042
Quality Account
Quality report
Board statement
The production of a Quality Account originated from
the Lord Darzi review “High Quality Care For All”. The
aim is to ensure that NHS organisations will be able to
demonstrate that they prioritise quality improvement
with the same effort and emphasis given to
maintaining financial balance.
The provision of high quality services is the
responsibility of every member of staff. The Board of
Directors have very specific responsibilities in relation
to ensuring this is the case. High quality care means
services are safe, effective and delivered in a way that
protects the rights and dignity of people using the
services as well as supporting choice. A high quality
service is one that supports and involves carers, works
effectively with other organisations to deliver the best
possible care/treatment and works hard at maintaining
service users health and wellbeing in the broadest sense.
High quality has to be a value held by all staff and
part of the organisational culture, before it can be fully
and consistently realised in practice. The Trust’s Five
Year Business Plan, written in 2007 as part of our
application to become a Foundation Trust set a
strategic objective “To be a values-driven centre of
excellence” and the quality theme is reflected in this
and various aspects of the subsequent annual plans.
Quality is reflected throughout the organisation from
the strategic objective “to have a quality mental health
service“ and defines this as:
•complying with CQC standards and improve
performance against them year on year
•meeting all existing and new national targets for
mental health trusts
•promoting the mechanisms for achieving
this through governance, leadership and
partnership working
This Quality Account and the systems that support
its production are a way of the Board of Directors
demonstrating that it takes its responsibilities for
monitoring and leading on quality seriously. The systems
in place to monitor and improve quality include:
•A committee structure with explicit responsibility
for monitoring and leading on quality improvement
the Board of Directors, Audit and Risk Committee
and the Service Governance sub Committee.
•Locality governance systems feeding into a central
governance system.
•Performance management (e.g. via the Business
Performance Report)
•A training and development service to support the
needs of staff
•Implementation of outcome measures (e.g. Health
of the Nation Outcome scales. HoNOS)
•Information systems (e.g. Abacus and DATIX)
•Contract monitoring, including Commissioning for
quality and innovation (CQUIN).
•Workforce development (e.g. Modern Matron and
Nurse consultant posts)
•Reviews of productivity and efficiency (e.g. Service
Standardisation)
•System for monitoring the Care Quality Commissions
“Essential Standards”
•Staff engagement work (e.g. The Big Conversation)
•Central governance systems (e.g. Complaints
management, risk management; clinical
effectiveness and clinical audit)
043
Summary of findings
This document identifies that quality is an integral part
of the organisation and evidence for this is found at
all levels. The trust is an active participant in national
audits and enquiries, learning lessons and producing
action plans to implement recommended changes.
At board level, quality is a priority with a number of
systems in place for monitoring and making
improvements Contract monitoring provides a robust
system of quality checks from the commissioners. Service
users and carers play an important role in monitoring
and maintaining quality through involvement in Trust
committees, local governance groups and specific service
user and carer involvement groups.
The Trust is an active participant in research, and
audits are carried out both within the central audit
schedule and locally initiated. In all cases the outcomes
are used as a basis for an action plan to improve quality.
The examples provided from the localities
demonstrate an active and diverse approach to
identifying issues that affect quality and a robust
commitment to taking action to improve quality.
The Trust is committed to working with partner
organisations and stakeholders to ensure that quality
is embedded throughout the organisation, learning
from complaints, developing and improving standards
and ensuring that the Trust consistently puts quality
at the forefront of services.
Quality Improvement initiatives
The Trust services are split into six geographical
locations providing inpatient and outpatient mental
health services for all age groups. In addition the Trust
runs two specialist services; an alcohol and drug
rehabilitation service, and a regional forensic service.
Across the Trust there are many examples of quality
improvement initiatives.
In the Trust alcohol and drug service (TADS,
following a restructuring of the existing teams, there
is now a dedicated Assessment and Brief Intervention
Team. The waiting time for assessment from day of
referral to assessment is currently 5–10 working days.
As an open access service this is a real achievement.
The number of clients that are discharged in the
Assessment team has increased, for example patients
just requiring an alcohol detoxification within the
community. This has had a positive impact on reducing
caseloads in the longer term/ recovery teams and is
starting to have a positive impact on the planned
discharge rate.
In the North locality a Service Improvement Forum
has been set up to ensure the full and meaningful
involvement of service users and carers, together with
improving the way mental health services are delivered
in the Locality, in line with the Government objectives
outlined in ‘Putting people First’ 2007, and latterly,
‘New Horizons’ 2010.
In the South locality, responding to increasing
demands on services, a six-month pilot of a Primary
Care Worker has been conducted across GP practices
in the Dereham area.
The evaluation shows increased number of referrals
being managed within Primary Care, reduced waiting
times, increased proportion of face-to-face patient
contacts, and very positive feedback from GPs and
Care Homes.
The evaluation showed excellent results in
supporting care homes to manage residents with
dementia exhibiting challenging behaviour, with 28
of 29 referrals from care home being successfully
managed within the care home setting.
In the West locality the Intensive Support Team (IST)
within CAMHs continues to develop to provide
intensive support and assistance to children and young
people as an alternative to admissions.
The IST for Older People has improved community
services for older people with mental health issues by
supporting early discharge or reducing admission stays.
Patients and their carers feel reassured by having this
additional contact.
Within the City locality, the Primary Care Link-Worker
Team was launched in July 2009 and full recruitment is
now complete. This service is provided across all GP
surgeries within the Norwich City boundary and at the
point of the initial six-month review the feedback from
GPs to the service change is very positive, with particular
reference being made to the benefit of link-worker
continuity and direct access to Primary Care specific
medical staff. The City’s Lead Clinician has also
undertaken to visit local GP surgeries (she has currently
visited about 50 %) as part of the Locality Strategy to
improve engagement, and interest has been shown so
far in GP educational meetings that the Trust hopes to
convene in 2010.
044
In Great Yarmouth locality, the staff in the Older
Peoples Community team audited a selection of
patient’s notes against CPA. Following feedback to
the Service Improvement Meeting (SIM), it was
identified that staff were not evidencing that they
had provided patients with copies of their care plans.
This is now being dealt with in supervision sessions.
The forensic service has established a Clinical
Interventions Management Group with the aim of
developing the delivery of psychological interventions to
meet service user needs utilising best-evidenced practice.
This multi-disciplinary group, including the newly
appointed cognitive behaviour therapy (CBT) therapists,
is also working with the UEA on a research project to
evaluate the resultant impact on patient outcomes.
In the Waveney area the Acute Services gym opened
in July 2009 providing top of the range total access
equipment in a relaxed, friendly environment. The
equipment is suitable for the full range of abilities and
those with disabilities. Staff from the Acute Services
have been trained as gym instructors providing flexible
opening hours taking into account individual needs.
The gym is a focal point offering services that aim
to improve physical health and wellbeing thereby
providing huge positive benefits to mental health.
The development of the Quality Account
The starting point for this Quality Account was for the
organisation to hold three Quality Stakeholder Events
across the two counties. These public events invited
key stakeholders and were also advertised in the local
press. Attendees included service users, the voluntary
sector, general practitioners, members of the public,
staff, governors, county councillors and the Trust’s
commissioners. The events were chaired by the Trust’s
Chair and brief introductory statements were made by
members of the executive team, including Aidan
Thomas (Chief Executive) and Anthony Jackson
(Governor – who chairs a Board of Governors sub-group
with an interest in quality). The Trust is extremely
grateful to those who attended and acknowledges
that this Quality Account has been strongly influenced
by the events, including the agreement of future quality
priorities, which came directly from them. The Trust
plans to hold these events annually in order to actively
involve the public and interested parties in the
development of future priorities as well as to continue
to develop a shared understanding of what quality in
mental health provision means.
In addition to this public involvement draft copies
of this report have been shared with the local LINk
network (public involvement group); the Trust’s
commissioners; and the two Overview and Scrutiny
Committees for Norfolk and Suffolk. Each group has
been given an opportunity to influence the content and
provide a written statement of their own.
To the best of my knowledge the content of this
Annual Quality Account for Norfolk and Waveney
Mental Health NHS Foundation Trust is accurate and a
true representation of the quality of services provided.
Signed:
(Aidan Thomas – Chief Executive Officer)
Dated: 4 June 2010
045
Quality Account
Quality priorities 2010–2011
Priorities:
• Priority 1: Improved access to services for people with
a learning disability
• Priority 2: The development of service user led
outcome measures
• Priority 3: Implementation of an additional system
that is validated through research, of both capturing
and acting on feedback from service users and carers.
Rationale for the choice of priorities
Following extensive stakeholder engagement a range
of potential priorities were presented to the Board of
Directors around the key themes of:
•Access
•Outcomes
•Personalised care and treatment
•Partnership working
•Mental health promotion
•Information/communication
Priority 1 is nationally mandated and measured by the
care quality commission through the green light toolkit.
This is important because there are national concerns
that people with a learning disability are not given the
same fair access to health services as other people. In
addition services are not designed to meet their specific
needs, meaning that when they are offered services
they are unable to make best use of them. This priority
will ensure that the Trust appropriately meets the
mental health needs of people with a learning disability.
Priority 2 has been highlighted by service users as
meaningful to them, based on person centred care.
When looking at quality improvement it is essential that
the very people who use the services are part of
defining what should be different for them as a result
of accessing treatment and support.
Priority 3 is a national priority for mental health
trusts and highlighted by users and carers and will
complement the current Patient Experience Tracker
(PET) system. The system chosen is the Carer and User
Experience Survey (CUES). This priority is really about
the Trust having an ongoing system of capturing service
user and carer feedback in order to monitor the quality
of services and make changes to services that are
meaningful to those who rely on them.
046
Monitoring quality priorities
Action plans
Priority
Improve access for people
with a learning disability
Indicator measure
To comply with the
requirements set out in
“Healthcare for all”
(2008) and the Disability
Equality duty set out in
the disability
discrimination act
Expected outcome
An action plan
identifying required
improvements and how
these will be achieved
including timeframes
Monitoring/reporting
Quarterly progress reports to service
governance sub committee
The development of
service user led outcome
measures
To inform the development
of service user led outcome
measures and to provide a
forum from which further
initiatives will develop as a
result of the feedback to
improve service provision
in the future
An action plan
identifying relevant
service user outcomes
that can be measured
and reported to inform
the quality agenda
Monthly updates and Quarterly progress
reports regarding:
Q2 – Report identifying project plan by
31st July 2010
Q3 – Report of progress against project plan
by 31st Oct 2010
Q4 – Report following event, covering
outcomes, feedback and action plans by
31st Jan 2011
Implementation of an
additional system that is
validated through
research, of both capturing
and acting on feedback
from service users and
carers
There are 1.2 million
people in the UK who care
for others full time and 4.8
million who care for others
part-time, but carers are
often overlooked even
though they make a major
contribution
The implementation of
CUES which will inform
action plans for future
service improvements
Monthly updates and Quarterly progress
reports regarding:
Q2 – Report of findings and agreed
methodology and sample group by
31st July 2010
Resources
The Board of Directors initially ring-fenced £50,000 of
additional resource to support the development of
these priorities. This resource includes the funding of:
•1 Whole Time Equivalent (WTE) band 4 Audit
assistant
•0.5 WTE band 3 admin support to implement CUES
•Partial funding of a band 4 psychology assistant.
Priorities 2 and 3 were also agreed as CQUIN Targets
and so linked to incentive payments by commissioners.
This will help the organisation manage its quality
improvement programme, ensure regular external
monitoring and provide some financial benefits to
ensure continued improvement.
Q3 – Report of progress against
implementation plan by 31st Oct 2010
Q4 – Report findings of surveys and action
plans based on results by 31st Jan 2011
047
Quality Account
Quality overview
The quality report for 2009/10 identified four priorities:
1. To increase the provision of Cognitive
Behavioural Therapy (CBT) for people with
a recent diagnosis of schizophrenia
The latest quarter 3 audit completed in January
identified that only 28% of those audited received,
were offered, or CBT was not applicable.
Total number of those audited
who received, or were offered,
CBT, or CBT was not applicable
(an exception) in the previous
12 months*
Total number of service users
audited
Question 2.2
Total number of those audited
who received CBT, AND for whom
CBT was undertaken or planned
for more than six months OR
more than ten sessions
Total of those audited who
received some CBT in the
previous 12 months* (but not
as described to NICE Guidelines)
July 2008
Sept 2009
Feb 2010
48
8
29
100
26
102
National guidance has also been unclear in defining
what should be delivered and by whom. This has now
been clarified in national Clinical Guideline 82, which
sets out exactly what CBT should look like, and
recommends a Randomised Controlled Trial (RCT) to
investigate the competencies required to deliver
effective CBT to people with schizophrenia.
In order to improve the quality of this intervention
the governance team will review the current guidance
and present an action plan to the Service Governance
sub Committee.
2. To increase the number of service users who say
a member of their care team has fully discussed
their medication with them in the last 12 months
This indicator was measured using the Patient
Experience Tracker (PET)
5
0
7
QUESTION
Do the staff clearly explain
the purpose, benefits and
risks of your medication?
10
2
11
Are you involved in making
decisions about the
medication that you take?
The figures reported in last year’s quality report were
48% for the Trust. However, the audit was carried out
on a revised basis compared to the previous year. The
sample sizes differ greatly but the table does demonstrate
that there was an increase in those service users for
whom CBT was appropriate, receiving the service.
Sept 2008
– March
2009
April 2009
– March
2010
70%
87%
77%
83%
048
4. To increase the number of assessments and
referrals for inpatients wishing to quit smoking
The latest quarter 3 audit carried out in March 2010
has demonstrated that there has been an increase in
the number of smoking assessments carried out from
the 13% identified in the 2009 quality report to 36%.
As shown in figure 1 there has been an incremental
increase across the quarterly audits completed.
Smoking Assessments Completed
% of SUs audited
3. To achieve increased rates of diagnosis of
dementia at an early stage of the illness along
with provision of high quality information as
described in the National Dementia Strategy
It is very disappointing that the Trust has been unable
to set a baseline and improvement target for this
priority in spite of joint working with the Primary Care
Trust (PCT) and regional groups working on the
National Dementia Strategy. One reason for this is
because of weaknesses in national and local
information systems. To address this issue the
Commissioning for Quality and Innovation (CQUIN)
targets set with the PCT for 2010/2011 includes a
target for data quality improvement.
In addition, although no hard data is available, the
Trust has run a number of ‘Memory Matters’ road show
events across the localities in public venues. These road
shows have actively engaged members of the public,
giving them information and where appropriate
providing them with letters to take to their GP for
referral for memory assessment. The Trust has also
worked in partnership on the development of new
Dementia Advisor posts.
40
35
30
25
20
15
10
5
0
Aug 09
(Quarter 1)
Nov 09
(Quarter 2)
Audit Date
Feb 10
(Quarter 3)
049
Quality Account
Mandated quality statement
Quality review
During 2009/2010 the Norfolk and Waveney Mental
Health NHS Foundation Trust provided and/or
sub-contracted six NHS services, Adult services, prison
mental health services, children’s services, drug and
alcohol services, older people’s services and non NHS
Norfolk contracts including forensic services.
The Norfolk and Waveney Mental Health NHS
Foundation Trust has reviewed all the data available to
them on the quality of care in all of these NHS services.
The income generated by the NHS services reviewed
in 2009/2010 represents 97.8 per cent of the total
income generated from the provision of NHS services
by the Norfolk and Waveney Mental health NHS
Foundation Trust for 2009/2010.
During that period Norfolk and Waveney Mental
Health NHS Foundation Trust participated in two (50%)
national clinical audit and one (100%) national
confidential enquiry of the national clinical audits and
national confidential enquiries that it was eligible to
participate in.
The national clinical audits and national confidential
enquiries that Norfolk and Waveney Mental Health NHS
foundation Trust was eligible to participate in during
1st April 2009 – 31st March 2010 are as follows:
•National Falls and Bone Health Audit
•Royal College of Physicians Continence Care audit
•Pharmacy Observatory of Mental Health (POMH):
prescribing topics in mental health services
•National association for the prevention and treatment
Clinical and National Audit
of depression (NAPTAD): anxiety and depression
During the period 1st April 2009 – 31st March 2010,
two national clinical audits and one national confidential
enquiry covered NHS services that Norfolk and Waveney
Mental Health NHS Foundation Trust provides.
•National Confidential Enquiry into Suicide and
Homicide by People with Mental Illness
The national clinical audits and national confidential
enquiries that Norfolk and Waveney Mental Health NHS
foundation Trust participated in during 1st April 2009
– 31st March 2010 are as follows:
Name
National Clinical Audits
National Audit of the
Organisation of Services
for Falls and Bone Health
of Older People
Completed & status
No. of cases audited and percentage of population
Completed
Service / site audit only looking at the service we
provide. Monitoring 100% of the service offered.
Royal College of Physicians
Continence Care audit
In progress
Cases audited: 36
Percentage of total population: Approx. 90%
of qualifying population.
Continuous audit
- Notification letter 26/06/09
quotes a response rate for
Trust of 99.26% (national
response rate 98.19%).
Response rate for the sudden
unexplained deaths study
97.44% (national average
95.86%)
Audit data provided on 278 service users in this
period. This is 100% of service users to whom
this is applicable.
National Confidential Enquiries
National Confidential Enquiry
into Suicide and Homicide by
People with Mental Illness
050
The following table demonstrates the actions planned
by Norfolk and Waveney Mental Health Foundation
Trust in response to the two national audits. The table
also identifies three other National Audits were
completed in the time frame and reported as tabled
below (These were selected as part of the Annual Audit
Programme approved by the Board of Directors).
Audit
National Audit of the
Organisation of Services
for Falls and Bone Health
of Older People
(Report: March 2009)
Compliance Good.
Rate of falls below the
national average
Agreed action
The Trust should re-establish links with the PCT to develop a shared falls referral
pathway via the Trust’s own Falls group to agree access to falls clinics and community
based services
Informal training should be developed in collaboration with the Training and Education
department and made available to staff working within older peoples’ services across
the Trust
Data provided on incident reports should inform the training
Consideration should be given to including a risk assessment for osteoporosis and
fractures within the falls assessment
An audit of the falls care pathway should be included in the 2009 audit schedule
The Royal College of
Physicians Continence Care
Audit
In progress – Start date Oct 09 end date estimated spring 2010
Depression Screening and
Management of Staff on
Long-term Sickness
Absence – Occupational
health practice in the NHS
in England
(Report: January 2009)
Royal College of Physicians
Faculty of occupational
medicine (RCP FOM NHS
Plus)
Consider own results in light of targets and in comparison with the national results
Where consultations do not meet the standards set in the National Institute for Clinical
Excellence (NICE) Guidelines, practice to be reviewed to develop mechanisms for service
improvement; including
Education and training
Sharing good practice between staff of the department, regionally and more widely
Developing tools to facilitate improvement
Developing systems to support comprehensive documentation of consultations
Back Pain Management –
Occupational health
practice in the NHS in
England
(Report: January 2009)
(RCP FOM NHS Plus)
Consider own results in light of targets and in comparison with the national results
Where consultations do not meet the standards set in the FOM Guidelines, practice to
be reviewed to develop mechanisms for service improvement; including:
Education and training
Sharing good practice between staff of the department, regionally and more widely
Developing tools to facilitate improvement
Developing systems to support comprehensive documentation of consultations
Single Sex (Inpatient)
Department of Health
2009
Survey conducted on a number of beds over 5 sites. All Localities have individual action
plans which are displayed on the Trust website
The reports of 15 local clinical audits were reviewed in
the period 1st April 2009 – 31st March 2010 and the
Trust intends to take the following actions to improve
the quality of healthcare provided:
051
Audit
Completed Actions Reported – April 2009
NICE Guidance – Violence; the short-term
management of disturbed / violent
behaviour in Psychiatric in-patient settings
and Emergency departments
Agreed action
Smooth Transition from Child and
Adolescent Mental Health Services to
Adult Mental Health Services
Key recommendations (for only 2 localities) – Adult Mental Health Link workers should
ensure that they confirm in writing which service the young person is being referred to.
Formal transfer of the case should take place at the time of a joint appointment.
Cardio-Pulmonary Resuscitation
Key Recommendations – the Resuscitation Co-ordinator recommends that staff are
trained to Intermediate Life Support (ILS) level and that Prevention and Management of
Aggression (PMA) instructors are trained to deliver this.
Refresher sessions are provided for staff between annual up-dates.
Key Recommendations – The rational for not giving service users copies of their care
plans must be documented. As required prescriptions for medications used in rapid
tranquilisation must have a stop date to ensure that regular reviews take place. Some
areas need to review the availability of Procyclidine and Flumazenil injections for use, if
required during rapid tranquilisation.
Completed Actions Reported – July 2009
Consent to Acupuncture (Great Yarmouth
Trust Alcohol and Drug Service) 2009 Audit
report (486a) July 2009
No recommendations required. Fully compliant
Physical Health Assessment & Smoking
Cessation Referral for Inpatients (491b)
August 2009
Re-audited November 2009 – to reassess compliance. Repeat Audit to be reported March
2010.
Refer to Quality Objective Action Plan
Completed Actions Reported – October
2009
Monitoring of Prescribing and
Administration of Medicines 2008/09
Modern matrons to produce local action plans to address trends in drug administration
errors for their areas.
Covert Administration of Medicines
Five recommendations made, including; recording Pharmacists decisions in health record
and documenting reviews of decisions and care plans.
Audit of Care Pathway for Pressure Ulcer
Assessment and Prevention 2008/09
Review of the Waterlow paperwork required – to be actioned by the Physical Health
Forum. This to be implemented in relevant clinical areas
Prevention of Death by Suicide and
Undetermined Injury
Continue work with commissioners
Individual case reviews to take place
Audit of revised Care Programme Approach (CPA) policy
Distribute and raise awareness of pamphlet for paid and non-paid carers
Central audit compliance with relevant NICE guidelines.
Completed Actions Reported – January 2010
Doctors awareness of the potential
adverse effects of mood stabilisers in
women of childbearing age who suffer
from Bipolar Affective Disorder.
January 2010 reported to Service
Governance sub-Committee
Key recommendations –
Pre-conception consultation should be offered routinely
At least one clinician in each team should be encouraged to develop a specialist interest
Consultants should ensure that trainees have adequate awareness of the potential
adverse effects of mood stabilisers
Staff Supervision (468)
Report for – Trust-wide
Managerial and Clinical supervision – minimum time period for supervision sessions
achieved and an agreed contract signed by supervisors and supervisees. Supervision
delivered in quiet areas away from distractions and copies of the records kept by both
parties. Caseload management included in clinical supervision; including the quality of
the health records.
Planned Discharge from Inpatient Area
(449)
Report for – Trust-wide – Older Persons
and Adult Inpatient Areas
Reasons for cancelling pre-discharge meetings recorded. Carers invited to pre-discharge
meetings. Compliance with Trust procedures on Section 117 meetings achieved. Crisis
planning documented in health records; Crisis Plans produced for discharge. Risks
reviewed prior to discharge and forwarded to appropriate professionals. Service Users
are given clear details of follow-up arrangements and service users and carers given a
copy of Care Plans and Crisis Plans.
Emergency Restraint (482)
Report for – Trust-wide (Inpatient)
Service users involved in care planning. Staff take account of any advanced decisions.
Staff include all relevant information in the health records and incident reports.
Transfers between clinical teams (including
Older Persons) (450)
Report for – All Clinical Teams
Service users and carers involved in the transfers process. Written requests sent from
transferring teams to receiving teams including a clear statement of needs; formal
responses returned within 2 months. Joint visits carried out for all cases. Copies of crisis
plans provided at time of transfers (including to service users and carers).
Drug Administration Errors (452)
Report for – Trust-wide Inpatient areas
Staff ensure monthly audits completed and stored in a folders on the wards. Registered
nurses record details of actual harm on incident forms and on section B of incident
books. All drug errors recorded in health records and staff complete appropriate Drug
Error (DE) forms for drug administration errors; appropriate action taken. Form DE 3
completed where more than 5 omissions recorded.
052
There are three National Confidential Enquiries which
should also be reported on for 2009/10:
•National Confidential Enquiry into Patient Outcome
and Death (NCEPOD)
•Centre for Maternal and Child Enquiries (CMACE)
•National Confidential Enquiry (NCE) into Suicide and
Homicide by People with Mental Illness (NCE/NCISH)
The Trust participates in the National Confidential
Enquiry (NCE) into Suicide and Homicide by People
with Mental Illness as previously documented, with
excellent compliance scores. Should the Trust have
serious case review (SCR) resulting from child deaths
these would be reported through the Norfolk
Safeguarding Children’s Board and be reported in the
three year National Report. However for the period
being looked at there have been no SCRs.
Of the 34 National Clinical Audits for inclusion in
Quality Accounts 2009/10, published on the
Department of Health website, only four are relevant
to the service provided by Norfolk & Waveney Mental
Health NHS Foundation Trust.
Norfolk& Waveney Mental Health NHS Foundation
Trust has engaged in three national audits that are not
represented in the list under quality accounts clinical
audits. They are included in the table above with
relevant action /recommendations.
Participation in clinical research
The number of patients receiving NHS services
provided or sub-contracted by the Norfolk and
Waveney Mental Health NHS Foundation Trust from
April 2009–10 that were recruited during that period to
participate in National Institute for health research
(NIHR) portfolio studies, approved by a research ethics
committee was 224.
This level of participation in clinical research
demonstrates the Trust’s commitment to improving
the quality of care offered and to making a contribution
to wider health improvement.
The Trust was involved in 37 clinical research studies
during the specified time. The Trust used national
systems to manage the studies in proportion to risk.
Of the 14 studies given permission to start, five were
given permission by an authorised person less than
30 days from receipt of a valid complete application.
28 of the studies were established and managed under
national model agreements and 50% of the 28 eligible
research involved used a Research Passport.
Between April 2009 – April 2010 the National
Institute for Health Research (NIHR) supported 18
of these studies through its research networks.
Use of the Commissioning for Quality and
Innovation (CQUIN) framework
A proportion of Norfolk and Waveney Mental Health
NHS Foundation Trust income in 2009/2010 was
conditional on achieving quality improvement and
innovation goals agreed between Norfolk and Waveney
Mental Health NHS Foundation Trust and any person or
body they entered into a contract, agreement or
arrangement with for the provision of NHS services,
through the Commissioning for Quality and Innovation
payment framework.
Further details of the agreed goals for 2009/2010
and for the following 12-month period are available on
request from:
Sue Barrett (Head of Governance)
Tel: 01603 421617
Email: sue.barrett@nwmhp.nhs.uk
Statements from the Care Quality
Commission (CQC)
Norfolk and Waveney Mental Health NHS Foundation
Trust is required to register with the Care Quality
Commission (CQC). Its current registration status
announced on the 26th March 2010 is to provide two
regulated activities as defined by the CQC at the nine
registered sites across the Trust:
•Treatment of disease, disorder or injury
•Assessment or medical treatment for persons
detained under the Mental Health Act 1983
Norfolk and Waveney Mental Health NHS Foundation
Trust has no conditions on registration. The CQC has
not taken enforcement action against Norfolk and
Waveney Mental Health Foundation Trust during
2009/2010 as of 31 March 2010.
Norfolk and Waveney Mental Health NHS
Foundation Trust is subject to CQC Periodic Reviews,
but to date none have yet taken place.
Norfolk and Waveney Mental Health NHS
Foundation Trust has not participated in any special
reviews or investigations by the CQC during the
reporting period.
Data Quality
Norfolk and Waveney Mental Health Foundation Trust
submitted records during April 2009 – 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 that included:
The patient’s valid NHS number was:
•99.21% for admitted patient care
•Not Applicable for out patient care
•Not Applicable for accident and emergency care
053
The patient’s valid General Medical Practice Code was:
We have identified success in these areas as:
•99.47% for admitted patient care
•Not Applicable for out patient care
•Not Applicable for accident and emergency care
•Ensuring our workforce is financially affordable
•Stimulating innovation
•Increasing productivity
•Ensuring the sustainability of the organisation
•Managing risks to the organisation and exploiting
Norfolk and Waveney Mental Health Foundation Trust
score as at 31 October 2009 for Information Quality
and Records Management, assessed using the
Information Governance Toolkit was 83%.
Norfolk and Waveney Mental Health Foundation
Trust was not subject to the Payment by Results clinical
coding audit during 2009/10 by the Audit Commission.
Workforce Strategy to support Quality
Improvement
The Trust has a five-year workforce strategy (2007–12)
that has been approved by the Trust Board of Directors.
It was developed with staff involvement taking account
of feedback from focus groups, the staff survey and
union colleagues.
As part of our wider organisational strategy to
“be recognised as a values-driven centre of excellence
in Mental Health Care that enhances the wellbeing of
the communities of which we are a part”, we have
identified two specific workforce objectives to support
the delivery of this vision:
•To have a workforce that is fit for purpose and
delivers first time, every time
•To attract the very best staff, retain them by
rewarding them well in ways that motivate them
further and provide every opportunity for them
to develop to their fullest potential
Our workforce strategy has four main themes:
•The financial impact of the workforce
•The behaviour and culture of the workforce
•Being a model employer/employer of choice
•The value added by a high performing HR function
1
As at March 2010
opportunities
•Ensuring we recruit and retain the right staff
required to deliver our services
•Responding to and leading on equality and
diversity agendas
The Trust recognises the importance of a high quality
workforce that is committed, engaged, trained and
supported in order to deliver high quality patient care.
The Trust has a stable turnover of approximately
10%1, which is below the average for health and social
care organisations. This includes a stable fringe turnover
of leavers within their first year of employment (2%).
The Trust has had challenges in recruiting staff to
some specialisms and more remote rural geographical
locations over recent times but has addressed this
through its recruitment strategies. The Trust held a
recruitment day in July 2009 that attracted over 400
visitors from across the county and wider. It has recently
established a steering group to support co-ordinated
and more innovative recruitment approaches across
the localities and services. We have recently introduced
psychometric and aptitude testing as a mandatory
requirement for the recruitment of senior managers
and clinicians to support the recruitment of high quality
senior leaders with the relevant aptitudes for leading
the delivery of high quality mental health services. We
have also devised a development centre approach to
assessing staff skills in delivering patient-centred care in
order to ensure staff have the requisite skills, attitudes
and development opportunities to work within a centre
of excellence in dementia care. This approach will be
shared elsewhere in the Trust.
054
In the 2009 Staff Survey, 92% of our staff surveyed
(higher than average for mental health/learning
disabilities Trusts) agreed that their role makes a
difference to patients. This represents an improvement
on 5% of the previous year’s results. There was no
change since the 2008 survey, however, in respect of
the percentage of staff surveyed who are satisfied with
the quality of work and patient care they are able to
deliver and the quality of job design. The Trust
therefore wishes to explore these areas further with
a view to improvement as part of its action plan arising
from the most recent Staff Survey.
A programme of work is currently underway to
review clinical team structures across the localities with
an objective of identifying the best way of delivering
clinical services to ensure quality, efficiency and value
for money and with a view to a standardised approach
wherever appropriate. This process is being undertaken
with the involvement of clinical staff and involves
role-redesigning some posts. Other initiatives that are
also exploring opportunities for improvements to the
delivery of quality and efficient care are using lean
methodologies to release more time through process
reviews for direct patient care with the objective of
improved clinical care and patient experience. One such
programme is the ‘Releasing Time to Care’ project.
The Trust is committed to the development of its
staff; indeed, this is core to delivering quality services.
The 2009 Staff Survey results show a higher than
average number of respondents reporting that they feel
there are good opportunities to develop their potential
at work and to have received job-relevant training,
learning or development within the last 12 months.
We have also seen an improvement from 2008 to
2009 in respect of those reporting to have supportive
managers although this is an area that we wish to
see further improvement in. Over the last year, we
have launched a culture changing management and
leadership development programme. Approximately
200 leaders have undertaken this to date. First line
managers attend a course called ‘Good to Great’ and
more senior managers undertake a programme
accredited with the Institute of Leadership and
Development. The objective of the programmes is to
give those in management and leadership roles the
knowledge, and skills to be competent and confident
leaders, displaying appropriate leadership styles and to
empower them to instigate positive change.
The Staff Survey results in respect of the percentage
of respondents who reported they had received an
appraisal within the last 12 months are disappointing
with the Trust in the bottom 20%. In advance of the
results being available, however, the Trust had already
identified the rate of appraisals as a priority area for
improvement. The current figure is that 83%2 of staff
have been appraised within the last 12 months. This
is being monitored as a key performance indicator
by the Executive Operational Team and by the Board
of Directors.
The Trust is moving towards using e-KSF (Knowledge
and Skills Framework) that will automatically generate
personal development plans. Work is also being
instigated to review the appraisal process to improve
quality as part of a wider performance management
strategy. The Trust is also in the process of developing
a Talent Strategy to support our ability to recruit and
retain high quality staff.
The Trust has been proactively working, in
partnership with our union colleagues, to reduce
sickness absence rates. Whilst currently above the
national average for healthcare Trusts, there has been
a significant reduction in our absence rates over the
past 12 months. This is a key performance indicator
for the Trust and we are on track to achieve our target
for 2009/10. We recognise the impact that sickness
absence can have not only on temporary staffing costs
but the quality and consistency of patient care.
Through our Workforce Strategy and the supporting
workforce quality and cost improvement plans, we are
committed to ensuring our workforce is engaged, fit
for purpose and developed to deliver quality, safe,
efficient patient services.
2
As at March 2010
055
Board of Directors’ Monitoring of Quality
A comprehensive quality review must include the
monitoring of patient safety, clinical effectiveness as
well as the patient experience. For this reporting period
the Board of directors selected the following Key
Performance Indicators (KPIs) in order to monitor the
quality of the services provided:
Key performance indicator
Target
Trust
position*
95%
97.59%
Absconsion of detained
patients as a ratio of 100
detained patients at end
of period
4.10
4.44
Ratio of in-patient serious
untoward incidents (e.g.
suicide) per 10,000
occupied bed days
2.86
Patient safety
7 day follow up of service
users post discharge from
in-patient services
Clinical Effectiveness
Access to Crisis Resolution/
Home Treatment Services
In addition to the Key Performance Indicators used by
the Board of Directors to monitor quality the following
has been used to evaluate services:
3.06
Safety
90%
94.94%
Delayed transfers of care
None
declared
1.52%
Drug mis-users in effective
treatment
None
declared
87.28%
Increased provision of
Cognitive Behaviour
Therapy for people with a
diagnosis of Schizophrenia
52.8%
28%
Earlier diagnosis of
dementia
It is not possible to draw comparisons with other trusts
as there is limited data available from Monitor, and the
CQC will not release its figures until later in the year.
Key performance indicators are either set by the
Trust or enforced by external partners/organisations as
part of contractual obligations. Strategically the Trust
will have applied indicators to what it sees as the key
areas for focus as part of the Trust strategy for
improving health and lives. Commissioners often
require such indicators to illustrate that the Trust is
doing what it is being financed to do.
The Business Performance Report is used on a
monthly basis to inform the Board of Directors of the
status of the Key Performance Indicators.
•Monthly Serious Untoward Incident (SUI) Reports
•Suicide Audit
•Quarterly Risk reports
•National Patient Safety Agency report on the Trust
•Independent assessment by the National Health
Service Litigation Authority
•Self evaluation against the “7 steps to patient safety”
Clinical Effectiveness
•Baseline assessments of compliance with National
Institute for Health and Clinical Effectiveness (NICE).
•Lean Exercise into Trust processes for implementing
See above
NICE guidance
72%
87.57%
•Quarterly Clinical Effectiveness reports
•Programme of clinical audit
15.6%
36.25%
Patient experience
1%
0.3%
0
0
Social care clients receiving
direct payments
350
427
Social care clients receiving
individual budgets
100
19**
Patient Experience
Medication and side effects
discussed with service users
Smoking cessation
assessments offered to
in-patients
Percentage of bed days
occupied by under 18 year
olds on adult acute
in-patient wards
Number of under 16 year
old patients admitted to
adult acute wards
•National Patient Survey
•Patient Experience Tracker
•Quarterly Complaints monitoring and PALs report
Evaluation of Patient Safety
* The Trust position against these targets is discussed
within this report.
** This continues to be a priority and following recent
communication from Norfolk County Council the
guidance as to how individual budgets can be applied
has changed which will facilitate their wider use.
The KPIs directly related to patient safety are:
Percentage of bed days occupied by under-18
year old patients on adult acute wards
The target set is 1% and the trust is currently meeting
the target at 0.3%. This is in contrast with National
data for the last available 2008/09 figures of 8% across
the NHS.
Number of under-16 year old patients
admitted to adult acute wards
The target is set for 0 and the Trust is meeting this target.
056
Absconscions of detained patients as a ratio
of 100 detained patients at end of period
The target for the full year is 4.10 but the final ratio is
4.44. While this figure indicates that the Trust has not
met the target, it does demonstrate an improvement
on last years figure of 5.29.
Where analysis of the data has indicated that
specific wards have high levels attributed to estates
issues, actions have taken place to improve this
including improved window security, fencing and entry/
exit systems.
A number of service improvement initiatives have arisen
as a result of identified recommendations within the
RCA reviews. These include:
•The review and strengthening of the Trust’s Dual
Ratio of inpatient SUIs per 10,000 occupied
bed days including leave
Diagnosis strategy. This has included the
identification of further training for staff.
•The amendment of a Trust policy describing the
process for the transfer to Trust services of a service
user from a different NHS Trust.
•Through the introduction of the updated Care
Programme Approach process, the Trust operates
a single robust risk assessment, which is founded
on evidence-based practice.
The target for the full year is 2.86 and the final figure
is 3.06.
Although this indicates that the Trust has not met the
target, it reflects the culture of reporting within the Trust.
A new system to speed up the identification of
problems to enable them to be effectively managed
has been introduced.
During this year the Trust has concentrated on training
senior managers with the facilitation skills required to
conduct Root Cause Analysis.
The Trust has had no SUIs involving personal data
as reported to the Information Commissioner’s office
in 2009/10.
Serious Untoward Incidents
The Trust continues to report all SUIs on receipt of an
initial report. Incidents may subsequently be stood
down if an explainable cause is identified i.e. if a death
is found to be as a result of natural causes, and will
not be subject to a coroner’s inquest.
In 2009/2010, 79 SUIs were issued of which 44 were
unexpected deaths. At the time of reporting, 8 deaths
have been determined due to a natural cause.
All other unexpected deaths reported as a SUI are
investigated using a process called Root Cause Analysis
(RCA).
Summary of other Personal Data-related
Incidents in 2009/10
Category
I
Nature of incident
Loss/Theft of inadequately
protected electronic equipment,
devices or paper documents from
secured NHS premises
Total
0
II
Loss/Theft of inadequately
protected electronic equipment,
devices or paper documents from
outside secured NHS premises
0
III
Insecure disposal of inadequately
protected electronic equipment,
devices or paper documents
0
IV
V
Unauthorised disclosure
Other
0
0
057
Suicide Audit
There had been a noticeable decrease in the numbers
of service users committing suicide or dying by
undetermined injury in the high-risk period (as an
in-patient, on leave or within 3 months of discharge).
This figure had dropped from 53% of the sample in
2006/07 to 23% in 2007/08. Action was taken
following the 2006/07 audit to focus on the seven-day
follow-up period – it is pleasing to note that this has
had a positive impact.
The Trust was largely compliant with the factors set out
in the National Institute for Mental Health (NIMHE)
Toolkit ‘Preventing Suicide’. Main areas of concern were:
•It was noted that only 50% of service users
demonstrating one or more high risk factors were
allocated to the enhanced tier of CPA –in several
cases this information could not be located in the
health records.
•In 26% of cases it was not possible to locate
information in the health records stating the level of
suicide risk.
A further audit has been carried out in 2008/09 and
the results are awaited.
The Trust reviewed and implemented a new CPA
recently. The lead for this work was the Trust’s Patient
Safety lead, who was also responsible for the Trust’s
Suicide Prevention Strategy.
No specific trends have been identified through the
risk reporting process within the Service governance
quarterly risk report. Peaks and troughs have been
identified in incident rates dependent on the patient
group involved. Where peaks have occurred, these are
usually linked to a small number of service users where
appropriate actions/interventions have already taken
place. Some of this can be due to the service user being
very unwell when first admitted but subsequently
responding to treatment.
Absconscions in an area where specific wards have
experienced higher than normal incident rates has
resulted in works being carried out (additional fencing,
improved window security and enhanced entry/exit
systems). A new process of monitoring is also being put
in place to more quickly identify issues that could be
rectified quickly to avoid further occurrences.
National Patient Safety Agency (NPSA)
Report
Last year the NPSA highlighted Norfolk and Waveney
Mental Health NHS Foundation Trust as being in the
top ten of mental health organisations nationally for its
incident reporting. The NPSA state that high reporting
levels are an indication of a positive safety culture.
Detailed data demonstrated that the Trust not only had
high rates of reporting, but that incidents resulting in
harm were below that of the national average.
The report did highlight higher than average
medication error rates. The majority of these were
prescribing errors. The organisation was aware of this
high rate of prescribing errors prior to the NPSA report
and had been monitoring and investigating trends. In
order to reduce prescribing errors by 90% the Trust is
introducing an electronic prescribing system.
The Trust’s eMMa (electronic Medicines
Management and administration) project began at the
start of 2009 with objectives of achieving clinical
benefits, operational efficiencies, financial savings, and
providing enhanced governance. It is intended to start
piloting the Ascribe electronic Prescribing and
Medicines Administration system in July 2010 and roll it
out across the Trust by the middle of 2011.
Our baseline data, gathered over a four-month period
in 2008, revealed 55 significant prescribing anomalies at
the Trust which, if we had reproduced the success of
Wirral University Teaching Hospital NHS Foundation
Trust’s 15 years of experience, would have been two or
less if electronic prescribing had been in place.
Although the Trust project is a first in Mental Health
in the UK, further details on the wider national
programme can be found on the Connecting For
Health web site at:
http://www.connectingforhealth.nhs.uk/
systemsandservices/eprescribing
The NPSA report for data between April and
September 2009 identifies that the trust has reduced
the number of medication errors from 168 (10.7% of
all incidents reported in September 2008) to 160
(10.1%of all incidents reported in September 2009).
This is compared to 7% of incidents across the cluster.
The Trust remains in the top ten for incident reporting.
058
NHS Litigation Authority (NHSLA) summary
On the 18th December 2008 Norfolk and Waveney
Mental Health NHS Foundation Trust underwent an
intensive two-day assessment process by NHSLA.
Following the assessment the Trust achieved Level 2
status.
The assessment for NHSLA consists of five standards
with ten criteria for level 1 and 2. Each of these ten
criteria can have up to six separate sub-criteria, in
which the Trust needed to provide assurance. To
achieve Level 2 we needed to evidence this assurance
in detail to what the Trusts states it provides in policies/
procedural documents.
The five standards were:
Standard 1 Governance
The Trust needed to show effective functioning of the
board, managerial leadership and accountability, and
the organisations systems and working practices ensure
that quality assurance, quality improvement and patient
safety are central to the activities of the organisation.
The Trust scored 8/10 for this standard.
Standard 2 Competent and Capable Workforce
The Trust needed to show that it delivers a safe
service to patients by ensuring appropriately qualified
and skilled professionals, are equipped to deliver
high quality care by receiving support and training,
on appointment and as an ongoing process.
The Trust scored 8/10 for this standard.
Standard 3 Safe Environment
A safe environment is essential to the provision of
healthcare to ensure that staff, patients and their
visitors are protected from accidents, injury and disease,
and to provide a safe place in which high quality care
can be provided.
The Trust scored 9/10 for this standard.
Standard 4 Clinical Care
The Trust must ensure the highest quality care is
delivered. Robust policies and procedures should be in
place for all clinical care. NHSLA identify higher risk
areas and selected these during the assessment
process. An example of these are resuscitation and
infection control processes.
The Trust scored 8/10 for this standard.
Standard 5 Learning from Experience
This standard covers reporting, investigating of
incidents including near misses, complaints and claims
when examined in conjunction with incident reports,
trends etc. Sharing lessons from others areas of the
organisation and wider, to enable learning to occur.
The Trust scored 7/10 for this standard.
The overall score achieved was 40/50.
Where full compliance was not awarded this has been
addressed, with some changes to protocols and policies.
Standard 1
Now has a new policy on implementing and developing
organisational–wide procedural documents and new
terms of reference that reflect committees’
responsibilities more clearly.
Standard 2
The Trust Training Needs Analysis at the time of the
assessment did not contain all the information required.
This has since been addressed with electronic
documentation that holds all training required as part
of the Minimum Data Set for NHSLA, with easily
accessible copies of staff training records. This also
includes clear records of Manual Handling training
that was not evident on assessment.
Standard 3
The Security Management Policy did not reflect the
requirement for the Trust to undertake appropriate
environmental risk assessments and evidence of this.
This is now evident and forms part of a standing
agenda item on the appropriate meeting.
Standard 4
The protocol for designing service users leaflets did
not clearly meet the NHSLA requirement, this has
since been reviewed several times and a policy has
been developed which looks at clinical leaflets and
information leaflets for service users. Health Records
Policy at the time of the assessment did not have a
clear monitoring statement; this has now been ratified
with a change in all new policies that are required by
NHSLA to have clearer monitoring statements for
purpose of implementation.
Standard 5
The process for dealing with different degrees of
investigation/ claims was not clearly identified within
the Trusts documentation at the time of assessment.
This was reflected in several of the standards so
compliance for these was not met. Since the assessment
the inputting of all incidents has been place on one
system so a more transparent analysis can be made.
The standard concerning complaints was passed but
the investigation regarding claims was not evidenced
sufficiently. This policy has since been reviewed.
In September 2009 the assessor was invited for an
informal visit to monitor the Trust’s progress. The
comments were positive with the assessor stating
that she felt the Trust was able to demonstrate the
necessary assurances and was also embedding the
safe assurances within practice.
059
7 Steps To Patient Safety
The Trust continues to support the 7 Steps to Patient
Safety reference guide first published in 2004. This
includes a commitment to embedding policies and
practices that provide a foundation for safe patient
care. The Trust promotes an open culture that patient
incidents are reported using prescribed processes.
The Trust is committed to undertaking incident
investigations into Serious Untoward Incidents using
nationally promoted methods. During investigations the
Trust seeks to identify underlying causes and solutions
to reduce the likelihood of incidents recurring.
Evaluation of Clinical effectiveness
Clinical Effectiveness is defined as “the application of
the best knowledge, derived from research, clinical
experience and patient preference, to achieve optimum
processes and outcomes of care for patients, the
process involves a framework of informing changing
and monitoring practice” Department of Health (1996)
Promoting clinical effectiveness. In other words, doing
the right thing at the right time for the right patient.
The revised Clinical Effectiveness Strategy was
approved in January 2010 and many of the proposals
are in place, however it is clear that further review of
this strategy is required in order to compliment changes
to local service models and to provide a framework
that will allow the Trust to meet national guidance
and requirements.
Further revision of the strategy will need to support
the services and localities in the following:
•Encourage services and localities to state where
services deviate from NICE guidance. The rationale
for this if practice is felt to be more advanced, or a
robust risk assessment be carried out where there
is a gap in service provision.
•Clear care pathways need to be in place for all
mental health conditions covered by NICE (unless
assessed as inappropriate or not relevant to the
Trust’s core business). The expectations of agreed
pathways should be communicated more effectively
to staff, service users and carers.
Clinical Effectiveness Strategy
Following the reconfiguration of functions within
the governance team, the Assurance and Clinical
Effectiveness functions have been separated. A
lean exercise was held to look at improving the
implementation of NICE Guidance, policy review, the
processes for conducting clinical audit and how the
two teams relate to each other. As a result, the process
for implementing NICE guidance has been decentralised
to take place within services and localities with support
from the Clinical Effectiveness team if required.
The Trust obligation to implement NICE guidelines can
be summarised as follows:
Clinical
guidelines
Interventional
procedures
Public health
Technology
appraisals
Number
issued
Number
implemented
Not
applicable
23
19
1
4
8
11
4
4
5
4
6
NB. The three clinical guidelines that have not been implemented are
currently “work in progress”.
The refined process allows more freedom for services
to assess and prioritise which aspects of the guidance
are most applicable and if necessary to decide not to
implement the guidance provided this is supported by
good rationale and a risk assessment. The new process
requires a risk assessment to identify any risks to the
organisation or direct care if the service or locality is
unable to implement essential components of the
guidance with the option to raise the issue in the
business and commissioning arenas within the Trust.
The Clinical Effectiveness team has worked with
some services and localities that have drawn up their
own audit schedules to evaluate the effectiveness of
their services and to inform service developments.
The Clinical Effectiveness Lead provides training on
clinical audit and effectiveness to services and localities
on an as required basis.
Process and Policy Integration Project
The overall objective of the project is to introduce a
Process Governance Model that provides a means to a
consistent interpretation and implementation of clinical
policy and a link from the Trust’s strategic objectives to
front line service delivery. A number of clinical policies
have been reviewed using process mapping techniques
whilst providing guidance to clinical staff which is
based on accepted best practice and aims to identify
and manage clinical risks.
Work is still in progress, the project will be evaluated
in the summer, and if the approach is effective the
project will expand to provide a streamlined approach
for all Trust policies.
060
Clinical audit
The audit department is a small team working within
the assurance department of the governance team.
Audit requests are taken from lead clinicians
throughout the Trust and then prioritised according to
need. A new system is currently being rolled out which
ensures that audits meet the need they are designed
for. Each audit will now have its own individual terms
of reference that will be developed prior to
commencement of the audit. This will allow clinicians
to be more involved in what they have identified and
improve the quality of the findings by ensuring the
correct questions are being asked. It will also encourage
ownership and thus improve the outcome of action
plans if required following the findings.
Audit is also involved in the guidance of monitoring
statements on policies as this is a key requirement
of NHSLA.
With audit embedded in the assurance team, it is
able to look at all assurance requirements for each
audit and cross reference these more smoothly, linking
one audit where appropriate to numerous assurance
requirements (such as CQC, Information Governance,
CQUIN) thus cutting down on duplication.
It may also be possible to link in other forms of
assurance such as data recorded within the Datix
system to achieve a more robust overview. Quarterly
audit reports are presented to the audit and risk
committee, which highlight trends and good practice.
Following an audit a full report is sent to localities with
recommendations, these are then followed up and
monitored.
Evaluation of Patient experience
The Care Quality Commission (formerly Healthcare
Commission) conduct a national service user survey
each year. Previously the survey has been of community
mental health services. For the first time in 2009 a
survey of in-patient mental health services was carried
out. This National survey enables the Trust to be
benchmarked against other mental health trusts in
relation to the following:
•
•
•
•
•
•
Induction to the ward
The ward environment
Staff attitude
Care and treatment provided
Rights under detention
Experience of discharge from in-patient services
In most areas surveyed the Trust scored slightly better
than average in comparison to other mental health
trusts. However in relation to the following the Trust
scored in the top 20% of trusts nationally:
• Not being bothered by noise at night
• Being treated with dignity and respect from nurses
• Finding talking therapy helpful
• Being involved in decisions about care and treatment
•Being offered an out of hours contact number on
discharge
• Being provided with crisis information on discharge
The Trust was in the bottom performing 20% of Trusts
in one area surveyed:
•Not enough activity on the wards being provided at
weekends
This issue has been highlighted and will be explored as a
service user performance indicator during a conference
to be organised as agreed in the CQUIN contract.
Service improvements were made in response to the
findings of this survey.
• Service users said that we needed to work on making
them feel welcome and help them to settle on our
wards – Our new housekeepers welcome service users
and their carers, to make sure that they know their
way around and are familiar with the ward routine.
•Service users didn’t like the food – The catering team
invited staff and service users to a menu tasting
session. New menus and suppliers were chosen and
with the money saved, we have been able to offer
additional choice, such as extra fresh fruit.
•Service users said that they would like details on
how to contact us when they left the ward – We
provide details of how to contact us urgently outside
of office hours with every discharge. We have
developed business cards with details of how to
contact individual care co-ordinators.
•Service users said that they would like more
information about their medication and any
significant side effects – We made sure that effective
medicine-education groups are available in all areas
of the Trust. Pharmacy provides written information
with every discharge. Staff are trained to identify and
assess side effects using a recognised rating scale.
In addition to actively addressing the results of the
survey all adult acute wards are working to the mental
health acute in-patient standards set by the Royal
College of Psychiatrists Accreditation for Inpatient
Mental Health Services (AIMS). This process actively
includes service users, and overlaps with many of the
themes of the national survey. It is anticipated that this
work will improve the experience of service users of
adult acute in-patient areas.
061
Patient Experience Tracker
The Patient Experience Tracker (PET) has been used
within the Trust since August 2008. It has continued to
provide data that has enabled the trust to monitor its
performance more efficiently. Sample questions
included and data returns for June 2009:
Q1 Do staff clearly explain the purpose benefits, and
risks of your medication?
Result is 81% YES.
Q2 Are you involved in making decisions about
medication you take?
Result is 73% YES
Q3. Have your family/carers been involved in making
decisions about your Care Plan?
Result is 60% YES (it is felt that this result does not
accurately reflect final findings as maybe
misinterpretation of the choices of answers)
Q4. Did the staff treat you with dignity and respect?
Result is 97% YES
Q5. Have you been involved in making decisions about
your Care Plan?
Result is 86% YES
Complaints
The Trust remains committed to resolving complaints
as quickly as possible in an open and transparent
way. Complaints offer an opportunity for the Trust
to learn about service provision and to initiate
service improvements.
This year the Trust received 320 complaints, a
reduction from last years total of 346. The highest
number of complaints related to ‘all aspects of clinical
care’ (45%), followed by ‘attitude of staff’ (14%) and
‘communication’ (8%).
Of these complaints 24% were upheld, 15% were
partially upheld and 40% were not upheld by the
Trust. 17% of complaints remain open at this time
and 4% of complaints were stood down.
The Trust has been informed that following the
response to a complaint, seven complainants requested
review of their complaint by the Parliamentary and
Health Service Ombudsman.
The Patients’ Advice and Liaison Service (PALS)
continues to be available to provide support to service
users, carers and the general public who seek to find
information/resolution to their concerns without the
desire or need to use the Complaints Procedure. PALS
can be contacted on 0800 279 7257.
Learning from complaints
Quarterly performance monitoring through the Service
Governance Sub-Committee ensures that all learning is
made use of throughout the Trust.
Specific learning recommendations and actions leading
to improvements have included:
•The implementation of a modified early warning
score algorithm to assist clinicians in identifying
support and actions required when a service user’s
physical condition changes
•Review of the Trust’s sudden death policy to clarify
when staff should inform family/carer members
following the death of a relative
•Reminder of the need to complete all aspects of the
service users documentation, with particular
observations made regarding the need to engage
service users in reading and signing documents
related to their care (e.g. risk assessments, care plans).
Additionally, clinical teams reminded of the need to
record the service user’s identification number on
each document page of the health record
Selection of quality indicators
Good practice guidelines state that a Trust should
provide a rationale for any changes to indicators from
the pervious years quality overview (2008/09). This is
to recognise that quality improvement is a year-on-year
process of sustained and continued development.
Any alterations to quality overview indicators need
to be explained and justified so that Trusts do not just
keep changing the way they measure quality, making
evaluation for the public challenging.
There have been significant changes to the quality
indicators used in this year’s report in comparison with
last year’s report. The main reason for this is that last
year’s report was a trial for quality accounts. Since that
time there has been more guidance available on the
development of the quality overview section of the quality
account. As well as key performance indicators providing
hard data, this year has used more qualitative evaluations
of quality. Last year the quality indicators were severely
limited by guidance that stated that where at all possible
the indicators should have data available from the
previous year and be able to be benchmarked nationally.
Although this is best practice the potential national
indicators available to mental health services are limited
– therefore limiting what this says about the quality of our
services. This year, where at all possible, an evaluation in
comparison to the national picture has been provided (e.g.
National Patient Survey results), however, what seemed
important to share with all interested parties was how
the Trust uses information to evaluate quality so that our
systems are transparent and open to scrutiny. Therefore
all key performance indicators used in 2009/2010 by the
Board of Directors relating to patient safety, clinical
effectiveness and patient experience have been included
in the overview. In addition, year-on-year comparison is
not always possible when systems change. For example,
some of the indicators related to patient experience were
drawn from the national patient survey, last year it was
focussed on community services and this year the
evaluation changed to focus on in-patient services.
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Statements from Local Involvement
Networks, Overview and Scrutiny
Committees and primary care trusts
Norfolk Health Overview and Scrutiny
Committee
The Norfolk Health Overview and Scrutiny Committee
has decided not to comment on any of the Norfolk
provider NHS Trust’s Quality Accounts for 2009/10 and
would like to stress that this should in no way be taken
as a negative comment. The Committee has taken the
view that it is appropriate for Norfolk’s Local
Involvement Network to consider the Quality Account
and comment accordingly.
Suffolk Health Scrutiny Committee
The Suffolk Health Scrutiny Committee has decided not
to comment on any of the Suffolk provider NHS Trust’s
Quality Accounts for 2009/10 and would like to stress
that this should in no way be taken as a negative
comment. The Committee has taken the view that it is
appropriate for Suffolk’s Local Involvement Network to
consider the Quality Account and comment accordingly.
Suffolk LINk
Suffolk LINk thanks the Norfolk and Waveney Mental
Health Trust Board for the opportunity to comment on
the Quality Accounts for 2009/2010.
The report clearly provides details of all the systems
in place to monitor and improve outcomes across
the organisation.
It would be hoped that the enlightened services
recently introduced in certain areas would be seen to
be expanded across the areas in the year ahead (e.g.
Acute Gym in Waveney). This active approach is an
example of an enlightened approach to the multifaceted
needs of the patient group within the report.
The detail within the report provides clear pathways
for the future which Suffolk LINk look forward to
seeing progressed in 2010/2011.
Marion Fairman, Chairman – Suffolk LINk
Norfolk LINk
Norfolk LINk appreciates having the opportunity to
comment on the Trust’s Quality Account for 2009/2010.
Our initial observation is to confirm Norfolk LINks’
agreement and support of the strategic objective “To be
a values driven centre of excellence”. This is a
commendable goal to strive for and one which enhances
the need to deliver a quality of service, which is
underpinned with identifiable and measurable criteria to
demonstrate that quality standards are being achieved.
It is pleasing to note that the report is
comprehensive and very much focuses on new service
delivery and innovation. However, changes to service
provision must also ensure that quality standards are
maintained during periods of change.
The report effectively raises the importance of many
complex issues. However, it is unrealistic to expect a lay
reader to be in a position to fully comprehend all the
jargon influenced commentary (a glossary would be
helpful). In essence there needs to be a balance
between the amount of complex detail within the
report and the need to enable the general public to
maintain a suitable grasp on the progress being made
and the identified actions going forward.
Overall, the report does clearly demonstrate a desire
to champion improvements in service provision. The
report is progressive, in that actions are taken and the
public can expect to see further improvements in the
future. It is noted that a strong emphasis has been
placed on staff training and development.
Removing social stigma around mental health needs
is essential. It is pleasing that the report focuses on
many positives, which will help to reduce this stigma.
Patrick Thompson, Chairman – Norfolk LINk
NHS Norfolk
NHS Norfolk are happy to verify the information
presented within this report is consistent with that
provided to NHS Norfolk either through performance
data or through our clinical quality and patient safety
discussions. The account represents an open and
honest review of the achievements of the trust and
identifies areas where improvements are required.
We are particularly please to have been involved in
stakeholder meetings with service users and partnership
organisations to contribute to the identification and
development of quality improvement priorities.
Daivd Stonehouse, Interim CEO – NHS Norfolk
Comprehensive statements will be included in the
online quality reports when published later in 2010.