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Quality Account
2009 - 2010
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Contents
Part 1
Introduction
3
The Trust’s Clinical Services
4
Part 2
Priority 1 – Improving the Car Pathway
6
Priority 2 – Improving the Patient Environment
8
Priority 3 – Improving Stakeholder Engagement
10
Statement of Assurance from the Board
12
Audit in the Trust
19
Research Activity
19
Commissioning for Quality and Innovation (CQUIN)
19
Care Quality Commission: Registration and Inspection
19
Data Quality
19
Part 3
2
Review of Quality Performance
20
Consultation Process
22
External Perspective on Quality of Services
22
Appendix 1
23
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Part 1 - Introduction
The combination of improving quality and
increasing value is the essence of strategic
objectives at Mersey Care. We aim to improve
the value given to the taxpayer and improve
quality for those who receive our services.
In this, the Trust’s first Quality Account I am
delighted to provide information on how the
quality of acute care has improved in the Trust
during 2009 - 2010 and the areas where further
improvement is required.
None of the improvements could have been
delivered without the commitment of our staff and
the involvement of service users and carers in the
work that we do. Through collaboration, sharing
knowledge and experience and learning from
failure we have achieved real improvements in the
way we deliver care. What those who receive our
care think is most important to us, so the
improvements evidenced in the results from the
National Patient Survey are a real encouragement.
Our improvement is also recognised by the
various regulators responsible for assessing the
Trust’s performance against a range of quality
measures. In 2009 - 2010 Mersey Care was rated
as the ‘most improved’ mental health trust and
achieved full compliance in relation to the care
standards contained within the Standards for
Better Health framework. The annual health check
rating for 2009 - 2010 scored ‘good’ for quality of
services and the Trust was registered ‘without
conditions’ by the Care Quality Commission for
safety, effectiveness and quality of the
arrangements in place to reduce healthcare
associated infection and to safeguard children.
At the start of 2009 - 2010 we launched our Care
Manifesto which outlined a clear commitment to
improving the quality of the patient experience.
Since its launch the Board and the Trust’s
services have adopted the principles contained in
the Manifesto and we are starting to see the
positive impact of this reflected in our governance
arrangements and in the feedback we receive
from service users and carers.
We know there is more to do and we will continue
our campaign to further improve the care and
services we provide. To assist us in determining
our priorities for quality improvement during
2010 - 2011 a range of engagement events were
held with staff and service users. The events
identified 3 main priorities for improving quality:
• Improving the care pathway
• Improving the patient environment
• Improving stakeholder engagement
Addressing these priorities will involve significant
effort over the next 12 months particularly in light
of the current economic conditions. Over the last
12 months we have enjoyed good working
relationships with our commissioners and we will
continue to work with them to deliver the quality
improvements specified within the contract they
have with us. We will be open and transparent
about what we can and will do to improve quality
and by involving other stakeholders we will find
ways to work better and more productively.
As we move towards becoming the equivalent of
a Foundation Trust we look forward to having a
Members Council and the contribution to be
made by all who have a stake in helping us
improve our quality. I extend a personal invitation
to come and join us as a member of the Trust and
be part of our campaign to deliver better mental
health. Please go to
http://www.merseycare.nhs.uk/foundation_trust/
membership_form.asp for an application form.
I hope that you find our Quality Account
informative and of help in assessing our progress
against the priorities we have identified for the
coming year. The information supporting the
content of the Quality Report is to my knowledge
accurate and was published by the Board on 30th
June 2010.
Alan Yates,
Chief Executive
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The Trust’s Clinical Services
Mersey Care Addictions
Clinical Business Unit
Mersey Care Liverpool
Clinical Business Unit
Addictions CBU provides drug and alcohol
services for the population of Liverpool, Sefton
and Kirkby and alcohol services only for
Knowsley, from Windsor Clinic and the Kevin
White Unit. Community services are also
provided.
Liverpool CBU provides mental health services
and care to adults in Liverpool. Services include
acute in-patient care, accident and emergency
liaison, crisis, community mental health teams,
assertive outreach, early intervention in
psychosis, homeless outreach and psychology. A
gateway system ensures that people are referred
to the most appropriate service for their needs.
The services provide care and treatment for
people suffering from alcohol or drug dependency
and offer a range of care pathways and
individually tailored therapeutic programmes
within both residential and community settings.
These are delivered by a consultant-led multidisciplinary staff group.
Service Director: Bob Dale
Clinical Directors: Jayne Bridge and
Dr Mohammed Faizal
Mersey Care High Secure Services
Clinical Business Unit
High Secure and associated services are
provided from Ashworth Hospital. Ashworth is
one of three high secure hospitals and serves the
North West of England, West Midlands and
Wales. It provides in-patient care and treatment
for men who are deemed to be a grave danger to
others, under the Mental Health Act 1983, in
conditions of maximum security.
Service Directors: Astrid Henderson and
Paul Weare
Clinical Director: Dr Caroline Mulligan
4
Service Director: Carol Bernard
Clinical Director: Dr Simon Tavernor
Mersey Care Positive Care
Partnerships CBU
Positive Care Partnerships CBU covers Sefton,
Kirkby and North Liverpool for adults and older
people. Services include acute care, accident and
emergency liaison, crisis, and gateway services,
community mental health teams, assertive
outreach and early intervention in psychosis and
psychology. Assessment and/or treatment is
provided for people experiencing mental health
difficulties. The aim is to deliver care that respects
individuals, values diversity, preserves dignity and
promotes recovery and inclusion.
Service Director: Karen Lawrenson
Clinical Director: Dr Sudip Sikdar
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Mersey Care Rebuild CBU
This CBU provides services for clients with
learning disabilities in Mossley Hill Hospital and
Olive Mount Mansion, including community
residential services, community teams, in-patient
services, respite services, on call service and the
Asperger’s service.
The Brain Injuries Rehabilitation service provides
in-patient and outpatient care. They specialise in
assessment and rehabilitation for people who
have an acquired brain injury. The aim of the interdisciplinary team is to maximise the service user's
rehabilitation potential and quality of life.
The Rehabilitation Unit is currently involved in a
process of review. The aim of this is refocusing
the team's approach to rehabilitation to one that
encompasses recovery, minimises hospital stay
and facilitates early return to appropriate settings.
Rehabilitation services are provided from
Rathbone Hospital.
Network Employment's experienced team of
employment advisors assist with job searches,
on-the-job training and employment support in
the workplace. They offer advice in relation to
equal opportunities and the Disability
Discrimination Act.
The supported housing scheme enables service
users to maintain their own tenancies within the
community, helping to develop skills and
independence and promote social integration as
well as providing a positive alternative to
in-patient care.
Service Director: Irene Byrne-Watts
Clinical Director: Dr Tim Matthews
Mersey Care SaFE
Partnerships CBU
SaFE (Safe and Forensic Environments)
Partnerships CBU provides medium secure and
low secure services, criminal justice liaison and
prison health liaison services.
The in-patient medium secure services at Scott
Clinic provide forensic mental health assessment
and rehabilitation to mentally disordered
offenders or others displaying similar behaviours.
Services include pre-admission assessment,
in-patient treatment and aftercare and are offered
to residents of Merseyside, Greater Manchester,
Lancashire and Cheshire. The services comprise
of an outpatient department based in Liverpool
city centre and provide support to community
service users via the forensic integrated resource
team. Also based at Scott Clinic are the Forensic
personality disorder assessment and liaison team
and substance misuse service for Cheshire and
Merseyside.
Low secure service users have severe and
enduring mental health problems, and are
preparing to return to life in the community. This
involves finding the most effective treatment and
therapy, finding ways to support independent
living, and locating residences which provide
appropriate support for people when they leave
Rathbone Low Secure Unit.
The criminal justice liaison team is a court based
mental health liaison service addressing the
needs of mentally disorded offenders at points of
the criminal justice system. The prison health
liaison team forms part of a national development
aimed at improving mental health care within
prisons. The team provides secondary mental
health services into HMP Liverpool in Walton, and
the prison based primary care psychological
service provides a range of psychological
interventions to offenders.
Service Director: Paul Ikin
Clinical Director: Hilary Lomas
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Part 2
Regular and ongoing consultation with service
users provided the Trust with qualitative
information on the range of improvements
required. This information was used in
conjunction with performance data to give an
outline of areas for consideration as key priorities.
These were discussed at both the Senior
Leadership Team meeting and the Clinical
Business Unit Leaders Forum, where there is
representation from senior service managers,
service directors and service users. Mersey Care
has chosen three specific areas for improvement,
designed to be entirely inclusive of all the Trust’s
services.
Priority 1 - Improving the Care Pathway
Rationale
The Trust is committed to improving quality and
enhancing value in relation to every aspect of an
individual’s care.
Aims
There will be an increased emphasis on how the
Trust can help to improve the physical health and
overall well being of service users during
2010 - 2011. We will develop a set of measures
that will enable us to record improvement in this
area. In addition we will also develop measures
that help us to assess progress in relation to other
components of recovery such as:
• employment status (experience)
• the effective use of the Care Programme
Approach (CPA) (effectiveness)
• guaranteeing a full review of needs every twelve
months (safety).
In 2010 - 2011 the Trust will develop its Quality
Strategy by establishing a more robust framework
for quality and service improvement. A new and
updated Suicide Prevention Policy and Dual
Diagnosis Strategy will be produced with clearly
defined outcomes associated with
implementation.
6
Current Status
A number of national priorities have directed the
quality improvement agenda in the Trust during
2009 - 2010 and these have been routinely
reported to the Trust Board. The Trust has
performed well against the existing set of quality
indicators in some areas but there are still areas
for improvement where the expected standards
need to be embedded into all agreed care
pathways.
At a local level, Mersey Care has been part of an
initiative to provide individual personalised
budgets and is keen to see this valuable leading
edge work further developed.
The Trust has also worked closely with other
partners and service users, carers and young
carers to promote and develop a number of
schemes designed to support families and young
people having to deal with the effects of mental
ill-health, for example Keeping the Family in Mind
project.
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The table below provides an indication of Trust performance against a number of national targets.
Quality Indicator
Performance
2008 - 2009
Performance
2009 - 2010
Trust Target for
2009 - 2010
Delayed Discharges
13.91%
10.04%
Less than 7.5%
Average length of stay
(excluding high secure services)
43 days
46 days
(to Feb 2010)
429
438
(as at end of
Feb)
414
Calculated using
different method
from current usage.
71.2%
(provisional)
90%
383
460
(to end Feb)
468
‘Did not attend’ rates (DNA)
excluding Addictions
13.52%
13.72%
(to end Feb)
CPA 7 day follow-up
94.99%
97.35%
(to end Feb)
Establish specialist teams and
reach agreed activity in relation to:
i) Assertive Outreach teams caseload
ii) Access to crisis resolution
and home treatment
iii) Early Intervention in
Psychosis caseload
95.00%
Identified Areas for Improvement
Measuring and Reporting Outcomes
The Trust is committed to achieving continuous
improvement in all aspects of the care pathway.
Three areas are in need of improvement on the
current performance:
It is recognised that further work is required to
determine appropriate indicators and metrics
associated with measuring and reporting
outcomes. The Trust is working with other mental
health trusts from the North West as part of the
Advancing Quality initiative to develop a common
set of metrics and outcome measures that will
enable Mersey Care to benchmark its
performance against best practice standards
relating to first episode psychosis and dementia
care. The Trust will also roll out the
implementation of HoNOS (Health of the Nation
Outcome Score), a scale used to measure the
health and social functioning of people with
severe mental illness.
• Access to Crisis Resolution Home Treatment
• Delayed discharges
• CPA 7 day follow-up.
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Part 2
Priority 2 - Improving the Patient Environment
Rationale
Service users expect to be treated with respect
and dignity at all times during their contact with
the Trust.
Aims
We aim to always meet the needs of service users
and carers as far as can be reasonably expected,
so it is important that arrangements are in place
which enable and encourage a strong service
user voice to be heard, listened to and responded
to appropriately. We will develop a set of
measures that will enable us to record
improvement that helps us to assess progress in
relation to the patient environment such as:
• Regularly asking service users if they were
treated with dignity and respect and were cared
for in gender appropriate environments
(experience)
• Routinely monitoring if service users were
involved in and were satisfied with their
individual care plans and had access to
appropriate activities and therapies
(effectiveness)
• Regularly asking service users whether they felt
safe whilst an in-patient (safety).
Current Status
During 2009 - 2010 the Trust gave greater
consideration to the service user experience
within the acute/in-patient environment.
Significant attempts were made to capture the
views of and provide a response to ‘hard to reach’
groups and also service users being cared for in
our secure care settings.
We routinely asked service users about their
experience of acute care and in particular whether
they felt safe and if their privacy and dignity had
been respected. The results of these surveys are
available for further review alongside details of the
8
Trust’s programme of work to address dignity and
privacy standards across the organisation during
2009 - 2010. The gender group successfully
conducted a programme of work that has
enabled the Trust to declare itself compliant
against the Delivering Single Sex Accommodation
(DSSA) standards.
The Trust continues to meet national patient
environment (PEAT) targets and has reviewed its
cleaning standards as part of its commitment to
enhancing the patient environment. The infection
control team works routinely with ward teams in
support of the ward based infection control link
nurses as well as providing high quality clinical
leadership with regard to inspection and
delivering assurance requirements in relation to
compliance with the Hygiene Code.
A number of wards have sought accreditation
from the AIMS programme (Acute In-patient
Mental Health Service) - an initiative run by the
Royal College of Psychiatrists - which identifies
and acknowledges services that have high
standards of organisation and patient care and
formally recognises enhanced practice standards.
All wards are engaged in the user-led ‘Star Wards’
initiative which gives practical ideas to ward
based teams for improving the daily experiences
and treatment outcomes for those in receipt of
acute care. Significant work has been undertaken
in the Trust to improve the quality of the patient
environment through the use of cultural activities
such as dance, health and wellbeing schemes,
musician in residence and use of reading groups.
All of these programmes continue to have a
positive impact on individuals’ lives. In-patient
areas have been involved in utilising some of the
service improvement tools available e.g. LEAN
methodologies and the Productive Ward series to
assist them in raising quality and standards.
Please note LEAN is a widely used term that
means a systematic approach to ensuring better
outcomes by eliminating waste and adopting
more efficient processes and methods. The
following table provides evidence of improvement
across a range of quality indicators relating to
in-patient areas.
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Quality Indicator
Current Performance
Trust Target
(where applicable)
Maintenance of NHSLA compliance
Compliant
Compliant
Physical security to the standard of security
expected by the Home Office in category B
prisons
96%
90%
The Standards for Medium Secure Units (MSUs)
include all the Department of Health standards
(Health Offender Partnerships, 2004) and extra
standards identified by members of the Quality
Network for MSUs
96%
90%
Delivering structured activity for service users.
All service users offered at least 25 hours
structured activity per week (High secure data
only for 2009 - 2010)
35 hours
25 hours
PEAT is an annual external assessment of
in-patient healthcare sites in England. It is a
benchmarking tool to ensure improvements are
made in the non-clinical aspects of patient care.
Environment – Good
Food - Excellent
Privacy and Dignity - Excellent
Benchmarked
performance against
previous years results
Action plans created within the appropriate
timescale after publication for all relevant NICE
Technological Appraisals and Clinical Guidelines
guidance
2 non-compliant
All comply
Number of hospital acquired infections reported
by the Trust (MRSA and C Difficile)
0
0
% of service users with known or suspected C
Difficile infection to be isolated within 4 hours
100%
100%
% of planned admissions assessed for MRSA
100%
100%
Compliance with prison security standards
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Part 2
Identified Areas for Improvement
Priority 3 - Improving Stakeholder Involvement
The Trust recognises that there is significant room
for improvement in the standard and quality of its
current buildings and estate. The current
environments in many cases cannot deliver the
standards service users should routinely expect
when admitted as an in-patient. The TIME project
(Time to Improve Mental Health Environments) will
eventually see the creation of a number of new
purpose built units across the Trust’s
geographical footprint. In the interim, a priority is
to make the safest and most effective use of
existing buildings to best support individual
privacy and dignity. These priorities are already
reflected in the Trust’s estates strategy and
capital plans.
Rationale
To become a better organisation by building on
our involvement with stakeholders and
strengthening our governance
The development of a large, diverse,
representative membership is a natural
progression for the organisation in building and
maintaining effective links with the communities
we serve and the staff we employ. It strengthens
the direct involvement of stakeholders in the
organisation’s corporate governance and
decision making processes.
Aim
Measuring and Reporting Outcomes
The annual patient survey provides an indication
of where the Trust can improve standards against
established internal benchmarks and those of
other similar organisations which are reflective of
the care they receive from clinicians and
professionals.
During 2010 - 2011 the Trust will develop a
matron-led clinical performance framework which
will report routinely on key areas of the in-patient
care patient experience. In addition we will
develop our arrangements for obtaining ‘real time’
feedback from service users through the
introduction of electronic survey methods which
will allow us to benchmark the quality of care
provided between each of the wards on our
in-patient units.
10
To improve involvement with all our stakeholders.
We will develop a set of measures that will help us
to assess progress in relation to stakeholder
involvement such as:
• Routine use of service user satisfaction surveys
and the creation of more specific opportunities
for carers to comment on the quality of services
(experience)
• Publication of actions or changes to practice
stemming from complaints (effectiveness)
• Supporting and facilitating enhanced input and
scrutiny of our service environments through
the greater use of the SURE (Service User
Research and Evaluation Group) and LINks
visits to our facilities (safety).
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Current Status
The development of the Members Council is work
in progress and builds upon the Trust’s existing
and well established stakeholder involvement
arrangements. Listening and responding to the
views and expectations of service users and
carers is at the heart of how Mersey Care does
business. Over 200 service users and carers are
actively involved in the work of the Trust and
have, for example, been involved in the
appointment of over 2,500 staff. The Trust also
recognises that to ensure good outcomes for
service users and carers it must make sure its
staff are well supported, effectively trained and
are empowered to work innovatively and
effectively. An action plan in response to the most
recent staff survey has been developed with the
aim of promoting an enhanced working
environment for all our staff to achieve these
goals. The work of the Members Council will
further strengthen the governance of the
organisation by operating as a strategic advisory
committee to the Board as defined in the
proposed terms of reference.
The Council will be responsible for representing
and presenting to the Board, the interests of the
members and partner organisations in the local
health economy and for providing regular
feedback and information about the Trust, to
constituencies and stakeholder organisations.
This includes consultation with the following
groups
• Commissioners
• Public/community
• Partner organisations
• Service users/ carers and families
• Staff.
When established, the Members Council will
provide a new forum where all of the above will be
represented collectively. The membership
numbers as at 31st March 2010 and targets for
future membership are detailed below.
Constituency
Actual
(31/03/10)
Minimum Required
for Election
Target
(31/03/10)
Target
(31/03/11)
Target
(31/03/12)
Public Liverpool
572
179
597
1194
1810
Public Sefton
138
115
384
768
1165
Public Knowsley
129
59
198
396
601
Public Wider
468
49
49
98
149
Public Total
1307
402
1128
2456
3725
Service User
232
145
484
968
1468
Carer
70
97
322
644
977
Service User/Carer
Unknown class
5
0
0
0
0
Staff
4368
4244
4244
4244
4244
Total
5982
4888
6278
8312
10414
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Part 2
Areas for Improvement
Statement of Assurance from the Board
During 2010 - 2011 we will improve the strategic
approach to working with identified partners in a
variety of ways. In particular we will review and
clarify our arrangements for patient and public
involvement and increase our activities in relation
to the development of social enterprise. The Trust
recognises that it is essential to work in partnership
with voluntary and charitable partners to provide
the best possible services to the communities we
serve and will seek out new ways to strengthen this
commitment further as part of our plans.
During 2009 - 2010 Mersey Care NHS Trust
provided and/or sub-contracted 74 NHS services.
It has reviewed all the data available on the quality
of care in all of these services. The income
generated by the NHS services reviewed in
2009 - 2010 represents 100 per cent of the total
income generated from the provision of NHS
services by the Mersey Care NHS Trust for
2009 - 2010.
We will also develop a more systematic approach
to engagement with service users and carers by
listening to their feedback, acting promptly to
respond to the issues they raise and improving our
overall approach to customer care.
Audit in the Trust
Measuring and Reporting Outcomes
The following measures will help us to identify
progress in relation to improving stakeholder
involvement
• Enhanced use of service user and carer
satisfaction surveys
National Audit of the Organisation of
Services for Bone Health of Older People
• Analysis of complaints and compliments
• At the time of the audit in November 2008,
Mersey Care did not have a falls prevention /
reduction policy; however one has been
developed since
• Number of PALS contacts per 1000 service users
on case load
• The effectiveness of the Members Council will be
evaluated annually based upon defined
outcomes determined by the Council at the start
of the year. This evaluation will specifically
include:
• The breadth of issues considered by the
Council
• Effectiveness of communication and
consultation with membership constituencies
• Effective application of Human Rights
principles
• Impact on organisational decision making
• Membership recruitment
• Response to members’ concerns
• Council members’ experiences – individual
and collective.
It is anticipated that the evaluation will be objective
and enhanced through the commissioning of the
SURE group.
12
During 2009 - 2010, there was one national clinical
audit and nil national confidential enquiries that
covered NHS services provided by the Trust.
During this period the Trust participated in 100% of
national clinical audits it was eligible to participate
in, and for which data collection was completed
during 2009 - 2010.
• At the time of the audit, the Trust did not
calculate in-patient falls; nor has the Trust
calculated its injurious in-patient falls, however,
since this audit the Trust now calculates falls rate
and injuries against occupied bed days
• At the time of the audit, the Trust had not
undertaken any local audits to assess aspects of
falls and bone health services; however the Trust
now undertakes quarterly audits.
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The Prescribing Observatory for Mental Health
(POMH-UK) runs national audit-based quality
improvement programmes open to all mental
health trusts in the United Kingdom
The national clinical audits (POMH-UK) that
Mersey Care NHS Trust was eligible to participate
in during 2009 - 2010 are as follows:
i) The prescribing of high dose and combination
anti-psychotics on adult mental health acute
and intensive care wards: time-series
benchmarking POMH-UK
ii) POMH-UK baseline audit, ‘Medicines
Reconciliation’
iii) POMH-UK audit 'Use of anti-psychotics in
people with learning disabilities'.
Additionally the following audits were available
Screening for metabolic side effects of antipsychotic drugs in patients treated by assertive
outreach teams and assessment of the side
effects of depot anti-psychotics. The Trust did not
take part in these topics.
The national clinical audits that Mersey Care
participated in, and for which data collection was
completed during 2009 - 2010, 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.
POMH-UK audit 'Use of anti-psychotics in
people with learning disabilities'
Thirty nine mental health trusts within the United
Kingdom participated in the baseline audit of a
quality improvement programme to address the
use of anti-psychotic medication in people with a
learning disability. Nationally data was submitted
for 2,319 service users from 145 clinical teams.
Mersey Care submitted 12 patient records from 2
clinical teams.
POMH-UK baseline audit,
‘Medicines Reconciliation’
Nationally, 42 trusts submitted data for 1,790
service users from 375 clinical teams. Mersey
Care submitted 51 patient records from 11 clinical
teams. This was a baseline audit for a quality
improvement programme addressing medicines
reconciliation. A re-audit is due to be conducted
in September 2010.
The prescribing of high dose and combination
anti-psychotics on adult mental health acute
and intensive care wards: time-series
benchmarking POMH-UK
POMH-UK is due to publish the annual report in
May 2010 for the data entry period April 2009March 2010. As of December 2009 the Trust had
submitted 126 entries relating to patient records.
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Part 2
The reports of 10 local clinical audits were also reviewed
by Mersey Care in 2009 - 2010 and actions taken in
response to the audit findings.
A summary of the audit findings is outlined below and
details of the improvements achieved in these areas are
recorded within the minutes of each local governance
forum.
1. CONSENT TO TREATMENT - FINDINGS
• All Forms 38 must be reviewed annually
• All Forms 39 which are invalid must be reviewed
immediately
• Mental Health Act Commission (MHAC) 1 forms must
be completed and stored as per the requirements of
the MHA and as detailed within the Trust policy
• All discussions held with the patient must be
documented in the clinical notes
• All qualified nursing staff and medics to ensure that the
consent to treatment form corresponds to medication
currently prescribed
• Consent to treatment forms must be attached to the
prescription sheet.
Actions taken: This audit was presented to the
Clinical Governance Committee in April 2009. Since
the audit the Checklist document has been revised to
capture more specific information required for the
audit and to include Mental Capacity Act information.
A re-audit was scheduled and undertaken in
November 2009. The audit results will be shared in
June 2010.
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2. HANDLING MEDICINE (MEDICINE
MANAGEMENT) – FINDINGS
3. AUDIT ON HEALTH RECORD
KEEPING - FINDINGS
• Ward staff and pharmacy staff to ensure that
inspections by pharmacy are recorded for
monitoring purposes
• Management to discuss the practice of Mersey
Forensic Psychiatry Services with regard to
hand written documents being removed and
replaced by typed versions
• Management to decide whether it is sufficient
for any qualified staff to hold the keys or that
the designated key holder must be the nurse in
charge at all times and the policy to be revised
accordingly
• Myrtle Ward to purchase a medicine cupboard
or medicine trolley
• Wards to be reminded of the importance to
secure the medicine trolley when not in use
• Wards to be reminded of the importance to
segregate internal and external preparations.
Actions taken: This audit was presented to the
Clinical Governance Committee in March 2009.
Since the audit, specific areas of the Trust
have agreed that all qualified staff are suitable
to hold the keys to medicine cupboards and
trolleys. A re-audit was scheduled and
undertaken in June 2010 and the report of that
audit is to be shared with the Trust in October
2010.
• Consideration to be given to either merge Trust
Policies IT09, and IT06, or to revise Trust policy
IT06 to include requirements of the Mental
Health Guidance: requirement 403, and
paperwork to be revised accordingly:
o All documents in the health record to include
the service user’s name
o All documents in the health record to include
the service user’s ID
o All documents in the health record to be filed
chronologically.
Actions taken: This audit was presented to the
Clinical Governance Committee in April 2009.
Since the audit staff have been briefed
regarding proposed revision to Trust policy
and improvement will be monitored through
re-audit. A re-audit is scheduled to be included
in the 2011 - 2012 clinical audit programme.
4. HANDLING OF SUSPECTED ILLICIT
SUBSTANCES – FINDINGS
• Management to agree whether it will assist
monitoring if a record is made to indicate that a
DOOP container is not deemed appropriate
• Management to decide whether it is sufficient
that the DOOP container is denatured by
pharmacy staff rather than a registered nurse
and the policy to be revised accordingly
• The policy to be revised to ensure the same
terminology is used throughout when referring
to the controlled drug register.
Action taken: This audit was presented to the
Clinical Governance Committee in June 2009.
Since the audit discussions took place
regarding expanding the audit in future to
include information stored on the patient
electronic systems. A re-audit was scheduled
and undertaken in December 2009 and the
report of that audit is to be shared with the
Trust in July 2010.
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Part 2
5. SUPERVISION OF CLINICAL
PRACTICE - FINDINGS
6. SERVICE USER MISSING FROM AN
IN-PATIENT AREA – FINDINGS
• Appendix 2 to the policy, Clinical Supervision
Agreement, to be amended to include a section
to record the agreed frequency of sessions,
allowing for this frequency to be reviewed when
necessary
• The audit results to be considered when the
policy is revised
• All staff who participate in supervision of clinical
practice must complete a Clinical Supervision
Agreement document with their supervisor
• A Supervision Recording Form must be
completed during each supervision of clinical
practice session
• Supervisors and supervisees must arrange
supervision of clinical practice sessions to take
place during the supervisee’s normal working
week, as specified within the policy
• The next audit of Trust policy SD33 to include
the following issues:
o Staff to explain reasons supervision of clinical
practice sessions are held outside of their
normal working week
o Staff to provide information regarding their
lack of preparation prior to entering a
supervision of clinical practice session.
Actions taken: This audit was presented to the
Clinical Governance Committee in June 2009.
Policy is being reviewed and a re-audit is
scheduled to be undertaken in March 2011 and
improvements in practice will be monitored.
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• Where the policy specifies ‘where further action
is needed’, staff must make it clear in
documentation that further action was
considered and deemed unnecessary to ensure
that a lack of further action is not misinterpreted
during future monitoring.
Actions taken: This audit was presented to the
Clinical Governance Committee in March 2010.
Since the audit specific areas of the Trust
monitor staff compliance with the policy
during reflective practice reviews. Policy is
under review with a target completion date of
July 2010. A re-audit is scheduled to be
included in the 2011 - 2012 clinical audit
programme.
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7. RESUSCITATION POLICY
REQUIREMENTS - FINDINGS
8. COPYING CLINICAL
CORRESPONDENCE - FINDINGS
• Emergency contact numbers to be put on all
telephones in in-patient areas
• When a service user completes a consent form
to indicate whether they do or do not wish to
receive copies of clinical correspondence, the
form must be filed appropriately and the policy
to specify where the form should be filed
• Notices to be placed in in-patient services
identifying the nearest location of defibrillators
and resuscitation bags
• The policy to be explicit regarding identifying
designated staff to undertake Basic Life
Support (BLS)
• If the decision is made to withdraw first
responder services from the Maghull site
(outside high secure services) by HSS, then
consideration is to be given to train other staff
as first responders to cover the Maghull site
and this must be reflected in the policy.
Actions taken: This audit was presented to the
Clinical Governance Committee in August
2009. Since the audit emergency contact
numbers and the location of equipment have
been displayed in all in-patient areas. The
decision to withdraw first responder services
outside HSS on the Maghull site has been
taken and the transition successfully
implemented. A re-audit is scheduled to be
included in the 2011 - 12 clinical audit
programme.
• The address of a service user must be checked
at the time a letter is to be written and the
policy to suggest the forum in which this check
should be undertaken. (HSS to determine
whether a service user wishes correspondence
to be posted to their ward address or an
external, postal address)
• When a service users expresses a wish to
receive copies of clinical correspondence every
attempt must be made to accommodate this,
unless it is deemed inappropriate to do so, in
which case a reason will always be
documented
• The policy to specify that when it is deemed
inappropriate to copy letters to service users,
the reasons must be documented in the clinical
notes
• Consideration to be given to the practice of
ensuring service users are asked if they would
like to receive, and do receive, copies of clinical
correspondence to be included in the CPA
process.
Action taken: This audit was presented to the
Clinical Governance Committee in January
2010. Since the audit service users are now
asked whether they wish to receive
correspondence at their annual CPA meeting.
Specific areas of the Trust plan to develop a
local procedure which will better meet the
needs of their patient group. A re-audit is
scheduled to be included in the 2011 - 2012
clinical audit programme.
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Part 2
9. SEARCHING SERVICE USERS
AND PROPERTY - FINDINGS
• The audit results to be considered when the
policy is revised
• A set of clinical standards for physical health
care are to be devised
• Information leaflets to be obtained by ward
managers and made available to service users
• The physical health screening tool to be revised
and an electronic version to be available on
EPEX which will be integral to the CPA process
• Ward managers to ensure that service users
and visitors are made aware that searches may
be undertaken in accordance with the policy
• Staff to be made aware of the importance to
complete the assessment and store it in the
service user’s health record
• Staff to be reminded of the procedures to follow
when there is cause to necessitate a search:
• Staff to be made aware of the importance to
complete all relevant sections of the
assessment and to identify if / when a section is
not applicable to the service user.
o Justification for the search must always be
documented in the clinical notes
o Reasons for the search must always be
shared with the service user
o A clear rationale for the search must always
be documented in the clinical notes
o The outcome of the search must always be
documented in the clinical notes
o The service user’s feelings regarding the
search must always be recorded in the
clinical notes
• A designated Mersey Care Services Search
Register document must be used in all
instances.
Action taken: This audit was presented to the
Clinical Governance Committee in March 2010.
Since the audit specific areas of the Trust
monitor staff compliance with the policy
during reflective practice reviews. A re-audit is
scheduled to be included in the 2011 – 12
clinical audit programme.
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10. PHYSICAL HEALTH CARE - FINDINGS
Action taken: This audit was presented to the
Clinical Governance Committee in August
2009. Since the audit the Physical Health
Screening Tool has been revised for use
across the Trust and incorporates clinical
standards for physical health care. A re-audit
is scheduled to be undertaken in November /
December 2010 and the report of that audit will
be shared with the Trust in early 2011.
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Research Activity
The number of patients recruited during
2009 - 2010 to participate in research approved
by a research ethics committee was 424. During
the period April 2009 to March 2010, 41 studies
recruited service user and carer participants. Of
these studies the breakdown of participants was
413 service user and 11 carers.
Commissioning for Quality and Innovation
(CQUIN)
A proportion of Mersey Care income in
2009 - 2010 was conditional on achieving quality
improvement and innovation goals agreed
between the 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 (CQUIN) payment framework.
The performance management report produced
for the Board each month details the achievement
against CQUIN targets.
Care Quality Commission:
Registration and Inspection
Following introduction of the new regulatory
standards for quality and safety the Trust is
required to register with the Care Quality
Commission and its current registration status is
‘Registered without Conditions’. The Care Quality
Commission has not taken enforcement action
against Mersey Care NHS Trust during
2009 - 2010.
The Trust has participated in special reviews or
investigations by the Care Quality Commission
relating to the following area during 2009 - 2010:
• Inspection report on the prevention and control
of infections on 21st and 22nd October 2009.
At an un-announced follow-up inspection, full
assurance was provided on the three areas for
improvement raised by the Care Quality
Commission.
Data Quality
The Trust submitted records during 2009 - 2010
to the Secondary Uses Service for inclusion in the
Hospital Episode Statistics which are included in
the latest published data. The percentage of
records in the published data:
• which included the patient’s valid
NHS number was:
74.5% for admitted patient care;
81.3% for outpatient care.
• which included the patient’s valid General
Medical Practice Code was:
100% for admitted patient care;
99.9% for outpatient care.
Mersey Care’s provisional score for 2009 - 2010
for Information Quality and Records Management
assessed using the Information Governance
Toolkit was 86%.
Mersey Care NHS Trust was not subject to the
Payment by Results clinical coding audit
during 2009 - 2010 by the Audit Commission.
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Part 3
Review of Quality Performance
In addition to the measures outlined in the three priority areas, the Trust routinely tracks
performance against the following measures:
Indicator
Description
Thresholds
Performance
2009 - 10
Quality-Clinical Effectiveness
Accommodation status
% of service users on current
caseload who have had their
accommodation status recorded
>=80% green; 60%-80%
amber; <60% red
16.63%
Number of occupied bed days
for patients aged under 18 on an
adult ward
< previous year green; >
previous year red
208
Number of admissions of
patients aged 17 or under to
acute psychiatric wards
From Jan 10 =0 admissions
green; >0 red unless authorised
by commissoners
Delayed transfers of care
% of occupied bed days
accounted for by delayed
transfers of care (including leave)
<=7.5% green 7.5%-15%
amber; >15% red
10.04%
Employment status
% of service users on current
caseload who have had their
employment status recorded
>=80% green; 60%-80%
amber; <60% red
17.78%
Readmissions within 28 days of
discharge as % of total
admissions. Excludes Addictions
and Learning Disabilities services
and admissions from other NHS
providers
<=5% of admissions green;
5%-6% amber; >6% red
Readmissions within 90 days of
discharge as % of total
admissions. Excludes Addictions
and Learning Disabilities services
and admissions from other NHS
providers
<=7% of admissions green;
7%-10% amber; >10% red
Admissions and occupied
bed days for patients
under 18
Readmissions
1
4.36%
8.22%
Quality-Patient Experience
Cancellations by provider
% of booked outpatient
appointments cancelled by provider
<10.18% green; >=10.18%
-<=14.45% amber; >14.45% red
11.40%
Cancellations by service user
% of booked outpatient
appointments cancelled by provider
<8.49% green; >=8.49%<=10.66% amber; >10.66% red
12.17%
Patients on CPA offered a copy
of their care plan
% of patients on CPA who have
been recorded as having been
offered a copy of their care plan
>95% green; 85%-95% amber;
<85% red
80.65%
% of service users on current
caseload who have had their
ethnicity recorded or do not wish to
state ethnicity
>=95% green; 90%-95% amber;
<90% red
94.12%
Number of service users not seen
within 6 weeks of referral by GP
0 breaches green; >0 red
Number of service users waiting
more than 6 weeks for their
appointment as at month end.
(Excludes Low and Medium Secure
Services.)
0 waiting over 6 weeks green;
>0 red
Service user ethnicity
Waiting times-Outpatients
Waiting times-Psychological
Services
20
56
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Indicator
Description
Thresholds
Performance
2009 - 10
83.01%
Quality-Patient Safety
Bed occupancy-Local
Services
Occupied bed days excluding
leave as a % of available bed
days
>80% - <=90% green; >75%
- <=80% or >90% - <=95%
amber; <75% or >95% red
Bed occupancy-Low and
Medium Secure Services
Occupied bed days including
leave as a % of available bed
days
>=85% - <=95% green;
>95% or <85% red
Bed occupancy-High Secure
Services
Occupied bed days excluding
leave as a % of available bed
days
>=91%-<=95% green;
>=89%-<91% or >95%<=97% amber; <89% or
>97% red
91.77%
91.18%
Number of 'Never Events' as
defined by the National Patient
Safety Agency
0 green; >0 red
0
Number of escapes-High Secure
0 green; >0 red
0
Number of escapes-Medium
Secure
0 green; >0 red
0
Number of absconds from leave
of absence-High Secure
0 green; >0 red
0
Number of absconds from
escorted leave-Medium Secure
0 green; >0 red
Absconds from unescorted leave
as a % of total unescorted leaveMedium Secure
0%-5% green; 5%-10%
amber; >10% red
0.01%
Workforce-Sickness absence
% of available time lost due to
staff sickness
<=5.65% green; 5.65%6.65% amber; >6.65% red
6.17%
Workforce-Knowledge and
Skills Framework
% of posts recorded as having a
KSF outline as at quarter end
>= 90% green; 80%-90%
amber; <80% red
96.00%
Workforce-Personal
Development Plan
% of staff recorded as having
had a PDP review within the last
12 months as at quarter end
>= 90% green; 80%-90%
amber; <80% red
61.00%
Incidents
3
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Consultation Process
External Perspective on Quality of Services
Mersey Care NHS Trust is committed to involving
all stakeholders and has a structured consultation
process in place to gather opinion and feedback
from service users and members of the public
including the use of NHS Choices and the Patient
Opinion website and has utilised this involvement
to inform the content of our Quality Report.
During the consultation a number of constructive
and pragmatic suggestions were made as to how
we could enhance this process and ensure
greater and more regular contributions to the
construction of a meaningful Quality Report.
We have also consulted with our commissioners
in Liverpool, Sefton and Knowsley to ensure
agreement on the key priorities and have sought
the views of local LINks and the Overview and
Scrutiny Committee both to obtain a direct
perspective of Mersey Care’s Quality Account
for 2009 - 2010 and to determine a collaborative
and ongoing approach to supporting quality
and improvement.
These proposals and enhancements will be
adopted as part of the programme of work for
2010 - 2011 which will see much greater
engagement with all our stakeholders including
our local LINks networks.
As part of the Trust’s commitment to equality and
diversity in line with current legislation, this
document has also been impact assessed by the
equality and diversity team.
We have involved service users and carers with
the purpose of securing their input into this
document regarding its content and helping us to
identify those areas which should be considered a
priority for quality improvement. As part of the
work to establish systems which will embed
systematic improvement and learning in the Trust,
service users and carers have identified a number
of explicit areas of the ‘patient experience’ which
they want the Trust to take greater account of,
and to monitor progress against during
2010 - 2011. The future development of the
Trust’s Quality Account will therefore ensure an
active level of engagement with members of the
service user and carer forum and other
stakeholders to capture the patient experience on
a more sustained and responsive basis.
22
The Trust has received feed-back from local
LINks. These responses acknowledged the need
to build more substantive relationships with the
Trust to ensure the issues contained with the
Quality Account are addressed in a sustainable
way that will ensure openness and appropriate
challenge. Specific comments about the content
and style of the report have to some extent been
incorporated into it. The distinctions and
differentiations between services and specialities
requested by Sefton LINks have been
incorporated into the public report and a glossary
of terms will be produced to accompany the
publication of the report in future. The full written
narrative from our lead commissioner and Sefton
LINks are attached in Appendix 1.
The Quality Account was finalised and
confirmed at the June Trust Board meeting
and published on the Trust’s website on
30th June 2010.
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Appendix 1
Commissioning PCT Statement
On behalf of Liverpool Primary Care Trust, the
lead commissioner for Mersey Care NHS Trust I
would like to acknowledge the progress made in
the drive to deliver high quality care for all those
using their services.
As Director for Service Improvement and
Executive Nurse in Liverpool PCT I can confirm
that to the best of my knowledge this Quality
Report is a true and accurate reflection of the
2009 - 2010 progress Mersey Care NHS Trust has
made against the identified quality standards. The
Trust has complied with all contractual obligations
and has made good progress over the last year
with evidence of significant improvements in key
quality measures.
Liverpool PCT is supportive of the process
Mersey Care NHS Trust has taken to engage with
patients, staff and stakeholders in developing a
set of quality priorities and measures for
2010 - 2011 and applaud their continued
commitment to improvement.
We find the submitted Quality Report to represent
an appropriate level of effort and areas of focus
for service improvement and we look forward to
Mersey Care NHS Trust continued improvement
of quality standards in 2010 - 2011.
Sefton Local Involvement Network (LINk)
response to Mersey Care NHS Trust Quality
Report 2009 - 2010
It appears that the Trust is presenting general
information as opposed to detailed and concise
accounts of the individual areas. We felt an
introduction to Mersey Care and its services
would have been helpful. In addition to this
introduction, further details of the sites and
services provided across Merseyside would have
also been helpful.
We were pleased to see the addition of audits and
details of services, medicines, wards and facilities
were included, but for the reasons stated above,
we were unable to put these in the geographical
context of the areas covered by Mersey Care.
We could find no reference to hospital discharge
within the Report.
There is no clear definition between mental health
services and learning disability services. This is in
reference to patients and service users of Mersey
Care. Sefton LINk feels strongly that there should
be a clear distinction between these conditions.
We felt a glossary or some explanation of terms
would be a helpful addition to the report,
especially if it were intended to be viewed by the
general public.
Trish Bennett
Director for Service
Improvement & Executive Nurse
Liverpool Primary Care Trust
We would like to commend the Trust on their
patient involvement strategy and we feel this is a
positive area that has been well presented in the
Report. While Sefton LINk welcomes the fact that
the Mersey Care report are brief, we feel that
more details and substance should have been
included.
Ann Bisbrown-Lee
Chair, Sefton LINk Steering Group
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Mersey Care NHS Trust
Communications Department
Trust Offices
Parkbourn
Maghull
L31 1HW
0151 473 2885
www.merseycare.nhs.uk