit Group
and is chaired
the Trust’s Committee
Medical Director,
Dr by the Medical Director. The CSCGC is a
Care by
Governance
(CSCGC)
Research is essential to the successful promotion
Steve Colgan.
outcomes
at the
formalThe
committee
of of
thediscussion
Trust Board
with responsibility for advising the Board on all
of health
and
well-being
and identifying
is a core part of the
clinical and non-clinical
issues,are
which
affect patient
care
and
services, and
NICE Implementation
and Audit Group
fed up
NHS. The
Trust
has activity
an active
research
areas
of concern,
change
development related
to the
clinical
of the
Trust. function
to the Trust’s
Clinical
and Social
Careand
Governance
– as demonstrated
below
– whichbyis driving
To (CSCGC)
ensure thisbyresponsibility
discharged appropriately,
the CSCGC
is chaired
Committee
the Medicalis Director.
one of the Trust’s non-executive directors to
(Professor
Karen Luker)
make research
part ofand
theincludes
Trust’s everyday
The CSCGC is a formal committee of the Trust
representation from the Trust’s medical, business.
nursing, psychology and pharmacy
Board with
responsibility
for advising
the Board
workforce.
The Trust
Board receive
and review the ratified minutes of every CSCGC
on all clinical
and
non-clinical
issues,
which
affect
meeting and are apprised of audit outcomes
improvement
plansreceiving
in this way.
Theand
number
of patients
NHS services
patient care
and services,
identifying
areas the Trust Board may also receive more
Depending
on theand
topic
being audited,
provided or sub-contracted by GMW in the year
comprehensive
updates on individual
of concern,
change and development
related toaudit outcomes via audit leads or corporate
to 31 March 2009 that were recruited during
sponsors.
the clinical
activity of the Trust. To ensure this
that period to participate in research approved
responsibility is discharged appropriately, the
by a research ethics committee was 794.
CSCGC is chaired by one of the Trust’s non2.4
Participation in Clinical Research
executive directors (Professor Karen Luker) and
Of the 794 service users participating in ethically
includes representation
from the Trust’s medical,
Research is essential to the successful promotion
of health
and well-being
and iswere
a recruited
approved
research
studies, 216
nursing, psychology
andNHS.
pharmacy
workforce.
core part of the
The Trust
has an activeinto
research
function
–
as
demonstrated
studies on the National Institute for Health
The Trustbelow
Board– receive
review
the ratified
which isand
driving
to make
research part of the Trust’s everyday business.
Research (NIHR) portfolio in 2008/09. Studies on
minutes of every CSCGC meeting and are
the NIHR portfolio are funded by grants from
number
of patients
NHS services provided or sub-contracted by GMW
apprised The
of audit
outcomes
andreceiving
improvement
external
bodies
NIHR. In
in the
year
to 31 March
2009
thatbeing
were recruited
during
that issued
period by
to the
participate
in addition,
plans in this
way.
Depending
on the
topic
290
Trust
staff
were
recruited
into
18
ethically
research
by also
a research
audited, the
Trust approved
Board may
receiveethics
morecommittee was 794.
approved research studies during the year to 31
comprehensive updates on individual audit
Of the 794 service users participating in ethically
studies,
216
March approved
2009 andresearch
the Trust
also supported
49
outcomeswere
via audit
leadsinto
or corporate
sponsors.
recruited
studies on
the Nationalstudent
Instituteresearch
for Health
Research
(NIHR)
projects as follows:
portfolio in 2008/09. Studies on the NIHR portfolio are funded by grants from external
bodies issued by the NIHR. In addition, 290 Trust staff were recruited into 18 ethically
• Doctor of Philosophy (PhD) projects – 21
approved research studies during the year to 31 March 2009 and the Trust also
• Doctorate in Clinical Psychology (DClinPsych)
supported 49 student research projects as follows:
•
•
projects – 23
Doctor of Philosophy (PhD) projects –•21Masters projects – 4
• Undergraduate
-1
Doctorate in Clinical Psychology (DClinPsych)
projects –projects
23
38
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201037
Complete data on participation in all ethically
approved research studies during 2009/10 is not
available at the time of writing. For the period 1
April 2009 to 15 March 2010, it is known that
430 service users were recruited by the Trust
into NIHR portfolio studies. This is an increase
on participation in 2008/09.
In a 2009 audit, 29 out of 72 studies audited
(40%) declared some level of service user
involvement in the research process itself. This
involvement included involvement in:
•
•
•
•
•
The application process
Project design, direction and dissemination
Commenting on and reviewing the Protocol
Acting as critical reviewer
Design or review of questionnaires and
manuals
• Activity on Steering Committees and
Management Groups
• Activity on Service User Reference Groups
• Feedback on completion of the study
In particular, the Trust has a successful track
record of service user-led research related to
psychosis. The Trust employed four service
users with a history of psychosis to work under
the supervision of Professor Tony Morrison
to conduct user-led research in this area. The
outcomes of this research has had direct impact
on service provision locally, nationally and
internationally, and resulted in a number of
influential publications and successful research
grant applications to the NIHR. These grants
include a £2million grant for research focusing
on recovery from psychosis, which was inspired
by the original user-led research. The Trust
actively supports the personal and professional
development of its service user researchers.
The increasing level of participation in clinical
research demonstrates GMW’s commitment
to improving the quality of care we offer,
encouraging service user involvement in every
aspect of the research process and to making
our contribution to wider health improvement.
GMW was involved in 107 clinical research
studies as either a host site or a participating
site, during the year ended 31 March 2010. 61
of these studies remained open and active at 31
March 2010. Of this 61, 37 studies open during
the year 2009/10 were on the NIHR Portfolio
and supported by NIHR research networks.
GMW uses national systems - for example,
NIHR’s CSP (co-ordinated system for gaining
NHS permission) - to manage its research
studies in proportion to risk. Of the studies
given permission to start, the average time for
permission to be given by an authorised person
from receipt of a complete, valid and ethically
approved application was 11 days in 2009. This
figure compares to 17 days in 2008. 89% of
studies were approved in under 30 days, with a
maximum approval time 49 days.
In 2009, 43 researchers external to the Trust were
issued with either honorary research contracts
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201038
In the last three years (2007-2009) 199 publications have resulted from researchers
linked to the Trust, helping to improve outcomes and experience across the NHS.
2.5
Commissioning for Quality and Innovation (CQUIN)
The Commissioning for Quality and Innovation payment framework (CQUIN) aims to
embed quality as the organising principle for NHS services and place quality at the
heart of every organisation’s operations.
A proportion of GMW’s income in 2009/10 was conditional on achieving quality
improvement and innovation goals agreed between GMW 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 12 month period
are available on request from communications@gmw.nhs.uk.
(16 issued) or letters of access (27 issued) using
2.5 Commissioning for Quality
the Research
process.
Thisconditional
compareson
to the achievement of CQUIN goals in 2009/10
The Passport
proportion
of income
1
and Innovation (CQUIN)
was research
0.5%. This
equatesand
to £0.5million
27 honorary
contracts
23 letters across all applicable contracts . The goals
and
its honorary
commissioners for 2009/10 were as follows. Rationale
of accessagreed
being between
issued inGMW
2008.
The
The Commissioning for Quality and Innovation
for
these
goals
is
also
provided.
research contracts and letters of access issued
payment framework (CQUIN) aims to embed
during 2009
were linked to 38 projects newly
2009/10 CQUIN goals:
quality as the organising principle for NHS
approved during that year.
services and place quality at the heart of every
CQUIN Goal for 2009/10
Rationale
organisation’s operations.
In the last
years Approach
(2007-2009)
199– Undertaking CPA reviews within 6Care three
Programme
(CPA)
75% have
of service
usersfrom
on CPA
reviewed monthly intervals will:
publications
resulted
researchers
A proportion of GMW’s income in 2009/10 was
within
6 monthly
linked to the
Trust,
helpingintervals
to improve outcomes
on delivery
achievingofquality
improvement
• conditional
Support the
recoveryand experience across the NHS.
and
innovation
goals agreed between GMW and
focussed
services
any
person
or
body
entered
into a contract,
• Ensure compliancethey
with
the Trust’s
‘CPA Policy’
agreement
or arrangement with for the provision
• ofReduce
clinical
NHS services, risks
through the Commissioning for
• Quality
Ensure and
that care
plans remain
relevant
Innovation
payment
framework.
and
effective
Further details of the agreed goals for 2009/10
Dual Diagnosis – 75% of dual diagnosis Dual diagnosis is associated with poorer
and for the following 12 month period are
service users to have a CPA plan in outcomes in a number of areas of clinical
available
onthose
request
from in
communications@
care
than for
individuals
contact
place.
gmw.nhs.uk.
with
mental health services who do not
Dual diagnosis service users are those use substances.
with a substance misuse diagnosis and
The proportion of income conditional on the
Ensuring
that of
service
users
with
dual
another mental illness diagnosis
achievement
CQUIN
goals
in 2009/10
was
diagnosis
have
a
care
plan
in
place
will:
0.5%. This equates to £0.5million across all
applicable contracts1. The goals agreed between
• Better meet the needs of service users
GMW
and its commissioners for 2009/10 were
with dual diagnosis
follows.
Rationale for these goals is also
• asImprove
outcomes
provided.
• Improve understanding
• Improve collaboration between mental
health and substance misuse services
CQUIN was not applied to the Trust’s contracts for community substance misuse
services or therapeutically enhanced medium secure services for women (TEMSS) in
2009/10. TEMSS is a national pilot and therefore excluded from CQUIN on this basis.
1
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201039
40
The proportion of income conditional on the achievement of CQUIN goals in 2009/10
was 0.5%. This equates to £0.5million across all applicable contracts1. The goals
agreed between GMW and its commissioners for 2009/10 were as follows. Rationale
2009/10 for
CQUIN
thesegoals:
goals is also provided.
2009/10 CQUIN goals:
CQUIN Goal for 2009/10
Rationale
Care Programme Approach (CPA) – Undertaking CPA reviews within 675% of service users on CPA reviewed monthly intervals will:
within 6 monthly intervals
• Support the delivery of recoveryfocussed services
• Ensure compliance with the Trust’s
‘CPA Policy’
• Reduce clinical risks
• Ensure that care plans remain relevant
and effective
Dual Diagnosis – 75% of dual diagnosis Dual diagnosis is associated with poorer
service users to have a CPA plan in outcomes in a number of areas of clinical
care than for those individuals in contact
place.
with mental health services who do not
Dual diagnosis service users are those use substances.
with a substance misuse diagnosis and
Ensuring that service users with dual
another mental illness diagnosis
diagnosis have a care plan in place will:
• Better meet the needs of service users
with dual diagnosis
• Improve outcomes
• Improve understanding
• Improve collaboration between mental
CQUIN Goal for 2009/10
Rationale
health and substance misuse services
• Reduce clinical risk
175% of service users on CPA, or their
The 5forareas
selected
were identified
CQUIN was not applied to the Trust’s contracts
community
substance
misuse as
areas
for
improvement
in
the
Trust’s
carers,
have:
services or therapeutically enhanced medium secure services for women (TEMSS)
in
community
mental
health
service
user
•2009/10.
Been TEMSS
given anisinformation
pack
a national pilot and therefore excluded from CQUIN on this basis.
• Been given or offered a copy of their survey in 2008
care plan
40
• Had their views taken into account Delivering these improvements will:
• Support the delivery of recoverywhen their care plan is produced
focussed services
• Had the side effects of their
•
Ensure compliance with the Trust’s
medication discussed
‘CPA
Policy’
• Received or been offered a carers
• Reduce clinical risks
assessment
• Ensure that care plans remain relevant
and effective
• Increase user and carer involvement in
decision making
Physical Health – Development of a Individuals with mental health problems
physical health shared care agreement
suffer significantly poorer health than the
rest of the general population and are
more likely to die young of major physical
health problems
Individuals with mental health problems
are found to have higher levels of unmet
physical health need and to receive less
effective treatment
GMW is committed to the principle that
users of mental health services should
have access to the same quality of
Greater Manchester West Mental Health Foundation NHS Trust physical
Quality Account
/ 201040
health2009
services
as the general
population
• Support the delivery of recoverywhen their care plan is produced
focussed services
• Had the side effects of their
• Ensure compliance with the Trust’s
medication discussed
‘CPA Policy’
• Received or been offered a carers
• Reduce clinical risks
assessment
• Ensure that care plans remain relevant
and effective
• Increase user and carer involvement in
CQUIN Goal for 2009/10
Rationale
decision making
Physical Health – Development of a •Individuals
with mental
Reduce clinical
risk health problems
physical
health shared
agreement
suffer5 significantly
poorer
health
than the
areas selected
were
identified
as
75%
of service
users care
on CPA,
or their The
rest of for
the improvement
general population
are
areas
in the and
Trust’s
carers, have:
more likely tomental
die young
of major
physical
community
health
service
user
• Been given an information pack
health
problems
survey
in
2008
• Been given or offered a copy of their
care plan
Individualsthese
with improvements
mental health will:
problems
• Had their views taken into account Delivering
found to the
havedelivery
higher levels
of unmet
•areSupport
of recoverywhen their care plan is produced
physical
health
need
and
to
receive
less
focussed
services
• Had the side effects of their
effective
treatment
• Ensure compliance with the Trust’s
medication discussed
‘CPA Policy’
• Received or been offered a carers
is committed
to the principle that
•GMW
Reduce
clinical risks
assessment
users
of
mental
health
should
• Ensure that care plans services
remain relevant
have
and access
effective to the same quality of
physical
health
the general
• Increase
user services
and careras
involvement
in
population
decision making
individuals
learning
Learning
Disabilities
– Action plan
Physical Health
– Development
of in
a For
Individuals
with with
mental
healthdisabilities
problems
and
mental
health
problems
the
types
place
to
progress
requirements
of
the
physical health shared care agreement
suffer significantly poorer health than
the
and
quality
of
services
available
Green Light Toolkit.
rest of the general population and vary
are
from
locality
morelocality
likely totodie
young of major physical
health problems
Working to deliver the requirements of
the
Green Light
improve
multiIndividuals
with Toolkit
mentalwill
health
problems
agency
working
and
better
support
are found to have higher levels of unmet
individuals
with need
mental
problems
physical health
andhealth
to receive
less
and
a learning
disability
effective
treatment
Through commitment and focused effort from
staffisacross
the organisation,
the Trust
GMW
committed
to the principle
that
achieved all of its CQUIN goals in 2009/10users
and received
the
full
monetary
of mental health servicespayment
should
associated with this.
have access to the same quality of
physical health services as the general
In 2010/11, 1.5% of the Trust’s income will
be conditional on the achievement of
population
CQUIN.
The
goals
agreed
for
2010/11
are
more
challenging
andlearning
indicate disabilities
continued
with
Learning Disabilities – Action plan in For individuals
commitment
from
both
the
Trust
and
our
commissioners
to
delivering
meaningful
health
types
to progress
requirements
of
the and
Through place
commitment
and focused
effort
from
• Amental
scheme
with problems
the
NorththeWest
Specialised
quality
improvements.
The Trust
has
agreedand
two
CQUIN
schemes
for 2010/11:
quality
of
services
available
vary
Green
Light
Toolkit.
staff across the organisation, the Trust achieved
Commissioning Team (NWSCT). NWSCT
from locality to locality
all of its CQUIN goals in 2009/10 and received
the full monetary payment associated with this.
commission a number of our secure and
specialist
services
our medium
and
Working
to deliver
theincluding
requirements
of
low
secure
services
(Edenfield
and
Bowness);
the Green Light Toolkit will improve multiIn 2010/11, 1.5% of the Trust’s income will be agency
mental
health and
and better
deafnesssupport
services
(John
working
41
individuals
with
mental
health
problems
conditional on the achievement of CQUIN. The
Denmark Unit); adolescent psychiatry services
a learning disability
goals agreed for 2010/11 are more challenging and (McGuinness
Unit); forensic assessment,
and indicate continued commitment from both
consultation and treatment service for children
and focused
effort from staff
the organisation,
theSt.
Trust
the Trust Through
and ourcommitment
commissioners
to delivering
andacross
adolescents
(FACTS); and
Joseph’s Bail
achieved all of its CQUIN goals in 2009/10 and received the full monetary payment
meaningful
quality improvements. The Trust has
Hostel.
associated with this.
agreed two CQUIN schemes for 2010/11:
In 2010/11, 1.5% of the Trust’s income will be conditional on the achievement of
• A scheme
withThe
ourgoals
PCT agreed
commissioners
(co-are more challenging and indicate continued
CQUIN.
for 2010/11
commitment
from
the Trust
and our commissioners to delivering meaningful
ordinated
on behalf
of both
all PCTs
by Bolton,
improvements.
Salfordquality
and Trafford
PCTs) The Trust has agreed two CQUIN schemes for 2010/11:
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201041
41
•
Scheme
PCT
Scheme
A scheme with the North West Specialised Commissioning Team (NWSCT).
NWSCT commission a number of our secure and specialist services
including our medium and low secure services (Edenfield and Bowness);
mental health and deafness services (John Denmark Unit); adolescent
psychiatry services (McGuinness Unit); forensic assessment, consultation
and treatment service for children and adolescents (FACTS); and St.
Joseph’s Bail Hostel.
CQUIN Goal for 2010/11
Rationale
Advancing Quality (AQ) – Collection • AQ is about giving the best quality
and reporting of data required for the
treatment first time, every time
two AQ work-streams (dementia and • AQ applies a systematic approach to
psychosis)
care by measuring and monitoring
interventions to ensure they happen.
This goal is a regional goal established • Existing data for dementia and
by the strategic health authority (NHS
psychosis is currently poor on a
North West) for achievement by all
regional basis
mental health organisations in the North • AQ will provide the opportunity for
West
organisations across the North West to
benchmark and compare
Learning Disabilities (Green Light As per 2009/10 scheme
Toolkit) – To have in place an action
plan, which will enable people with • Green Light Toolkit promoted as an
learning disabilities who have a mental
effective tool by NHS Evidence and
health problem to access services and
supported by ‘Valuing People Now’ and
be treated equally. 90% of actions that
‘Healthcare for All’, which place an
are within GMW’s sole ability to achieve
emphasis on partnership working to
to be achieved by year-end.
meet the mental health needs of
people with learning disabilities and the
This goal is a regional goal established
right of people with learning disabilities
by the strategic health authority (NHS
to benefit from the same standards of
North West) for achievement by all
mental health treatment as the general
mental health organisations in the North
population.
West.
• Use of the Toolkit is supported by
users and carers
As per 2009/10 CQUIN scheme. Target
Care Plan Assessment (CPA) ‘stretched’ to 85% to enable further
1) 85% of service users on CPA improvements
reviewed within 6-monthly intervals
2) 85% of service users on CPA, or
their carers, have:
• Been given an information pack
• Attended or been invited to attend
their CPA review
• Been given or offered a copy of
their care plan
• Had their views taken into
account when their care plan is
produced
• Had the side effects of their
medication discussed
CQUIN
Goal for 2010/11
• Received
or been offered a Rationale
carers assessment
Physical Healthcare – To ensure
compliance with the minimum standards
for the physical healthcare of service
users across all Trust directorates as
set out in the Trust’s ‘Physical
Healthcare Policy’. Audit of compliance
to be undertaken
Clinical Outcomes –
As per 2009/10 CQUIN scheme.42This
goal builds on the progress made with the
development of a shared care agreement
for physical healthcare in 2009/10.
To ensure effective clinical care, which
can be monitored and reviewed to identify
1) 75% of service users discharged individual outcomes for service users
Greater Manchester West
Mental
Health services
Foundation
NHS had
Trust a
Quality Account 2009 / 201042
from
inpatient
have
diagnosis confirmed
carers assessment
Scheme
Physical Healthcare – To ensure
compliance with the minimum standards
for the physical healthcare of service
users across all Trust directorates as
set out in the Trust’s ‘Physical
Healthcare Policy’. Audit of compliance
to
be undertaken
CQUIN
Goal for 2010/11
Clinicalcarers
Outcomes
–
assessment
As per 2009/10 CQUIN scheme. This
goal builds on the progress made with the
development of a shared care agreement
for physical healthcare in 2009/10.
Rationale
To ensure effective clinical care, which
can be monitored and reviewed to identify
individual
outcomesCQUIN
for service
users This
As per 2009/10
scheme.
goal builds on the progress made with the
development of a shared care agreement
for physical healthcare in 2009/10.
1)
75% of
service users
discharged
Physical
Healthcare
– To
ensure
from inpatient
have
had a
compliance
with theservices
minimum
standards
diagnosis
confirmed
for the
physical
healthcare of service
2)
of service
users
have hadas
a
users75%
across
all Trust
directorates
of the‘Physical
Nation
set HONOS
out in (Health
the Trust’s
Outcomes
Scales)
Healthcare
Policy’.
Audit of assessment
compliance
completed
at
the
last
CPA
review
to be undertaken
is required
to work
accordance
Anti-Psychotic
for GMW
To ensure
effective
clinicalin care,
which
Clinical Outcomes – Prescribing
guidelines
to ensure
best
Individuals Diagnosed with a Psychiatric with
can beNICE
monitored
and reviewed
to identify
practice.for
Achievement
of this
Illness
– of service users discharged prescribing
individual outcomes
service users
1) 75%
from inpatient services have had a goal will enable benchmarking and may
1) diagnosis
To establish
a baseline, via clinical also help deliver best value.
confirmed
of
current
prescribing
2) audit,
75% of service
users have
had a
practice
of
HONOS (Health
of anti-psychotic
the Nation
medication
Outcomes Scales) assessment
2) completed
To develop
a protocol
for antiat the
last CPA review
psychotic prescribing
Anti-Psychotic
Prescribing
for GMW is required to work in accordance
As perNICE
PCT CQUIN
scheme
NWSCT Advancing
Quality
(AQ)
–
Data
guidelines
to ensure best
Individuals Diagnosed with a Psychiatric with
collection
Illness – and reporting for psychosis prescribing practice. Achievement of this
and dementia. As per PCT CQUIN goal will enable benchmarking and may
scheme.
1) To establish a baseline, via clinical also help deliver best value.
Outcomes
Use of To improve and demonstrate outcome
audit, Measurement
of
current –prescribing
appropriate
HONOS to measurement
practice version
of of anti-psychotic
measure
outcomes.
medication
2) To develop
for antiRecovery
Planninga – protocol
Implementation
of Recovery plans indicate a clear pathway
psychotictool
prescribing
a recognised
for recovery planning. and milestones for both service users and
carers
work
towards.
Once tool is implemented,
every
per to
PCT
CQUIN
scheme
NWSCT Advancing
Quality (AQ)
– service
Data As
user should
be reporting
offered the
collection
and
for opportunity
psychosis
to complete
a recovery
planPCT CQUIN Achieving this goal will:
and
dementia.
As per
scheme.
Outcomes Measurement – Use of •ToEnsure
improve
and are
demonstrate
outcome
services
recovery-focussed
appropriate version of HONOS to •measurement
Reduce length of stay
measure outcomes.
Ensure service users are cared for in
indicate
a clear pathway
Recovery Planning – Implementation of Recovery
the leastplans
restrictive
environment
and milestones
for both
service users and
a recognised
tool–forUse
recovery
ward
environments
are
Ward
Climate
of aplanning.
climate Supportive
carers to workas
towards.
Once tool isscale
implemented,
every
a pre-condition for
evaluation
to measure
and service
enable recognised
userdevelopment
should be offered
the opportunity
the
of a supportive
ward successful treatment.
Achieving this goal will:
to
complete
a
recovery
plan
environment
Initiatives Developed from Service User Achieving this goal will improve service
• Ensureexperience
services are recovery-focussed
Views – Demonstrate at least 3 new user
and
promote
• Reduce length
service
user
defined
service engagement
withof stay
service users. The
Scheme improvements
CQUIN Goal for 2010/11
Rationale
for
each
service. initiatives
will provide
a platform
Ensure service
users are
cared for for
in
eliciting
the
views
of
service
users
and
Improvements to be implemented:
the least restrictive environment
provide opportunities
for real and valued
ward environments
are
Ward Climate – Use of a climate Supportive
service
improvements
•
Audit ofscale
‘ThetoDining
Experience’
evaluation
measure
and enable recognised as a pre-condition43 for
• development
Implementation
GMW Advance
the
of of
a supportive
ward successful treatment.
Decision Plan
environment
•
Progress
against from
CPA Service
questions
on Achieving this goal will improve service
Initiatives
Developed
User
information
pack, care
plans,
side user
Views
– Demonstrate
at least
3 new
experience
and
promote
effects user
of medication
views engagement with service users. The
service
defined and service
taken into account
improvements
for
each
service. initiatives will provide a platform for
Therapeutic Activity – Medium and low Achieving this goal will:
secure providers to meet the quality
standard
of aHealth
minimum
of 25 NHS
hours
per
Greater Manchester
West Mental
Foundation
Trust
Quality
Account 2009
/ 201043
• Ensure
service
users are able
43 to
week per service user of structured
access therapy
Improvements to be implemented:
•
•
Scheme
Audit of ‘The Dining Experience’
Implementation of GMW Advance
Decision Plan
•
Progress against CPA questions on
information pack, care plans, side
effects of medication and views
CQUIN
Goal
2010/11
taken
intofor
account
Improvements
to be implemented:
Therapeutic
Activity
– Medium and low
secure providers to meet the quality
•
Auditof
of a‘The
Dining of
Experience’
standard
minimum
25 hours per
week
per service user
of structured
•
Implementation
of GMW
Advance
therapeutic
activity
Decision
Plan
•
Progress against CPA questions on
information pack, care plans, side
effects of medication and views
taken into account
Therapeutic Activity – Medium and low
secure providers to meet the quality
standard of a minimum of 25 hours per
week per service user of structured
therapeutic activity
eliciting the views of service users and
provide opportunities for real and valued
service improvements
Rationale
eliciting
of service users and
Achievingthe
thisviews
goal will:
provide opportunities for real and valued
service
improvements
• Ensure
service users are able to
access therapy
• Assist service users to progress
through services in as short a time as
necessary
• Promote a structured and meaningful
day with real opportunities for work,
Achieving
will:
therapy this
andgoal
leisure
• Deliver
improved
service
user
• satisfaction
Ensure service users are able to
• access
Promotetherapy
principles of recovery
• Assist service users to progress
through services in as short a time as
necessary (CQC)
2.6
Registration with the Care Quality Commission
• •Meadowbrook,
Stott Lane,
M6 8HD
Promote a structured
andSalford,
meaningful
2.6 Registration with the Care
Moorside,
Moorside
Trafford
General
day withregulator
real opportunities
forand
work,
The Care Quality Commission (CQC) is the •
independent
of Unit,
all health
Hospital,
Moorside
Road,
Trafford,
M41
5SL
therapy
and
leisure
Qualityadult
Commission
(CQC)
social care in England and has responsibility for protecting the rights of
Deliver
improved
serviceRoyal
• •Rivington,
Rivington
Unit,
Bolton
individuals detained under the Mental Health
Act. Through
its processes
ofuser
satisfaction
registration,
review,
visits
and
reporting,
the
CQC
aims
to
make
sure
better
care
is
Hospital,
Minerva
Road,
Farnworth,
Bolton,
The Care Quality Commission (CQC) is the
•BL4
Promote
provided
for everyone.
0JR principles of recovery
independent
regulator
of all health and adult
• Woodlands, Peel Lane, Worsley, Salford, M28
social care in England and has responsibility for
required to register with the Care Quality
Commission and its current
0FE
protectingGMW
the isrights
of individuals detained
2.6
Registration
with the
Care
Quality
Commission
(CQC)
registration
status is certified
by the
CQC
to carry
out the following
regulated activity:
under the Mental Health Act. Through its
The
Care
Quality
Commission
has
processesThe
of•Care
registration,
review,
visits
and
Quality Commission
(CQC)
is for
thepersons
independent
regulator
health
andnot taken
Assessment
or
medical
treatment
detained
under of
theallMental
Health
enforcement
action against
GMW
reporting,adult
the CQC
aims
sureand
better
social
care to
in make
England
has responsibility
for protecting
the rights
of during
Act 1983
2009/10.
care is provided
everyone.
individuals
detained
under disorder
the Mental
Health
Act. Through its processes of
• for
Treatment
of disease,
or injury
registration, review, visits and reporting, the CQC aims to make sure better care is
provided
hasfor
the
following
registration:
GMW is subject to periodic review by the
GMW is GMW
required
toeveryone.
register conditions
with the on
Care
Care Quality Commission. GMW has not
Quality Commission and its current registration
The
regulated
activity
identified
above
may
only
be Commission
carried
at
the
GMW
is
required
to
register
with
the
Care
Quality
and
itsfollowing
current
participated
in a out
Care
Quality
Commission
status is certified by the CQC to carry out the
locations:
registration status is certified by the CQC to carry out the following regulated activity:
periodic review during 2009/10 and is currently
following regulated activity:
awaiting
guidance
on periodic review topics for
• Bramley
Street,
Lower Broughton,
Salford,
M7detained
1YE
Assessment
or medical
treatment for
persons
under the Mental Health
2010/11.
• Assessment
medical
treatment
for Street,
personsSalford,
Act
1983House,
• orCharles
Charles
M6 7DU
detained under
the Mental
HealthWest
Act
1983
Treatment
of disease,
disorder
or injury
• Greater
Manchester
Mental
Health NHS Foundation Trust, Prestwich
GMW
has participated in special reviews or
• Treatment of disease,
orRoad,
injuryPrestwich, M25
Hospital,disorder
Bury New
3BL
GMW
has
the
following
conditions
on
registration:
by the Care Quality Commission
• Meadowbrook, Stott Lane, Salford, M6investigations
8HD
Moorside,
Moorside
Trafford General
Hospital,
relating
to theMoorside
followingRoad,
areasTrafford,
during 2009/10:
GMW has the•following
conditions
onUnit,
registration:
The regulated
M41 5SLactivity identified above may only be carried out at the following
locations:
• Safeguarding children
The regulated activity identified above may only
be carried out• atBramley
the following
Street,locations:
Lower Broughton, Salford, M7 1YE
TheM6
CQC
• Charles House, Charles Street, Salford,
7DUundertake detailed work in relation to
44
all
organisations’
arrangements
for safeguarding
• Bramley Street,
Lower
Broughton,
Salford,
• Greater Manchester West Mental Health NHS Foundation
Trust, Prestwich
children.
M7 1YE
Hospital, Bury New Road, Prestwich, M25
3BL GMW has contributed to a national
CQC
• Meadowbrook,
StottSalford,
Lane, Salford,
• Charles House,
Charles Street,
M6 M6 8HDreview of safeguarding arrangements. The
review
specifically
looked
at Trafford,
board assurance
• Moorside, Moorside Unit, Trafford General
Hospital,
Moorside
Road,
7DU
M41
5SL
around child protection systems, including
• Greater Manchester West Mental Health NHS
governance arrangements; training and staffing;
Foundation Trust, Prestwich Hospital, Bury
and arrangements for health organisations to
New Road, Prestwich, M25 3BL
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201044
44
The CQC undertake detailed work in relation to all organisations’ arrangements for
safeguarding children. GMW has contributed to a national CQC review of
safeguarding arrangements. The review specifically looked at board assurance
work in partnerships
otherssystems,
to safeguard
GMW intends
to take the
following
around child with
protection
including governance
arrangements;
training
and action
children. staffing;
The Trust’s
to this
below organisations
to address
or requirements
and response
arrangements
for health
to the
work conclusions
in partnerships
with
others
to
safeguard
children.
The
Trust’s
response
to
this
below
is
outlined
below.
All
reported by the CQC.
is outlined below. All improvement actions
actions identified
identifiedimprovement
have been completed
by thehave
endbeen
of completed by the end of March 2010.
GMW has made the following progress by 31
March 2010.
GMW intends to take the following action to address the conclusions or requirements
March 2010 in taking such action – all actions
reported by the CQC.
complete at 31 March 2010.
GMW has made the following progress by 31 March 2010 in taking such action – all
Actions based on the outcomes of the review
actions complete at 31 March 2010.
of safeguarding children arrangements:
Actions based on the outcomes of the review of safeguarding children
arrangements:
Issue Identified
by the CQC
Corporate
awareness of
child
safeguarding
Training
Issue Identified
by the CQC
Performance
Human
Resources
Safeguarding
children
resources/
capacity
2.7
Action(s)
Audit the number of occasions child safeguarding has been on
the agenda of the Trust Board and Clinical and Social Care
Governance Committee
Update Child Safeguarding work-plan
Include statement with regard to child safeguarding in the Trust’s
annual report
Re-affirm the role of Executive lead for child safeguarding at the
Trust Board
Submit declaration on safeguarding to Monitor and the Care
Quality Commission and publish declaration on Trust website
Update the Trust’s strategy for safeguarding training and seek
sign-off of the strategy at the 6 Local Safeguarding Children
Boards (LSCBs). The Trust is represented on each LSCB.
Review records of safeguarding training (internally and externally,
and at all levels of training)
Establish robust systems to monitor all child safeguarding
incidents
Action(s)
Establish robust systems to monitor all child safeguarding
incidents
Agree schedule of audits with reference to views of staff and
45
service users
Review job description of executive lead, named nurse and
named doctor for child safeguarding in light of CQC findings
Review the Trust resources available to support the child
safeguarding agenda
Develop a business case for a Child Safeguarding Practitioner
and appoint Child Safeguarding Practitioner (subject to business
case approval)
Data Quality
The Trust recognises that the provision of high quality and accurate data underpins
the delivery of effective care and is critical to making improvements in the quality of
services provided.
The following statements provide an example of the quality of data provided by the
Trust to external sources during 2009/10.
GMW submitted records during April 2009 to January 2010 to the Secondary Uses
Service for inclusion in the Hospital Episode Statistics which are included in the latest
Greater Manchester
Westdata.
Mental
Health
Foundation
NHS TrustinQuality
Account 2009
/ 201045
published
The
percentage
of records
the published
data:
2.7 Data Quality
The Trust recognises that the provision of
high quality and accurate data underpins
the delivery of effective care and is critical to
making improvements in the quality of services
provided.
The following statements provide an example
of the quality of data provided by the Trust to
external sources during 2009/10.
GMW submitted records during April 2009 to
January 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:
• 98.9% for admitted patient care
• 99.1% for outpatient care
- which included the patient’s valid General
Medical Practice Code was:
• 100% for admitted patient care
• 100% for outpatient care
(GP). The Trust’s high levels of performance in
these two areas provides assurance that service
users are being appropriately identified and that
information sharing between services can be
facilitated.
The Trust recognises the need to continuously
monitor and improve its data quality. The Trust
has a robust Data Quality Policy, which is focused
on building data quality from the point at which
information is captured and recorded and
includes the following principles of information
management:
• Information should be captured once only
• Information should be accurate, complete
and timely the first time it is recorded
• Information for management purposes
should, wherever practicable, be derived from
the information captured to support patient
care.
To support the delivery of these principles, the
policy clearly sets out the roles and responsibilities
of clinical, managerial and administrative staff
across the organisation in relation to data
quality.
Accurate reporting of NHS numbers will
reduce the likelihood of incidents arising from
misidentification. Valid General Medical Practice
Codes are essential to enabling the transfer of
information (where appropriate) between a
Trust and a service user’s General Practitioner
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201046
2.8
Information Governance
2.8 Information
Governance
The Trust aims to
deliver a standard
sets national standards for achievement to
of excellence in Information Governance by
ensure
that efficiently
organisations
maintain in
high levels
ensuring that information is dealt with legally,
securely,
and effectively
confidentiality
of information
delivera standard
the best of
possible
care to of
oursecurity
service and
users.
The Trust has
an
The Trust order
aims totodeliver
excellence
at
all
times.
In
implementing
the
Information
established
Information
Strategy and Policy, which provide a framework
in Information
Governance
by Governance
ensuring that
for
the
management
of
all
service
user,
organisational
information.
Governance
Toolkit,
the Trust’s approach is
information is dealt with legally, securely,staff and
always to establish an appropriate balance
efficiently and effectively in order to deliver the
Implementing the requirements of the Information
Governance
part of this in the
between
opennessToolkit
and is
confidentiality
best possible
care to our service users. The Trust
framework. The Information Governance management
Toolkit sets and
national
standards
for
use of information.
has an achievement
established Information
Governance
to ensure that
organisations maintain high levels of security and
Strategy and
Policy, which
provide a at
framework
confidentiality
of information
all times. In implementing the Information Governance
GMW’san
score
for 2009/10
for Information
for the management
of all service
user,isstaff
andto establish
Toolkit, the Trust’s
approach
always
appropriate
balance
between Quality
and
Records
Management,
assessed
using the
openness
and confidentiality in the management and use of information.
organisational
information.
Information Governance Toolkit, was 79%.
GMW’s
score
for
2009/10
for
Information
Quality and Records Management,
Implementing the requirements of the
assessed using the Information Governance Toolkit,
was 79%. has been calculated against
This performance
Information Governance Toolkit is part of this
specific requirements of the Toolkit as follows:
framework.
The
Information
Governance
Toolkitagainst
This
performance
has
been calculated
specific requirements of the Toolkit as
follows:
Information Governance Toolkit Requirement
401 – Does the Trust have a strategy to ensure the
correct NHS number is recorded for each active
client/service user and ensure that it is routinely used
in communications?
402 – Does the Trust have documented and
implemented procedures for the identification and
resolution of duplicate or confused patient records?
403 – Does the Trust have an organisation-wide,
multi-professional audit of clinical record keeping
standards, including accuracy, for all professional
groups in all specialities?
404 – Does the Trust have paper health records of a
standard design, combined with a locally agreed
standard format for filing within the health record?
405 – Does the Trust have robust procedures and
processes for monitoring all data collection activities
across the Trust?
406 – Does the Trust have procedures and
processes in place to enable it to regularly monitor
measure and trace paper health records?
407 – Does the Trust ensure that Accident and
Information
Governance
Toolkit within
Requirement
Emergency
records
are contained
the main
record for patients who are subsequently admitted
and is there a system to ensure that the GP is sent a
copy of the A & E record?
SelfAssessment
Score (0 – 3)
3
Maximum
Possible
Score
3
2
3
3
3
3
3
2
3
3
3
0
SelfAssessment
Score (0 – 3)
0
Maximum
N/A–- The
N/a
The
Possible
does
Trust
notScore
have an
A&E
department
3
47
2
408 – Does the Trust have procedures in place to
ensure that when new services are provided, or
where changes within the system are made, that
these do not adversely impact on information quality?
2
3
501 – Does the Trust ensure that NHS standard
definitions, values and validation programmes are
incorporated within key systems and that local
determination is updated as standards develop?
502 – Does the Trust use external data quality
2
3
reports for monitoring and improving quality?
2
3
503 – Does the Trust have procedures to ensure that
staff routinely check information about patients with
Greater Manchester
West Mental
Trustmade
Quality Account
2009 / 201047
the source
so Health
that Foundation
correctionsNHSare
as
necessary to appropriate records and does the Trust
Information Governance Toolkit Requirement
copy of the A & E record?
408 – Does the Trust have procedures in place to
ensure that when new services are provided, or
where changes within the system are made, that
these do not adversely impact on information quality?
501 – Does the Trust ensure that NHS standard
definitions, values and validation programmes are
incorporated within key systems and that local
determination is updated as standards develop?
502 – Does the Trust use external data quality
reports for monitoring and improving quality?
503 – Does the Trust have procedures to ensure that
staff routinely check information about patients with
the source so that corrections are made as
necessary to appropriate records and does the Trust
routinely undertake activity reconciliations between
the patient record and data on the Trust’s patient
administration system?
504 – Does the Trust have documented procedures
for using both local and national benchmarking to
identify possible data quality issues and to analyse
trends in information over time to ensure that large
changes are investigated and explained?
505 – Has the Trust had an audit of clinical coding
based on national standards and undertaken by a
member of staff from the NHS Connecting for Health
list of registered clinical coding auditors within the
last 12 months?
506 – Does the Trust have a documented procedure
and a regular audit cycle for accuracy checks on
patient data?
507 – Has the Trust completed and passed the
Completeness and Validity check for data as detailed
in guidance documents?
508 – Is the Trust involving clinical staff in validating
information derived from the recording of clinical
activity?
509 – Does the Trust have (or access) a formal,
targeted training programme for all staff involved in
the collection and management of patient-related
data covering the operation of key systems?
510 – Does the Trust use the training programme for
clinical coding staff entering coded clinical data that
are comprehensive and conform to National
Standards?
511 – Does the Trust have sufficient governance
processes in place to ensure adherence to the
principles enshrined in the Code of Conduct for
Payment by Results?
SelfAssessment
Score (0 – 3)
2
Maximum
Possible
Score
A&E
department
3
2
3
2
3
2
3
2
3
3
3
2
3
2
3
3
3
2
3
3
3
0
0
N/a –
Payment by
Results not
implemented
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201048
48
508 – Is the Trust involving clinical staff in validating
3
3
information derived from the recording of clinical
activity?
509 – Does the Trust have (or access) a formal,
2
3
targeted training programme for all staff involved in
the collection and management of patient-related
data covering the operation of key systems?
3
3
510 – Does the Trust use the training programme for
Information
Governance
Requirement
SelfMaximum
clinical
coding staff
entering Toolkit
coded clinical
data that
Possible
are comprehensive and conform to National Assessment
Standards?
Score (0 – 3)
Score
for mental
0
0
511 – Does the Trust have sufficient governance
health
N/a –yet
processes in place to ensure adherence to the
Information
Governance
Toolkit
Requirement
SelfMaximum
Payment
principles
enshrined
in thehave
Codedocumented
of Conduct and
for
2
3 by
601
– Does
the Trust
Possible
Results
not
Payment by Results?
implemented
procedures for the creation and filing of Assessment
Score
electronic corporate records to enable efficient Score (0 – 3) implemented
for mental
retrieval and effective records management?
health
2
3 yet
602 – Does the Trust have documented and
2
3
601
–
Does
the
Trust
have
documented
and
implemented procedures for the creation, filing
48
implemented procedures
for the creation
and
of
tracking/tracing
of paper corporate
records
to filing
enable
electronic
corporate
recordsrecords
to enable
efficient
efficient
retrieval
and effective
management?
retrieval and effective records management? TOTAL
45
57
2
602 – Does the Trust have% documented
and
PERFORMANCE
79% (45 / 57) 3
implemented procedures for the creation, filing and
tracking/tracingfor
of overseeing
paper corporate
records to enable
Responsibility
and implementing
the requirements of the Information
efficient retrieval
and sits
effective
management?
Governance
Toolkit
with records
the Trust’s
Information Governance Steering Group.
45 services and 57
TOTAL
The Group includes representation from clinical
and corporate
reports
%
PERFORMANCE
79%
(45
/
57)
progress to the Audit Committee (a sub-committee of the Trust Board). Where gaps
against the requirements of the Toolkit are identified, the Information Governance
Responsibility
overseeing
andforimplementing
Steering
Groupfor
identifies
actions
improvement.the requirements of the Information
Governance Toolkit sits with the Trust’s Information Governance Steering Group.
The Group includes representation from clinical and corporate services and reports
progress
to theCoding
Audit Committee (a sub-committee of the Trust Board). Where gaps
2.9 Clinical
against the requirements of the Toolkit are identified, the Information Governance
Steering
identifies
actions
for improvement.
Payment Group
by Results
has not
yet been
introduced for mental health services. As such:
GMW was not subject to the Payment by Results clinical coding audit during the
2.9
Clinical
reporting
periodCoding
by the Audit Commission.
Payment by Results has not yet been introduced for mental health services. As such:
GMW was not subject to the Payment by Results clinical coding audit during the
reporting period by the Audit Commission.
Responsibility for overseeing and implementing
the
requirements
of
the
Information
Governance Toolkit sits with the Trust’s
Information Governance Steering Group. The
Group includes representation from clinical and
corporate services and reports progress to the
Audit Committee (a sub-committee of the Trust
Board). Where gaps against the requirements
of the Toolkit are identified, the Information
Governance Steering Group identifies actions
for improvement.
2.9 Clinical Coding
Payment by Results has not yet been introduced
for mental health services. As such:
GMW was not subject to the Payment by Results
clinical coding audit during the reporting period
by the Audit Commission.
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201049
49
PART 3
Review of Quality
Performance
3.1 Quality Performance in
2009/10
To demonstrate the quality of care offered by
GMW in 2009/10, the Trust has selected a range
of indicators that include both organisation-wide
measure of quality and service specific measures
and also cover all three dimensions of quality.
This is to ensure that readers of this Quality
Account take away a fair and rounded picture
of quality. The indicators have been selected by
the Trust Board based on feedback from key
stakeholders.
and timing of PEAT assessments are set by the
National Patient Safety Agency (NPSA). The
annual PEAT assessment is a self-assessment
undertaken by inspection teams including
either the Director of Operations and Nursing or
Director of Estates and Facilities, Deputy Director
of Nursing, service user representatives, catering
team representative, infection prevention lead
and cleaning services representatives. The annual
assessment is supported by local assessments
undertaken on a monthly basis. PEAT was
suggested as a quality indicator by the Trust’s
Council of Governors.
Where the indicators relied on have changed
from those reported in the Trust’s 2008/09
Quality Report for Monitor, an explanation is
provided for this. Actions for improvement in
2010/11 are also identified where applicable.
In 2008/09, access to psychological therapies was
used as an indicator of quality by the Trust. As
the Trust is continuing to focus on psychological
therapies within its improvement priorities (see
Section 2.1), this indicator has been replaced
with outcomes of Patient Environment Action
Team (PEAT) inspections. The scope, standards
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201050
Indicators of Quality Performance in 2009/10:
Indicators of Quality Performance in 2009/10:
The
indicators
been
selected
evidence
quality performance in 2009/10:
The following
following indicators
have beenhave
selected
to evidence
quality to
performance
in 2009/10:
Quality
Dimension
Patient
Experience
Quality
Dimension
Indicator of
Quality
Performance
in 2009/10
Cleanliness –
compliance
with the
Hygiene Code
Outcomes of
Patient
Environment
Indicator
of
Action
Team
Quality
(PEAT)
Performance
assessments
in 2009/10
Informed
patients –
number of
service users
on CPA with a
Quality
Indicator
named
careof
Dimension co-ordinator
Quality
Performance
in 2009/10
Effectiveness % of delayed
transfers of
care
Rationale for Inclusion
Data Source
In April 2009, new regulations
(the Hygiene Code) were
brought in regarding
cleanliness and infection to
ensure that service users,
workers and others are
protected from the known risks
of acquiring a healthcare
associated infection (HCAI).
Organisations were required to
demonstrate compliance with
these regulations to be
registered with the Care
Quality Commission (CQC).
The Trust successfully
registered with the CQC on
these grounds.
Feedback from service users
surveys, complaints, incidents
and other forms of involvement
for Inclusion
andRationale
engagement,
has
identified the patient
environment as a key indicator
of quality. PEAT assesses all
areas of the patient
environment, including
cleanliness, hygiene, food,
privacy and dignity, infection
control, access, and external
areas
The appointment of a named
care co-ordinator is an
essential element of CPA
Rationale for Inclusion
Minimising delayed transfers
of care is a target set by
Monitor for achievement by all
mental health foundation trusts
in 2010/11 and is also a
national indicator set by the
CQC
Organisations have a
responsibility to ensure that
individuals move on from the
inpatient environment once
they are safe to do so
2009/10 Position and Actions for
Improvement in 2010/11
Historical and/or
Benchmark Data
GMW’s
Infection
Prevention lead
Fully compliant with all 9 areas of the
Hygiene Code
In 2008/09, the
Trust was also fully
compliant with all 9
areas of the
Hygiene Code
PEAT selfassessment
undertaken
Data 19
Source
during
January 2010
and 19 March
2010 and
reported to the
NPSA
Overall PEAT outcome for the Trust –
(94%) good. A more detailed
breakdown of the Trust’s PEAT
2009/10
Positioninand
Actions
for
scores
is provided
Annex
3
Improvement in 2010/11
The Trust’s position in 2009/10 is a
significant improvement on previous
years. Recognising the need to deliver
continuous improvements to the
patient environment, the Trust has
developed a series of actions to
respond to the findings of the 2010
self-assessment. The Trust will
monitor progress against this action
plan in 2010/11
100% of service users on CPA had a
named care co-ordinator at the end of
2009/10
ICIS
Data Source
ICIS
The Trust will aim to maintain this
position and improve monitoring
arrangements in 2010/11
The Trust will review and monitor
2009/10 Position
performance
againstand
thisActions
indicatorfor
in
Improvement
in 2010/11
2010/11
through the Data
Quality
Report and aim to maintain the
current level of performance
2009/10 position – 3.1%
The 2009/10 position represents a
significant improvement on previous
years’ performance and achievement
of the Monitor target. This is
demonstrated in the following chart
In 2010/11 the Trust will report on and
monitor progress against this indicator
via directorate performance reports.
Current systems for reviewing and
mitigating delays locally will continue.
The Trust will also share data on
delayed discharges with local
authority partners to ensure delays
are quickly resolved.
Overall PEAT
outcome for the
Trust:
Historical and/or
Benchmark
Data
2009
– 87% (good)
2008 – 84% (good)
2007 – 81% (good)
2006 – 87% (good)
51
Trust performance
in 2008/09 – 99%
Historical and/or
Benchmark Data
Trust performance:
2008/09 – 5.6%
2007/08 – 10.8%
Monitor target is to
minimise delayed
transfers of care to
less than, or equal
to, 7.5%
52
53
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201051
Quality
Dimension
Indicator of
Rationale for Inclusion
Quality
Performance
in 2009/10
Assessment of
Status
(Inpatients):
Effectiveness
% Smoking
of drug
Retention
of drug users in
users retained effective treatment is a CQC
in effective
priority for mental health
treatment
services.
Smoking Status
100.00%
Providing effective treatment
for drug users reduces rates of
individual harm and can also
contribute to significantly
reducing wider social harms
such as inquisitive crime
95.00%
90.00%
85.00%
80.00%
Quality
Dimension
Safety
Quality
Dimension
% of
inpatients who
have had
an
07/08
assessment of
smoking
status
Indicator of
Quality
Performance
in 2009/10
Degree of
harm incurred
by service
users in
Indicator of
incidents
Quality
reported
to
Performance
the
National
in 2009/10
Patient
Safety
Agency
(NPSA)
% of service
users on CPA
receiving
follow-up
within 7 days
of discharge
from inpatient
care
Quality
Dimension
No.s of under
18s admitted
to GMW adult
Indicator
of
mental
health
Quality
inpatient
Performance
wards
in 2009/10
Data Source
2009/10 Position
Historical and/or
Benchmark Data
Submissions to
the National
Drug Treatment
Monitoring
System
(NDTMS)
2009/10 – The Trust has maintained a
high % of drug users retained in
effective treatment. Final figures are
not available at the time of writing, but
current performance is at 87%
Trust performance:
The Trust’s ‘Non-Smoking
Policy’ requires that the
smoking status
of all
08/09
inpatients, or those planned to
be admitted, should be
Smoking… care
recorded. Appropriate
plans should be drawn up to
promote the non-smoking
Rationale
for Inclusion
policy
and achieve
smoking
cessation or reduction
ICIS
Analysis of the reported
degree of harm can indicate
how developed an
organisation’s reporting culture
Rationale
forhigh
Inclusion
is. For
example,
levels of
‘no harm’ incidents may
indicate a mature reporting
culture
Data reported
from the Trust’s
Datix system to
the NPSA
Data Source
This indicator replaces time
taken to report an incident to
the NPSA, which was used in
the Trust’s 2008/09 Quality
Report, The Trust views
degree of harm as a more
effective indicator of quality for
the public
Ensuring that a minimum of
95% of service users on CPA
receive follow-up within 7 days
of discharge is a target set by
Monitor for achievement by all
mental health foundation trusts
The Mental Health Act 2007
requires hospital managers to
ensure that young people
Rationale
Inclusion
aged
under 18,for
who
are
admitted to hospital for a
mental disorder on a detained
or voluntary basis, are
accommodated in an
environment that is suitable for
their age and subject to their
needs.
09/10
Data Source
The Trust will continue to monitor
performance against this indicator in
the Alcohol and Drugs Directorate
(A+DD) performance report in
2010/11. Good practice will also be
shared between A+DD services
2009/10 – 94.4%
This represents an improvement on
previous years’ performance. This
improvement is demonstrated in the
following chart
2008/09 – 87.68%
2007/08 – 85.591%
Trust performance:
2008/09 – 93.0%
2007/08 – 85.5%
In 2010/11 the Trust will continue to
2009/10
Position
monitor and
report on
this indicator via Historical and/or
Benchmark Data
Directorate performance reports and
also look at ways of improving data
capture in ICIS
74% of all reported patient safety
For the reporting
incidents resulted in no harm
period, GMW
reported the
highest level of ‘no
Reporting period April 2009 to
Historical
and/or
harm’
incidents
in
September2009/10
2009 Position
Benchmark
Data
its
cluster (74%
in
comparison to
55
61%)
56
ICIS
ICIS data
submitted as
part of quarterly
Data
Source
Vital
Signs
Monitoring
Return (VSMR)
2009/10 – 97.69%. The Trust has
maintained a high level of
performance in this area and
developed a procedure for collecting
the required data consistently across
the Trust
In 2010/11 the Trust will continue to
report on and monitor this indicator in
Directorate Performance Reports and
take action to review and, if possible,
resolve breaches
In 2009/10, 12 young people were
admitted to GMW adult psychiatric
wards. This is an improvement on the
2009/10
Position
previous years’
positions
as
demonstrated in the following chart
To further improve this position in
2010/11, the Trust will:
• Implement the Trust protocol for
managing under 18s admissions
• Continue to review all incidents
relating to under 18s admissions to
adult wards
• Continue to report position to the
Bolton, Salford and Trafford Local
Safeguarding Children Boards
(LSCBs)
• Continue to report position to the
Trust Board via the Board
Performance Report
Trust performance:
2008/09 - 97.2%
2007/08 - 99.4%
Monitor target is
95%
In 2008/09, 145
bed days on GMW
adult psychiatric
Historical
wards
were and/or
Benchmark
Data
occupied
by young
people. 14 young
people were
admitted to GMW
adult mental health
wards in 2008/09,
this compares to 26
admissions in 57
2007/08.
For other providers
of Child and
Adolescent Mental
Health Services
(CAMHS) in the
North West, the
number of bed
days occupied by
young people on
adult psychiatric
wards ranged from
14 to 1,349 in
2008/09 with a
median of 376 bed
days.
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201052
Delayed Transfers of Care:
Delayed Transfers of Care:
15.00%
Delayed Transfers of Care
It should be noted that th
less than, or equal to, 7.5
It should be noted that the Monitor target of
into force until 2008/09 i.e
less than, or equal to, 7.5% did not come
authorisation
into force until 2008/09 i.e. after
the Trust’s as an NHS
Delayed Transfers of Care
15.00%
10.00%
10.00%
5.00%
authorisation as an NHS Foundation Trust.
5.00%
0.00%
0.00%
07/08
07/08
08/09
08/09
09/10
09/10
Delayed
Transfers of
CareTarget
Delayed Transfers
of Care
Monitor
Monitor Target
Assessment of Smoking Status (Inpatients):
Smoking Status
100.00%
95.00%
90.00%
85.00%
80.00%
07/08
08/09
09/10
Smoking…
54
Quality
Dimension
Safety
Under 18s
Indicator of
Rationale for Inclusion
Data Source
Quality
Performance
in 2009/10
Data reported
Analysis of the reported
Degree of
from the Trust’s
harm incurred degree of harm can indicate
Datix system to
developed
an Health Wards:
by service to how
Admitted
Adult
Mental
organisation’s reporting culture the NPSA
users in
is. For example, high levels of
incidents
‘no harm’ incidents may
reported to
a mature reporting
the National
Underindicate
18's Admitted
to Adult MH Wards
culture
Patient Safety
2009/10 Position
74% of all reported patient safety
incidents resulted in no harm
Reporting period April 2009 to
September 2009
Historical and/or
Benchmark Data
For the reporting
period, GMW
reported the
highest level of ‘no
harm’ incidents in
its cluster (74% in
comparison to
61%)
30
20
56
10
0
07/08
08/09
09/10
Under 18's Admitted to Adult MH Wards
Greater
West Mental
Health
Foundation
Trust Quality
Account 2009
3.2 Manchester
Performance
against
Key
NationalNHS
Priorities
and National
Core/ 201053
Standards
0
07/08
08/09
09/10
Under 18's Admitted to Adult MH Wards
3.2
Performance against Key National Priorities and National C
Standards
In 2009/10, the Trust continued to strengthen its position against e
performance requirements and also responded positively to challengin
agendas.
3.2.1
Monitor
In terms of performance against indicators set out in Monitor’s Com
Framework, the indicators for mental health services for 2009/10 were as follow
•
3.2 Performance against Key
•
National Priorities and National
•
Core Standards
•
95% of service users on CPA receiving follow-up contact within 7 d
3.2.1
Monitor
discharge
from
hospital
Minimising delayed transfers of care to no more than 7.5%
Ensuring
90% of
to against
inpatient indicators
services had
In terms
of admissions
performance
setaccess to
resolution and home treatment teams
out in Monitor’s Compliance Framework, the
Maintaining level of crisis resolution teams (6 teams)
indicators for mental health services for 2009/10
were
as follows:
The Trust has
achieved
all of these targets in 2009/10. Performance agai
specific indicators is as follows:
strengthen
In 2009/10, the Trust continued to
its position against existing performance
requirements and also responded positively to
challenging new agendas.
3.2.2
3.2.2 Care Quality Commission
Indicator
7-day follow-up
Delayed transfers of
care
Indicator
Access
to crisis
resolution and home
treatment teams
Level of crisis
resolution and home
treatment teams
Threshold
95%
No more
than 7.5%
Threshold
90%
6 teams
Performance in
2009/10
97.69%
3.10%
Performance
98.85% in
2009/10
6 teams
Care Quality Commission
In the CQC Annual Health Check for 2008/09, which reported in Autumn 20
Trust achieved the maximum ‘excellent’ rating for Use of Resources and ‘ex
rating for the Quality of Services. This was an improvement on the previous
by the Trust’s compliance with the Standards
rating of ‘excellent’ for Use of Resources and ‘good’ for Quality of Services a
Better
Health.
Following
a review
of the
positioned thefor
Trust
amongst
the highest
performing
organisations.
evidence available to demonstrate compliance
In the CQC Annual Health Check for 2008/09,
The
Quality
of
Services
rating is informed,
in part,
by the Trust’s
compliance w
with
the Standards
for Better
Health,
the Trust
which reported in Autumn 2009, the Trust
Standards for Better Health. Following a review of the evidence availa
Board
is assured of the Trust’s compliance and
achieved the maximum ‘excellent’ rating
for
demonstrate
compliance with the Standards for Better Health, the Trust B
has
declared
itself and
as ‘fully
met’ against
Use of Resources and ‘excellent’ rating for
the of the
assured
Trust's
compliance
has declared
itself as all
'fully24
met' agains
core
standards.
core standards.
Quality of Services. This was an improvement on
the previous year’s rating of ‘excellent’ for Use of
Further information on the Trust’s performance in the CQC Annual Health Ch
Furtherin information
on the
Trust’s
performance
Resources and ‘good’ for Quality of Services
and is provided
2008/09
the Trust’s Annual
Report
for that
same period.
in the CQC Annual Health Check for 2008/09
has positioned the Trust amongst the highest
is provided in the Trust’s Annual Report for that
performing organisations.
same period.
The Quality of Services rating is informed, in part,
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201054
ANNEX 1
Statements from
Primary Care Trusts,
Local Involvement
Networks and
Overview and
Scrutiny Committees
healthy lifestyles and physical health outcomes;
strengthening mental health protective factors;
integrating primary, social and occupational
care support; harnessing activity associated with
wider policy programmes such as those relating
to ‘Putting People First, Transforming Social
Care’, Safeguarding Vulnerable Adults and
alcohol misuse; improving access to settled work
and homes; and increasing choice, control and
recovery outcomes for people accessing services
through spreading and deepening the impact of
personalisation/personalised approaches.
Bolton, Salford and Trafford
PCTs’ Statement on Greater
Manchester West NHS
Foundation Trust’s Quality
Account 2009/10
The GMW Quality Account 2009/10 is overall
an accurate, detailed account of the services
provided and positive progress made by the Trust
in line with this agenda. It also demonstrates
the progress delivered by local district services in
achieving all the objectives originally established
through the National Service Framework for
Mental Health more than 10 years ago. This
has resulted in safer, sound and supportive local
specialist mental health services, through various
community mental health teams and in-patient
services, with the critical Vital Signs indicators
for success being achieved across Bolton, Salford
and Trafford. The positive response to identifying
a wide range of service improvement priorities
and then demonstrating tangible improvements
in terms of achieving the quality indicators
and CQUIN (Commissioning for Quality and
Innovation) objectives is also to be commended.
We are particularly pleased with the focus on
responding to patient and carer experience
feedback and improved person-centred care
The future direction for mental health policy
and commissioning priorities remains clear
with the publication of New Horizons together
with the economic imperatives for quality and
efficiency or ‘better outcomes for less’. This
requires an increased focus on positive evidencebased actions including: improving access to
psychological therapies; enhanced diagnosis
and treatment; implementing clinically owned
and championed care pathway developments to
reduce inappropriate admissions, lengths of stay
and out-of-area placements; tackling stigma and
discrimination; targeting risk factors and high risk
groups; increased support for self care; ensuring
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201055
planning outcomes. The investment in improved
physical environments for patients and staff is
also recognised through the capital investments
and service reviews.
thirdly, to act now for the long-term agenda in
relation to delivering value for taxpayers’ money
as part of the partnership agenda.
It is clear that 2010/11 will be a pivotal year for
the wider NHS, for mental health services and
for GMW given the changing policy and financial
context. As we move towards establishing the
new standard NHS Contract, involving joint
reviews of all service specifications/models, we
continue to believe that through collaborative
action we have a real opportunity to make
a difference in terms of achieving sustained
longer-term quality outcomes.
Trafford LINk’s Statement on
Greater Manchester West NHS
Foundation Trust’s Quality
Account 2009/10
As such, PCT commissioners remain committed
to working with GMW to build on the positive
results noted in this Quality Account report and
acknowledge a need to jointly identify significant
efficiency savings to reinvest within health
services to continue delivering year on year
quality improvements. This will be tough but it
is possible with a focus on three things. Firstly,
improving quality whilst improving productivity,
using innovation and prevention to drive and
connect them. Secondly, having local clinicians,
managers and commissioners and service users
working together across boundaries to identify
opportunities to innovate through service
redesign and to pursue the ethos contained in
New Horizons which requires services to move
upstream’ to deliver a more preventative agenda
whilst, at the same time, recognising the need
to provide excellent specialist services. And,
The Quality Accounts developed by Greater
Manchester West Mental Health Foundation
Trust is clear and gives a detailed picture of the
current status of the Trust and the areas that it
wishes to improve.
In 2009 LINk in Trafford has developed a positive
working relationship with the Trafford Moorside
Unit. A robust communications system is in place
that allows us to more easily raise the concerns
of users and careers of the service.
However we have concerns with Trafford
residents’ access to the Trust’s primary care
psychological services and will closely monitor
the progress of GMW Trust in improving access
and reducing waiting times over 18 weeks.
The LINk in Trafford will also monitor the progress
of the GMWMHFT in 4 other priority areas
• Effectiveness
of
patient
experience
questionnaire to gather realtime feedback.
• Improving
career
engagement
and
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201056
involvement.
• Improving access to physical healthcare
services.
• Improving outcomes through delivery of
recovery- focused services.
Trafford LINk will wish to receive regular updates
on progress of the priority areas.
We look forward to continuing our involvement
with the Moorside Unit and to support them in
partnership with Service User Forums in ensuring
the residents of Trafford continue to receive a
quality service.
Ann Day
Chair
Trafford LINk
LINk in Salford Quality Accounts
submission
On the 28th April 2010 the LINk was requested
to make comments on the Quality Account for
Greater Manchester West Mental Health NHS
Foundation Trust 2009-10. The LINk in Salford
Steering group members agreed to submit a
commentary on behalf of the residents of Salford.
The Quality Accounts developed by Greater
Manchester West Mental Health NHS Foundation
Trust is reasonably clear and outlines in details
the approach to provide an effective overall
picture of the current status of the Trust and
the areas that it wishes to improve. However
the LINk in Salford feels that the layout could be
clearer and the use of “jargon “rather less. The
GMWMH (see what we mean) could possibly
look at the Quality accounts of the Salford
Royal Hospital Trust which we feel epitomises,
in layout at least what these documents should
aim for when, as they are in this case, their
target audience is mostly lay people rather than
NHS professionals.
The LINk in Salford model adopted in Salford
encourages local people to identify and prioritise
their top three priorities each financial year. With
this model in mind the LINk has not currently
worked with any issues relating to the GMW
Trust and therefore would not be in a position to
comment in any particular areas of the accounts
with conclusive evidence.
Although, while the LINk in Salford and the
GMW Trust has a willingness to work together
through good communications externally or
internally for effective patient experience; the
LINk wishes to develop stronger and influential
partnership with the GMW Trust to continue
to sustain the excellent quality of services to
patients and carers.
The LINk in Salford will monitor the progress of
the GMW Trust in 4 of the 7 priorities in total;
in particular
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201057
• Improving access to the Trust’s primary care
psychological therapies services in Salford
towards reducing services users waiting over
18 weeks
Greater Manchester West
Mental Health NHS Foundation
Trust Joint Scrutiny Committee
• The effectiveness of patient experience
questionnaire to gather real time feedback
Statement on GMW’s Quality Account
2009/10
• That 75 % of patients to have had a HONOS
assessment completed at their last CPA review
to support the recovery focus
The Joint Scrutiny Committee would wish to place
on record its appreciation of the close, open and
honest relationship it has with Greater Manchester
West Mental Health NHS Foundation Trust (GMW)
and the opportunity given to the Committee to
comment on its 2009/10 Quality Account.
• Improvement of care planning – 85% of
service users on CPA reviewed within a 6
monthly intervals
The LINk will wish to receive regular updates on
the progress of the Quality Accounts outlined
and to support the GMW Trust in implementing
the Quality Accounts in partnership with the
Service User Forums to ensure the residents of
Salford continue to receive quality services from
GMW Mental Health NHS Hospital Foundation
Trust.
Thank you
Royston Futter
Chair of LINk in Salford
The Joint Scrutiny Committee received an
informative presentation on Quality Accounts
at its meeting on 23rd March 2010, and gave
feedback on what it considered to be of sufficient
importance to include in the draft document. A
copy of the draft Quality Account was received
on 29th April, 2010, which incorporated this
feedback. Each of the three composite authorities
was given opportunity to comment on the draft
Account. One initial comment was that, at some
70 pages, the document was detailed and the
deadline for response gave limited opportunity
for consultees to get together to share knowledge
and experience which might inform the response.
It was recognised that the deadline for response
allowed 30 days to comment and was informed
by Monitor’s submission deadline.
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201058
The Joint Scrutiny Committee appreciated the
opportunity to discuss the draft Quality Account
with GMW at its meeting on 1 June 2010.
The main themes of the responses received are
as follows:
Bolton Council
• Green Light Toolkit – good to see progress
in Bolton but would seek clarification as to
why progress was not as significant as other
Authorities.
• Carers - Proposals around Carers for 2010
looks very good, robust and far reaching.
• Care Planning - Bolton welcomes the
decision to set care planning in the context of
personalisation and strengthen the account
on this agenda. The Transforming Social Care
agenda was for everyone and was ultimately
about improving quality in service user choice
and control.
initiatives can be incorporated into care for
GMW service users.
• Happy to see that further work is being done
to gather feedback from patients as this is
useful in evaluating and planning future
services.
Trafford Council
• The Quality Account is well presented and
comprehensive.
• Trafford Council recognise that in the area of
psychological services, some improvements
have been made and that the demand for
services has increased. There is still a concern
over the length of time taken both to assess
patients and provide access to therapies.
A more user-friendly summary of the Quality
Account would be welcomed by the Joint Scrutiny
Committee. The Joint Scrutiny Committee notes
that this summary will be published alongside
the final Account.
Salford Council
• Psychological Therapies – Should the plans
for integration of services be realised, Salford
are keen to ensure the sufficient resources
are available to deliver these services.
• Patient Experience Feedback - The video diary
seems like a good way of gaining people’s
views. Salford would be interested to see the
feedback on this method.
• CQUIN Care Planning – Positive to see that
service users’ views are taken into account
when care plans are produced. Would agree
with Bolton about how far personalisation
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201059
ANNEX 2
Review
Of Services
ANNEX 2
Services provided by GMW in 2009/10,
REVIEWorOF SERVICES
and specified in the contract agreement
arrangements under which these services are
Services
provided by
in 2009/10, and specified in the contract agreement or
provided, can
be summarised
asGMW
follows:
arrangements under which these services are provided, can be summarised as
follows:
No. Service Type
1
Acute Inpatient Care (Adults of Working Age)
Location
Bolton
2
Including PICU (Psychiatric Intensive Care Unit)
Acute Inpatient Care (Adults of Working Age)
Salford
3
Including PICU (Psychiatric Intensive Care Unit)
Acute Inpatient Care (Adults of Working Age)
Trafford
4
5
6
7
8
Including PICU (Psychiatric Intensive Care Unit)
Inpatient Rehabilitation Services (Bramley Street)
Acute Inpatient Care (Later Life)
Acute Inpatient Care (Later Life) - Woodlands
Acute Inpatient Care (Later Life)
Community Mental Health Services (Adults of Working Age)
Salford
Bolton
Salford
Trafford
Bolton
9
Including community mental health teams, crisis resolution and home
treatment, assertive outreach and early intervention in psychosis
Community Mental Health Services (Adults of Working Age)
Salford
10
Including community mental health teams, crisis resolution and home
treatment, assertive outreach and early intervention in psychosis
Community Mental Health Services (Adults of Working Age)
Trafford
11
12
13
14
Including community mental health teams, crisis resolution and home
treatment, assertive outreach and early intervention in psychosis
Community Mental Health Services (Later Life)
Community Mental Health Services (Later Life)
Community Mental Health Services (Later Life)
Early Detection and Intervention Team (EDIT)
Bolton
Salford
Trafford
Salford and
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201060
Ashton,
Wigan and
Including
community
mental
health teams,
resolution
homeagreement or
Services
provided
by GMW
in 2009/10,
and crisis
specified
in the and
contract
treatment, assertive
outreach
andservices
early intervention
in psychosis
arrangements
under which
these
are provided,
can be summarised as
11 follows:
Community Mental Health Services (Later Life)
Bolton
12 Community Mental Health Services (Later Life)
Salford
No.
Service Type
Location
13 Community
Mental Health Services (Later Life)
Trafford
1
Inpatient Care
(Adults of Working
Age)
Bolton and
14 Acute
Early Detection
and Intervention
Team (EDIT)
Salford
Ashton,
Including PICU (Psychiatric Intensive Care Unit)
Wigan and
2
Acute Inpatient Care (Adults of Working Age)
Salford
Leigh
15 Primary Care Psychological Therapies
Salford
Including PICU (Psychiatric Intensive Care Unit)
3
Acute
Inpatient
Care (Adults
Working Age)
Trafford
Including
high intensity
IAPT of
(Improving
Access to Psychological
Therapies) services
IncludingCare
PICUPsychological
(Psychiatric Intensive
16 Primary
TherapiesCare Unit)
Trafford
4
Inpatient Rehabilitation Services (Bramley Street)
Salford
Including
high intensity
IAPT
(Improving Access to Psychological
5
Acute
Inpatient
Care (Later
Life)
Bolton
Therapies)
services
6
Acute
Inpatient
Care (Later Life) - Woodlands
Salford
17 Acute
Secondary
CareCare
Psychological
Bolton
7
Inpatient
(Later Life)Therapies
Trafford
18
Secondary
Care
Psychological
Therapies
Salford
8
Community Mental Health Services (Adults of Working Age)
Bolton
19 Secondary Care Psychological Therapies
Trafford
No.
Service Type
Location
Including
community
mental
health teams, crisis resolution and home
20 Community
Rehabilitation
Services
Bolton
treatment, assertive
outreach
and early intervention in psychosis
21 Community
Rehabilitation
Services
Salford
9
Mental Health Services
Services (Adults of Working Age)
Salford
22
Community Rehabilitation
Trafford
23 Eating Disorder Services
The
68
Including community mental health teams, crisis resolution and home
Willows,
treatment, assertive outreach and early intervention in psychosis
Salford
10 Psychotherapy
Community Mental
Services
(Adults of Working
Age)
Trafford
24
and Health
Personality
Disorder/Complex
Needs
Service –
Swinton
The Red House
Including
mental
health
teams, crisis resolution and home
25 HM
Prisoncommunity
Forest Bank
In-reach
Service
Pendlebury
treatment,Adolescent
assertive outreach
and
early intervention
in psychosis
26 Inpatient
Psychiatry
Services
– McGuinness
Unit
Prestwich
11 Adolescent
Community Forensic
Mental Health
Services
(Later Life)
Bolton
27
Psychiatry
Outpatient
Services – McGuinness
Prestwich
12 Community
Mental
Health
Services
(Later
Life)
Salford
Unit
13
MentalSecure
HealthForensic
ServicesService
(Later Life)
28 Community
Inpatient Medium
for Adolescents – Gardener Trafford
Prestwich
14 Early
Salford and
Unit Detection and Intervention Team (EDIT)
Ashton,
29 Forensic Assessment, Consultation and Treatment Service for Children Prestwich
Wigan and
and Adolescents (FACTS)
Leigh
30 HMP and YOI Hindley In-reach Service
Wigan
15 St.
Primary
CareBail
Psychological
Therapies
Salford
31
Joesph’s
Hostel
Eccles
32 Mental Health and Deafness Services – John Denmark Unit
Prestwich
Including
high
intensity
IAPT
(Improving
Access
to
Psychological
33 Mental Health and Deafness Service Outreach Clinics
GP
Therapies) services
Practice,
16 Primary Care Psychological Therapies
Trafford
Glasgow
34 Sex Offenders Treatment Programme in HM Prison Manchester
Manchester
Including high
intensity Diversion,
IAPT (Improving
Accessand
to Psychological
35 Manchester
Offenders:
Engagement
Liaison Service
Sedgley
Therapies)
(MO:DEL) services
Park
17
Secondary
Care Services
Psychological
Therapies
Bolton
36 Medium Secure
– Edenfield
Centre
Prestwich
18 Secondary Care Psychological Therapies
Salford
19 Secondary
Care Psychological
Therapies
Including TEMSS
(Therapeutically
Enhanced Medium Secure Services Trafford
20 Community
Bolton
for Women) Rehabilitation Services
37 Medium Secure Services – Charles House
Salford
38 Low Secure Services – Bowness Unit
Prestwich
39 Medium Secure Step-Down Services
Prestwich
68
40 Mental Health Services to HM Prison Styal
Wilmslow
41 Inpatient Alcohol and Drug Unit – Chapman-Barker Unit
Prestwich
42 Adult Community Substance Misuse Services
Bolton
43 Adult Community Substance Misuse Services
Salford
44 Adult Community Substance Misuse Services
Manchester
45 Adult Community Substance Misuse Services
Wigan and
Leigh
46 Adult Community Substance Misuse Services
Blackburn
with Darwen
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201061
ANNEX 3
NEX 3
PEAT SELF-ASSESSMENT INSPECTION OUTCOMES 2010
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201062
ANNEX 4
Glossary of Terms
Advancing Quality (AQ)
AQ is an incentive programme that establishes
rewards, funded through investment of ‘new
money’, for improvements in quality and
innovation. Psychosis and dementia have been
agreed as the priorities for AQ. Work is ongoing
to agree the standards for achievement for
these priorities. Data collection will commence
in 2010/11.
AWOL
Absent without leave
Care Co-ordinator
The professional who, irrespective of their
ordinary professional role, has responsibility
for co-ordinating care, keeping in touch with
the service user, and ensuring the care plan is
delivered and reviewed as required.
Care Programme Approach (CPA)
CPA is a framework for assessing service users’
needs, planning ways to meet needs and
checking that needs are being met. Care Quality Commission (CQC)
The Care Quality Commission (CQC) is the
independent regulator of all health and adult
social care in England and has responsibility for
protecting the rights of individuals detained
under the Mental Health Act.
Carer
An individual who provides or intends to provide
support to someone with a mental health
problem. A carer may be a relative, partner,
friend or neighbour, and may or may not live
with the person cared for.
Carers Demonstration Site
Department of Health funded project in Bolton,
which is aiming to improve the involvement and
engagement of carers
CBT
Cognitive behavioural therapy
Commissioning for Quality and Innovation
(CQUIN)
A framework, which allows commissioners
to link income to the achievement of quality
improvement goals
Compliance Framework
Document setting out the approach Monitor
will take to assessing an NHS Foundation Trust’s
compliance with its Terms of Authorisation
CSCGC
Clinical and Social Care Governance Committee
- A formal committee of the Trust Board with
responsibility for advising the Board on all clinical
and non-clinical issues, which affect patient care
and services, and identifying areas of concern,
change and development related to the clinical
activity of the Trust.
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201063
CSP
Co-ordinated system for gaining NHS permission,
which ensures that all quality assurance and
statutory requirements in respect of clinical
research are met.
Forward to Excellence U2
Development programme for all staff at NHS
Band 8a or above who have a managerial role
or a managerial component to their role
GMW
Greater Manchester West Mental Health NHS
Foundation Trust
Green Light Toolkit
Framework and self-audit toolkit for improving
the support provided by mental health services
to people with learning disabilities.
High Quality Care for All
The final report of Lord Darzi’s ‘Next Stage
Review’. ‘High Quality Care for All’ makes clear
that quality should be the organising principle
for the NHS and should be at the heart of every
organisation’s operations.
HONOS
Health of the Nation Outcome Scale: Scale to
measure the health and social functioning of
people with severe mental illness.
Hospital Episode Statistics (HES)
National data warehouse for England of the care
provided by NHS hospitals and for NHS hospital
patients treated elsewhere. HES is the data source
for a wide range of healthcare analysis for the
NHS, government and many other organisations
and individuals.
IAPT
Improving Access to Psychological Therapies:
National programme aiming to improve access
to evidence-based talking therapies in the NHS
through an expansion of the psychological
therapy workforce and supporting services.
ICIS
Integrated Clinical Information System: The
Trust’s electronic patient record
IMCA
Independent Mental Capacity Advocate: Role
established under the Mental Capacity Act to
help vulnerable people who lack capacity and
are facing important decisions by the NHS and
local authorities about their treatment and care
LINks
Local Involvement Networks: LINks have been
set up in every local authority area and aim to
give citizens a stronger voice in how their health
and social care services are delivered. LINks are
run by local people, groups and organisations
and are independently supported.
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201064
Making Space
Registered charity offering support to those
suffering from mental health problems and their
families.
Mental Capacity Act (MCA)
A framework to empower and protect people
who may lack capacity to make some decisions
for themselves.
Monitor
The independent regulator of NHS Foundation
Trusts
NDTMS
National Drug Treatment Monitoring System:
The official method of monitoring the extent and
nature of structured drug treatment in England
Network Board Internal Trust meeting held on a quarterly basis for
the Trust’s district services and specialist services.
Network Boards aim to ensure that the clinical
services provided by the Trust are safe, effective
and efficient and form an integral part of the
performance and management arrangements
within the Trust.
New Horizons
A programme of action to improve the mental
well-being of people in England and drive up
the quality of mental health care
NICE
National Institute for Clinical Excellence:
Independent organisation responsible for
providing national guidance on promoting good
health and preventing and treating ill health
NIHR
National Institute for Health Research: The NIHR
commissions and funds a range of NHS and
social care research programmes
NPSA
National Patient Safety Agency
NTA
National Treatment Agency: Established by the
government in 2001 to improve the availability,
capacity and effectiveness for treatment for drug
misuse in England
NWSCT
North West Specialised Commissioning Team
OCD
Obsessive compulsive disorder
Our Health Our Care Our Say
White paper setting out a vision to provide
people with good quality social care and NHS
services in the communities where they live
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201065
Partnership Development Group
Internal Trust meeting including representatives
from Bolton, Salford and Trafford PCTs and
local authorities and the North West Specialised
Commissioning
Team.
The
Partnership
Development Group
PbR
Payment by Results: National tariff of fixed prices
for services. PbR has not been introduced yet for
mental health services. PIR
Post incident review: More in-depth investigation
of an incident conducted using a Root Cause
Analysis approach and undertaken by a senior
panel who are independent of the service where
the incident has taken place
TMR
Multi-disciplinary review of incidents, which
involves the gathering of information to enable
incident investigation.
TOPs
Treatment Outcomes Profiles: Tool developed by
the NTA, which enables clinicians and services
users to see if their drug treatment care plan
is working and provides commissioners with
information to assess the impact of treatment
UAcT
User Action Team
PTSD
Post traumatic stress disorder
SMI
Severe mental illness
Staffnet
The Trust’s intranet site for staff
SUS
Secondary Uses Service: Source of comprehensive
data to enable a range of reporting and
analysis
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201066
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201067
Greater Manchester West
Quality Account
2009-2010
Greater Manchester West Mental Health Foundation NHS Trust Quality Account 2009 / 201068