North Staffordshire Combined Healthcare
NHS Trust
A Keele University Teaching Trust
Working to improve the health and
wellbeing of our local communities
Quality Account 2009/10
Working to improve the health and wellbeing of our local communities
2
Quality Account 2009/10
Contents
Introduction
Page
Introduction to the Trust
5
Introduction to the Quality Account
7
Services Covered by this Quality Account
7
Part 1 – Statement on Quality
Page
1.1
Quality of Services - Key Achievements and Key Priorities
8
1.2
Trust Statement
9
Part 2 – Priorities for Improvement (Looking Forward)
Page
2.1
Plans for Improvement
10
2.2
Priorities for Improvement and Goals Agreed with Commissioners
10
2.3
Statement of Assurance from the Board
12
2.4
Review of Services
14
2.5
Participation in Clinical Audit
14
2.6
Participation in Research
17
2.7
Goals agreed with Commissioners
17
2.8
Statement from the Care Quality Commission
17
2.9
Statement on Data Quality
19
2.10
Statement from Key Partners - Stakeholders views on 2009/10
Quality Accounts
19
2.11
Statement of Changes to Content of Quality Account
21
Part 3 – Review of Quality Performance (Looking Back)
Page
3.1
Patient Safety
22
3.2
Clinical Effectiveness
26
3.3
Patient Experience
29
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Working to improve the health and wellbeing of our local communities
4
Quality Account 2009/10
North Staffordshire Combined Healthcare NHS Trust
2009-10 Quality Account
INTRODUCTION
WELCOME TO OUR TRUST
North Staffordshire Combined Healthcare NHS Trust was established as a Trust in 1994 and is responsible for
providing mental health and specialist learning disability care to people living in the city of Stoke on Trent and
North Staffordshire county and sometimes from outside of these areas.
We currently work from both hospital and community based premises. We provide services to people of all
ages with a wide range of mental health and learning disability needs. Sometimes our service users need to
spend time in hospital, but much more often we provide care in outpatients, community resource settings and
in people’s own homes. We also provide specialist mental health services such as parent and baby mental health
services, mentally disordered offenders and psychological therapies and until September 2009 we provided care
for older people with physical health needs, when this service was transferred to the management of a more
appropriate community health care provider - North Staffordshire Community Healthcare and Stoke on Trent
Community Health Services.
Our 1,967 clinical and support staff have around 380,500 contacts with people each year; have approximately 340
beds and total clinical income of c£78million.
We service a population of around 463,000 people from a variety of diverse communities. Our main NHS
partners are the two local Primary Care Trusts (PCTs) - NHS Stoke on Trent and NHS North Staffordshire and these
organisations commission the services provided. We also work very closely with the local authorities in these areas.
In addition, we provide a range of clinical and non clinical services to University Hospital of North Staffordshire
NHS Trust and a range of support services such as estates, health and safety and health informatics to the two
Primary Care Trusts. We have also forged closer links with the two local universities, University of Staffordshire
and Keele University. The organisation has been a partner in the development of the Keele University Medical
School.
We also work closely with agencies which support people with mental health problems, such as North Staffs
Users Group (NSUG), Approach, ASIST, Brighter Futures, Changes, EnGAGE, North Staffs Huntington’s Disease
Association, MIND, North Staffs carers Association, Rethink and Richmond Fellowship.
Our Annual Report for 2009/10 provides an overarching summary of the services, performance and finances for
2009/10. A copy is available from the Trust Secretary. The diagram on page 6 illustrates our purpose, vision and
values and how they link to our strategic goals and the strategies that will help us realise our aims. Further
information regarding our purpose, vision and values is contained in the Trust’s Annual Report.
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Working to improve the health and wellbeing of our local communities
Our strategy
Our purpose:
Working to improve the mental health and wellbeing of local communities
Our Vision
Our Values
• To provide patient centred
mental health, specialist learning
disability and related services for
people of all ages
• Person centred
• To be the best in all that we do
• Equality and respect
• To work in partnership to deliver
services that promote recovery,
wellbeing and independent living.
• Supportive and responsive
• Transparency and integrity
• Excellence
Our Strategic Goals
1. To deliver high quality person centred models of care, throughout the organisation
2. To be at the centre of an integrated network of partnerships to provide a holistic
approach to care.
3. To engage with our communities to ensure we deliver the services they require
4. To be a dynamic organisation driven by innovation
5. To be one of the most efficient providers.
Clinical Strategy
Financial
Strategy
6
Workforce
Strategy
Estate
Strategy
Customer
Focus
Strategy
IM&T
Strategy
Governance
Strategy
Innovation
Strategy
Quality Account 2009/10
WELCOME TO OUR FIRST QUALITY ACCOUNT
Welcome to our first Quality Account which covers the financial year 2009/10, ie 1 April 2009 to 31 March 2010
and focuses on the quality of services we deliver to service users. For this year the Trust has been asked to provide
a report on the quality of it’s acute inpatient services for mental health and learning disabilities and is structured
to examine:
•
•
•
•
What our organisation is doing well
Where improvements in quality are required
What the Trust priorities for improvements are for 2010/11
How we have engaged our stakeholders in the determination of priorities for improvement
We hope that you find this Quality Account helpful in informing you about our work to date and future priorities
to improve local NHS Services. We also look forward to your feedback which will assist us in improving the
content and format of future Quality Accounts.
SERVICES COVERED BY THIS QUALITY ACCOUNT
The Trust is required for 2009/10, to produce a Quality Account focusing on acute inpatient services. In future
years the account will cover all functions including community based services. The services falling into the acute
definition are:
•
Community mental health beds based at:
1. Lymebrook (Bradwell, Newcastle under Lyme)
2. Ashcombe (Cheddleton, Staffordshire Moorlands)
3. Bennett (Shelton, Stoke on Trent)
4. Sutherland (Dresden, Stoke on Trent)
•
Acute Adult beds at Harplands Hospital:
5. Ward 1
6. Ward 2
7. Ward 3
•
Old Age Psychiatry Assessment based at :
8. Ward 7 (Harplands Hospital)
9. Lymewood Ward (Bradwell Hospital)
•
Learning Disability Assessment and Treatment Services:
10. Assessment and Treatment (Harplands Hospital)
11. Telford Unit ( Harplands Hospital)
The Trust does not subcontract out any services to another non NHS body.
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Working to improve the health and wellbeing of our local communities
PART 1 – STATEMENT ON QUALITY
1.1 QUALITY OF SERVICES – KEY ACHIEVEMENTS AND KEY PRIORITIES
KEY ACHIEVEMENTS
During the year we have been revising our five year Integrated Business Plan (IBP) to ensure that we are well placed
to provide quality services through increased productivity whilst at the same time being mindful that we meet the
personalised care needs for every individual. In addition, we have also been progressing our Foundation Trust (FT)
application. We continue to be actively supported by both of our local commissioners and are working together
to ensure our business plan is aligned and responsive to the local commissioning intentions and priorities.
For 2009/10 we have once again achieved full compliance with all the Core Standards for Better Health which
are a range of quality standards assessed by the Care Quality Commission. In addition, and for the first year of
operation, we have achieved compliance with the Regulations defined by the Health and Social Care Act 2008
resulting in us being successfully registered by the Care Quality Commission. We are very pleased with our service
user survey results which showed a significant improvement on the previous year’s results, the feedback we received
about the cleanliness of our premises, we are pleased to report that we have had no cases of Methicillin-resistant
Staphylococcus Aureus (MRSA) and a continued year on year reduction in Clostridium Difficile (CDiff).
In the Care Quality Commission ratings for 2008/09, we were rated as ‘good’ for quality of financial management
but regrettably dropped from good to ‘fair’ for our quality of services as we failed one national indicator (access
to crisis resolution home treatment) and marginally underachieved four national indicators (delayed transfers
of care; completeness of the Mental Health Minimum Data Set (MHMDS); child and adolescent mental health
services; and the provision of mental health services for people with a learning disability). We are committed to
improving the quality of services and have put action plans in place to address the areas which resulted in the
Trust’s ‘fair’ rating with the aim of significantly improving our ratings.
Our quality ratings for 2009/10 will be released by the Care Quality Commission in October 2010.
KEY PRIORITIES
In any year Trusts have a number of competing priorities to improve service delivery, value for money and the
quality of the service provision. With regard to improving the quality of services, we have chosen to align our
priorities for improvement in the coming year with the Commissioning for Quality Innovation (CQUIN) Scheme for
2010/11 which is a range of quality related indicators agreed to further improve services for the people who use
them. We have identified 10 priority areas which contribute to improved safety, clinical effectiveness and service
user experience.
As mentioned above we dropped from ‘good’ to ‘fair’ as assessed by the Care Quality Commission’s Periodic Review
for 2008/9 and raising our performance is a key priority for 2009/10 onwards. For 2009/10 we are confident that
we have improved the quality of services and have met the national indicator for access to crisis resolution and
home treatment services, child and adolescent mental health services and provision of mental health services for
people with a learning disability. We are working with local commissioners to reduce the number of delayed
transfers of care and are working hard to improve the recording of service user data assessed by the completeness
of the Mental Health Minimum Data Set (MHMDS) indicator and await the Care Quality Commission’s view of our
performance in these areas.
We will continue to build capacity and capability to deliver our priorities through improved strategic planning,
working with our partners, developing the quality improvement infrastructure, developing and supporting our
workforce, making better use of information and improving feedback mechanisms.
All of the areas above are explained further in this document.
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Quality Account 2009/10
1.2 TRUST STATEMENT
Our Trust is pleased to publish this first Quality Account for the financial year 2009/10, ie 1 April 2009 to 31 March
2010. For this year the Trust has been asked to provide a report on the quality of it’s acute inpatient services
for mental health and learning disabilities. The 2009/10 Quality Account represents the Trust’s commitment to
continually drive improvements in services and to be transparent and accountable to the general public, service
users, commissioners, key stakeholders and those that regulate our services. Throughout the period covered by
this account, the Board of Directors have worked to strengthen the quality reporting and monitoring systems
across the organisation. To try to ensure that the account covers the priority areas important to local people, the
Trust has consulted with our key stakeholders in the voluntary and statutory sectors. Their valuable comments
have been incorporated into the body of this account.
On behalf of the North Staffordshire Combined Healthcare NHS Trust, we confirm that the information contained
in this 2009/10 Quality Account is a true and accurate reflection of the Trust’s performance.
Chairman’s signature
Signed by the Chairman, Sir Philip Hunter on behalf of the Trust Board
of North Staffordshire Combined Healthcare NHS Trust
Signature
Signature
Fiona Myers Dr Mike Jorsh
Chief Executive
Medical Director
Signature
David Pearson
Director of Nursing and
Allied Health Professionals (AHPs)
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Working to improve the health and wellbeing of our local communities
PART 2 – PRIORITIES FOR IMPROVEMENT (LOOKING FORWARD)
2.1 PLANS FOR IMPROVEMENT
VISION, VALUES, STRATEGIC GOALS AND SERVICE IMPROVEMENT PLANS
The introductory section defines our vision, values and strategic goals. During 2009/10, the Trust produced a business
plan to guide its service development over the next 5 years. This Quality Account sets out the Trust’s commitment
to continue to improve the quality of services provided, to improve service user engagement and to develop new
approaches to enable people to regain maximum control over their lives. The Trust will strengthen its services
during 2010/11 by building high quality care delivered as close to home as possible, providing rapid response and
assessment and preventing inappropriate admission via a range of alternative responses. These priority areas build
on national policy (New Horizons, Department of Health 2009). In developing our provision for the following year
in partnership with our Commissioners, we have concentrated upon the following four key areas:
1. Informing and supporting people to make healthier and more responsible choices
2. Creating an environment in which the healthier and more responsible choice is the easier choice
3. Identifying, advising and treating those at risk
4. A delivery system that effectively prioritises and delivers actions to reduce harmful behaviours
2.2 PRIORITIES FOR IMPROVEMENT AND GOALS AGREED WITH COMMISSIONERS
PRIORITIES FOR IMPROVEMENT
In any year Trusts have a number of competing priorities to improve service delivery, value for money and the
quality of the service provision. With regard to improving the quality of services, we have chosen to align our
priorities for improvement in the coming year with the Commissioning for Quality Innovation (CQUIN) Scheme for
2010/11 agreed with our local Commissioners.
The CQUIN payment framework is a national framework for agreeing local quality improvement schemes and
makes a proportion of our income conditional on the achievement of ambitious quality improvement goals and
innovations agreed between Commissioner and Provider with active clinical engagement. The CQUIN framework
is intended to reward genuine ambition and stretch, encouraging a culture of continuous quality improvement
in all providers.
For 2010/11, as an incentive 1.5% of the Trust’s income for 2010/11 has been linked to delivery of these targets.
The Trust has agreed 10 CQUIN indicators which are shown below including whether each relates to patient
safety, clinical effectiveness, patient experience, or more than one.
Ref
CQUIN Area
1
Increasing safety through improved medicines management
2
Improving health by supporting people to quit smoking or to reduce tobacco use
3
Improving support through a clear understanding of accommodation and
employment needs
Service
User
Safety
Clinical
Effectiveness
Service
User
Experience
✓
✓
✓
4
Increasing the opportunity for people to be treated in their own home through
support from the Crisis Resolution and Home Treatment Team
✓
✓
5
Increasing the opportunity for people to return to their home as soon as possible
through discharge support from the Crisis Resolution Home Treatment
✓
✓
6
Improve the dementia patients’ experience by working closely with other
organisations to provide safe and effective care across different organisations
✓
7
Early identification and support for people who have untreated psychosis
8
Improve nutritional screening and support
9
Productivity Improvement Programme
✓
✓
✓
10
Understanding and improving the overall patient experience
✓
✓
✓
Further information about all of the areas above is available from David Pearson, Director of Nursing and Allied Health Professionals.
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Quality Account 2009/10
BUILDING CAPACITY AND CAPABILITY
We are committed to developing our capacity and ability to deliver improvements in quality for the people who
need our services through:
Improved Strategic Planning
During the year we have been revising our five year Integrated Business Plan (IBP) to ensure that we are well
placed to provide quality services through increased productivity whilst at the same time being mindful that we
meet the personalised care needs for every individual. In addition, we have also been progressing our Foundation
Trust (FT) application. A key focus going forwards is to:
• Finalise our five-year Integrated Business Plan (IBP);
• Work with the Strategic Health Authority to finalise our plans to achieve Foundation Trust status; and
• Commence the delivery of the Service Improvement Plans.
Quality Improvement Capacity
To ensure that we achieve our key priorities, a key focus going forwards is to:
• Review our internal structures and processes to ensure that both are sufficient and effective to support
the delivery of our key priorities.
Workforce
We employ over 1,900 staff and over 75% of our staff provide professional healthcare directly to our service users.
We understand that we will deliver our strategic plans though our workforce and that it is our workforce that has
a direct impact on the quality of services provided and the experience of service users. We recognise the need
to ensure we invest in resources to promote strong clinical leadership and during the year we appointed Clinical
Directors and Clinical Leads for services who are empowered to bring about service transformation that will meet
the needs of the future. A key focus for the Trust going forwards is to:
• To ensure that our clinical staff are supported by strong and effective managers who will back good
ideas and remove blockages in the system where this may prohibit service redesign and innovative
practice. We will actively support and encourage our clinical staff to innovate, collaborate and work
across the local economy in order to provide timely and appropriate care for service users where there is
a need;
• Develop our leaders and identify and support leadership talent at all levels through a Development
Centre for our senior leaders and managers. This will match existing skills against the competencies
required and will inform of future leadership development requirements;
• Ensure that all of our staff have an annual review of their performance;
• Internal training providers have reviewed and approved the content of the mandatory training courses
and a pilot project using the fire training package is nearing completion. Learning points will be
incorporated in the future rollout which aims to provide an e-learning option for all staff with a view to
ensuring that all staff are up-to-date with mandatory training programmes; and
• Our staff survey took place in November 2009. We have responded to those findings by extensively
sharing the results and we produced an action plan that we need to continue to implement during
2010-11 to ensure that staff satisfaction levels increase.
Better Use of Information
A key challenge for the Trust is make better use of the information which is available now, as well as planning
for information that is not currently available but may be in the future. During 2009/10 the Trust has made
significant progress by making more information available on-line and is using web technologies to improve
information sharing and is now in a position to build on this further. We have completed a project to understand
our information needs and to assess the electronic tools available and make all information available from one
place. A key focus for the Trust going forwards is to:
• Utilise more advanced software than is currently implemented in the Trust;
• Develop the Trust’s data warehouse; and
• Improve access to data for all staff in the Trust through the use of new Business Intelligence (BI)
solutions.
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Working to improve the health and wellbeing of our local communities
The Trust is committed to improving how it communicates with service users, carers, members of the general
public and staff. In January 2009 the Trust commissioned BT Engage to build a new Internet and staff website. A
key focus going forwards will be to:
• Continue to be improve the website with members and service user / carer involvement following the
launch of both sites in June 2010.
Continuous Feedback
We continue to focus on making the necessary changes to support and drive forward improved outcomes and
experiences for people who come into contact with our services and responding to their feedback with the
importance that it deserves. A key focus going forward will be to:
• Introduce service user and carer feedback tools to obtain near or real time feedback so that the Trust may
respond in a timely and pro-active manner to what service users and carers are telling us.
HOW PROGRESS WILL BE MEASURED AND MONITORED
The majority (80%) of services provided by North Staffordshire Combined Healthcare NHS Trust are commissioned
by two Primary Care Trusts, NHS North Staffordshire (36%) and NHS Stoke (44%). NHS North Staffordshire is
identified as the co-ordinating Commissioner. There is a contract in place to ensure that there is clarity regarding
the services commissioned for local people, the expectations of the service provider and expectations for the
quality of services.
We have a Performance & Quality Management Framework (PQMF) which supports the monitoring and scrutiny
of performance and the quality of services. Our main Commissioners have worked with the Trust to establish
a Clinical Quality Review Group which meets on a monthly basis. Attended by Commissioners and senior trust
clinicians, this group has a number of functions including the setting of Commissioning for Quality and Innovation
Targets (CQUIN) and other key performance and quality indicators. Through this structure, Commissioners
undertake reviews of performance associated with the quality of services and conduct clinical visits to assess for
themselves that the standards they set are being adhered to.
Quarterly reports will be presented to the Trust Board during an open meeting to provide progress in meeting
the key priorities outlined in our Quality Account. In addition, our Quality Account for 2010/11 will include clear
reference to our progress and hopefully our success in meeting the key priorities outlined in this document.
2.3 STATEMENT OF ASSURANCE FROM THE BOARD
This section is provided to offer assurance that the Trust is performing well as assessed internally via the Trust’s own
processes and externally. This provides independent assurance through processes to measure clinical outcomes,
through audit and research and development and through participation in national projects and initiatives.
PERFORMANCE & QUALITY MANAGEMENT FRAMEWORK (PQMF)
The Trust’s Performance & Quality Management Framework (PQMF) plays a key role in our drive for excellence,
providing the means to review and improve organisational performance and quality outcomes by linking and
aligning individual, team and organisational objectives and results. It provides a means of recognising good
performance and managing underperformance.
CARE QUALITY COMMISISON’S CORE QUALITY STANDARDS FOR BETTER HEALTH
The Care Quality Commission (CQC) is the independent watchdog of health and social care services. Since 1 April
2005 the Annual Health Check has been in place and all Trusts have been required to self assess against the core
quality standards defined by Standards for Better Health and submit an annual declaration of compliance to
the Healthcare Commission (HCC), and since 2008/9 to the Care Quality Commission (CQC). The Trust has always
had a comprehensive self assessment methodology in place and has rigorously implemented this to ensure that
the quality of services continues to rise year by year. The Trust is proud to report we were able to report full
compliance with all core standards for five consecutive years. This self declaration was supported by the Care
Quality Commission which assessed the Trust as ‘fully met’ for four consecutive years. A decision is awaited with
regard to the fifth and final year, 2009/10.
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Quality Account 2009/10
CARE QUALITY COMMISSION’S REGISTRATION UNDER THE HEALTH & SOCIAL CARE ACT 2008
From April 2010 Standards for Better Health is being replaced and all health and adult social care providers will
be required by law (Health & Social Care Act 2008), to be registered with the Care Quality Commission if they
provide regulated activities. All provider Trusts were required to self assess against the new regulations - ‘Essential
Standards of Quality and Safety’, inform the Care Quality Commission of the outcome of that assessment and
apply for Registration to provide regulated activities.
North Staffordshire Combined Healthcare NHS Trust self assessed against the outcomes defined by the regulations
and declared compliance with all of the outcomes. The Trust’s application for registration has since been
considered by the Care Quality Commission and a decision made to register without conditions to provide a
range of regulated activities.
We have developed a comprehensive self assessment and audit process to ensure we remain fully compliant with
the regulations and improve outcomes for all in contact with our services.
CARE QUALITY COMMISSION’S PERIODIC REVIEW
The Periodic Review, formally referred to as the Annual Health Check, is a process operated by the Care Quality
Commission to consider a range of quality standards and targets and assess an organisation’s performance and
whether levels of service are being maintained.
In the Periodic Review for 2008/09, we received a rating of ‘good’ for quality of financial management but
regrettably dropped from good to ‘fair’ for our quality of services as we failed one national indicator (access
to crisis resolution home treatment) and marginally underachieved four national indicators (delayed transfers
of care; completeness of the Mental Health Minimum Data Set (MHMDS); child and adolescent mental health
services; and provision of mental health services for people with a learning disability). We are committed to
improving the quality of services and have put action plans in place to address the areas which resulted in the
Trust’s ‘fair’ rating with the aim of significant improvement. Further information can be found in section 2.8.
MEASURING CLINICAL PERFORMANCE
Clinical Audit, Research & Development and Clinical Effectiveness all contribute to measuring effectiveness
(including both clinical outcomes and service user reported outcomes), safety and service user experience by
quantitative and qualitative information. This includes reporting experience and data regarding the impact of
services on service users. The clinical audit programme is developed to reflect these needs and national priorities.
Further information is contained below.
NATIONAL PROJECTS AND INITIATIVES
Commissioning for Quality and Innovation (CQUIN) Framework
We are fully engaged with Commissioners in the CQUIN payment framework which is a national framework
for locally agreed quality improvement schemes and makes a proportion of provider income conditional on the
achievement of ambitious quality improvement goals and innovations. The CQUIN framework is intended to
reward genuine ambition and stretch, encouraging a culture of continuous quality improvement in all providers.
The Trust and Commissioners worked together on a small number of schemes in 2009/10 and will be participating
fully in 2010/11.
Productivity Improvement Pathway Programme (PIPP)
Since 1 May 2009, all Mental Health and Learning Disability (MH/LD) Trusts across the West Midlands have taken
part in the newly developed and piloted Productivity Improvement and Pathway Programme led by the Strategic
Health Authority. The Trust took part in the pilot programme which included the development of a benchmarking
tool and the Time to Care Diary exercise. Both of these elements have been improved and will become part of the
overall programme. Undertaking the Programme enables Trusts to:
• Benchmark workforce productivity within and across its services as well as with other organisations within
the West Midlands.
• Assess the benchmarking tool to identify ways to improve productivity and services whilst maintaining
standards in key quality and performance indicators; and
• Develop knowledge and systems.
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Working to improve the health and wellbeing of our local communities
Quality, Innovation, Productivity, Partnership and Prevention (QIPPP)
• The QIPPP agenda, which stands for Quality, Innovation, Productivity, Partnership and Prevention, was
developed at a national level with an expectation that this would be rolled out through regions to local
health economies. QIPPP is identified as the means through which organisations will improve quality and
outcomes whilst managing increasing demand on services without further growth in investment.
National Quality Improvement Projects (Service Accreditation Programmes) - Managed by the Royal College of
Psychiatrists Centre for Quality Improvement (CCQI)
• The Trust has 1 ECT Clinic and it is accredited
• 3 wards (wards 1, 2 and 3 at the Harplands Hospital) for working age adults are accredited
Clinical Trials
The trust is involved in several clinical trials the main aim of which is to develop a culture where such activity is
promoted and supported as an integral part of the organisation and thus ensure best evidence-based practice in
healthcare. For research to be of value it must be used to inform and influence practice and ultimately improve
service user outcomes.
National Clinical Audits, National Confidential Inquiries and Prescribing Observatory for Mental Health (POMH)
The Trust is involved with all of the above and further information is contained in section 2.5 of this report.
LEARNING LESSONS
It is very important that service users, carers and the public have confidence in their local health services at all
times. We have undertaken a comprehensive review of lessons to be learnt from the Mid-Staffordshire Hospital
Care Quality Commission investigation and the subsequent independent Francis Inquiry. Any responsive actions
that we need to address will be taken forward and monitored at regular intervals.
In addition we have used the Audit Commission’s Taking it On Trust Toolkit to assess our Trust and again, we have
developed a comprehensive action plan to ensure that we are taking proactive action in a number of areas.
2.4 REVIEW OF SERVICES
This section is provided to offer assurance that we have included all of the services mandated to be included in
this first year of publication.
The Trust is required for 2009/10, to produce a Quality Account focusing upon the acute inpatient services and
these are outlined in the introductory section. In future years the account will cover all functions including
community based services.
During the period 1 April 2009 to 31 March 2010, North Staffordshire Combined Healthcare NHS Trust has reviewed
all the data available on the quality of care in 11 of these NHS services. The income generated by the NHS services
reviewed in 2009/10 represents 18% of the total income generated from the provision of NHS services by the
North Staffordshire Combined Healthcare NHS Trust for 2009/10.
2.5 PARTICIPATION IN CLINICAL AUDIT
National Confidential Enquiries and National Clinical Audits
Clinical Audit is a quality improvement process that seeks to improve service user care and outcomes against
specific criteria and the implementation of change. Where indicated, changes are implemented at an individual,
team, or service level and further monitoring is used to confirm improvement in healthcare delivery. As such,
Clinical Audit is an essential part of the quality assessment framework and a key element of clinical governance.
During 2009/10, 2 national audits and 1 national confidential enquiry covered NHS services that North Staffordshire
Combined Healthcare NHS Trust provides. During that period, North Staffordshire Combined Healthcare NHS Trust
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Quality Account 2009/10
participated in 1 of the 2 national clinical audits and in the 1 national confidential enquiry which it was eligible
to participate in:
The National Clinical Audits and National Confidential Inquiries that North Staffordshire Combined Healthcare
NHS Trust was eligible to participate in during 2009/10 are listed below and those that the Trust did participate in
during 2009/10 are shown with ✓
•
National Audit of Psychological Therapies in Anxiety and Depression (NAPTAD): Anxiety and Depression
•
Prescribing Observatory for Mental Health (POMH): Prescribing Topics in Mental Health Services ✓
•
National Confidential Inquiry (NCI) into Suicide and Homicide by People with Mental Illness (NCI/NCISH) ✓
Due to capacity issues, the Trust was not able to participate in the National Audit of Psychological Therapies in
Anxiety and Depression (NAPTAD): Anxiety and Depression. The National Audit of Dementia was not applicable
as North Staffordshire Combined Healthcare NHS Trust is a mental health trust not acute.
The National Clinical Audits and National Confidential Inquiries that North Staffordshire Combined Healthcare
NHS Trust participated in, and for which data collection was completed during 2009/10 are listed below alongside
the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases
required by the terms of that audit or inquiry:
Prescribing Observatory for Mental Health (POMH): Prescribing Topics in Mental Health Services
POMH TOPIC
Number of service users
enrolled by Trust
High dose and combined antipsychotics on acute wards
49
Benchmarking of high dose and combined antipsychotics on acute wards
28
Medicines reconciliation
5
Use of antipsychotics in people with learning disability
9
The reports of 4 National Clinical Audits, (as specified above) were reviewed by the Trust in 2009/10 and North
Staffordshire Combined Healthcare NHS Trust intends to take the following actions to improve the quality of
healthcare provided:
•
•
We have reviewed our audit systems with regards to the implementation of action plans for national audits
and as such the Trust has taken appropriate action to ensure these audits are monitored appropriately
through the Trust Clinical Effectiveness Group (TCEG). The Trust has accepted that there has been a
problem associated with implementing the above action plans due to structural anomalies. These have
been reviewed and addressed for the new financial year.
National Confidential Inquiry (NCI) into Suicide and Homicide by People with Mental Illness (NCI/NCISH)
20 people for the whole of North Staffordshire Combined Healthcare NHS Trust with a population of circa.
470,000.
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Working to improve the health and wellbeing of our local communities
Local Clinical Audits
In 2009/10 7 local clinical audits were undertaken. We reviewed the reports, and intend to take the following
actions to improve the quality of healthcare provided:
1) A Review of Mental Health Acute Admissions
• Further debate is to take place about who makes the decision to admit the service users to the ward;
• Staff are to be reminded to inform relevant people e.g. GP and carer (where appropriate) of a persons
admission;
• All junior doctors, nurse practitioners and ward based consultants are to agree the standards for the
production of discharge summaries. All staff will be reminded about the need to complete a discharge
summary and the maximum time period by which discharge summaries should be produced for all
inpatients;
• A pilot project relating to clinical outcome measures is to be taken forwards.
2) Audit of Inpatient and Outpatient Management of Service Users with Bipolar Affective Disorder against NICE
Guidelines:
• The audit will be presented at the Academic Forum for consideration and feedback of results and the key
findings will be communicated to appropriate clinicians.
3) Re-Audit of Clinical Coding:
• A protocol will be developed for completing the key records and disseminated to all wards;
• Options to provide an awareness session on the importance of accurate clinical coding and other related
issues will be investigated;
• Clinical coding process to be added to the junior doctor induction programme.
4) Re-Audit of Care Plan Processing Times for Service Users Registered on Enhanced Care Co-ordination:
• Evaluate the effectiveness of the new Care Programme Approach Information Technology System (CPA,
IT) to support care planning;
• Evaluate the quality of recovery, staying well and safety plans, focusing on content, contact details and
evidence of service user engagement;
• The implementation of the new I.T. system to support CPA requires that plans are published within 7 days
of the review meeting.
5) Audit of Assessment of Physical Health Needs on Admission for Inpatients with Mental Health Problems:
The Inpatient Physical Health Assessment document will be reviewed to:
• Ensure that it is completed consistently by clinicians;
• Gaps in the document will be identified and a new version developed, for example: extra space will be
created to allow the recording of additional information;
• Improvements will be made for example: Psychiatric admission document and In-patient Physical Health
Assessment document will be combined as a joint document; Dosages and frequencies of medications will
be documented clearly; Medicines reconciliation will form an integral part of physical health assessment;
• Where there is a delay (beyond 24 hours) in undertaking a physical health assessment, the clinical team
will make contact with relatives, GP and other sources to establish meaningful information about the
service user’s physical history and any other problems. A clinical incident form will be compiled on each
occasion a physical health assessment is not undertaken;
• Weekly audits of compliance.
16
Quality Account 2009/10
6) Prescribing Audit Risperdal Consta:
• Highlight important findings by email to appropriate clinicians.
• Consider whether a proforma should be completed prior to dispensing Risperdal Consta.
7) Audit of Serious Untoward Incidents (SUIs):
• The results of the audit will be communicated to key groups and recommendations of the report will be
sent to the Quality and Governance Committee for review / decision. A comprehensive action plan to
address the audit findings will be developed.
• A re-audit of the policy following implementation of revised guidance and procedures will be undertaken.
2.6 PARTICIPATION IN RESEARCH
Research is the attempt to derive new learning and knowledge. Research aims to find out what happens if we
add or change clinical or service practice in some way, or aims to find out in a systematic way the views, opinions,
experiences and understanding of stakeholders.
The Trust’s principal aim for Research and Development is to develop a culture where such activity is promoted
and supported as an integral part of the organisation and thus ensure best evidence-based practice in healthcare.
For research to be of value it must be used to inform and influence practice and ultimately improved service user
outcomes.
The Trust is a link site for the Mental Health Research Network (MHRN) and as such is actively involved in the
research projects they support.
The number of service users receiving NHS services provided or sub-contracted by North Staffordshire Combined
Healthcare NHS Trust in 2009/10 that were recruited during that period to participate in research approved by a
research ethics committee was 48.
2.7 GOALS AGREED WITH COMMISSIONERS
COMMISSIONING FOR QUALITY AND INNOVATION (CQUIN) FRAMEWORK
A proportion of the Trust’s income (0.5%) in 2009/10 was conditional on achieving quality improvement and
innovation goals agreed with Commissioners through the Commissioning for Quality Innovation (CQUIN)
Framework. As an incentive 1.5% of the Trust income for 2010/11 has been linked to delivery of these targets.
The Trust has agreed 10 CQUIN indicators with the Commissioners. The CQUIN indicators are shown in
section 2.2 of this report.
2.8 STATEMENT FROM THE CARE QUALITY COMMISSION
REGISTRATION
North Staffordshire Combined Healthcare NHS Trust is required to register with the Care Quality Commission and
its current registration status is registered without conditions.
CARE QUALITY COMMISSION ENFORCEMENT ACTION
The Care Quality Commission has not taken any enforcement action against North Staffordshire Combined
Healthcare NHS Trust during 2009/10.
CARE QUALITY COMMISSION’S PERIODIC REVIEW
The Periodic Review, formally referred to as the Annual Health Check, is a process operated by the Care Quality
Commission to consider a range of quality standards and targets and assess an organisation’s performance and
whether levels of service are being maintained.
17
Working to improve the health and wellbeing of our local communities
North Staffordshire Combined Healthcare NHS Trust is subject to periodic reviews by the Care Quality Commission
and the last review was in October 2009 relating to 2008/9. The Care Quality Commission’s assessment of North
Staffordshire Combined Healthcare NHS Trust following that review was fair for the quality of services provided
and good for the quality of financial management.
North Staffordshire Combined Healthcare NHS Trust intends to take the following action to address the points
made in the Care Quality Commission’s assessment:
• Crisis resolution: Ensure that service users admitted to adult acute services are admitted via the Trust’s gatekeeping process. The Trust put plans in place to achieve 90% for 2009/10 and to target 95% for 2010/11
•
Best practice in mental health services for people with a learning disability: Ensure that action plans are
delivered to further improve mental health services for people with a learning disability and achieve full
compliance with the Care Quality Commission’s self assessment template, ie a score of 48 out of a possible 48
•
Child and adolescent mental health services (CAMHS) service provision: Ensure that action plans are delivered
to further improve the CAMH services and achieve full compliance with the Care Quality Commission’s self
assessment template, ie a score of 24 out of a possible 24
•
Delayed transfers of care: Improve the Trust’s performance by reducing the number of delayed transfers
of care and target 7.5%. The Trust planned to take action in three key areas: 1) Review the processes for
routine delays and seek improved arrangements; 2) Reduce routine levels of delayed transfers of care; and 3)
Focus on service users who have been delayed for excessive periods of time due to being in an inappropriate
placement, ie service users counted as a delayed transfer of care who actually require a review of their longterm placement
•
Data quality as assessed by the Mental Health Minimum Data Set (MHMDS): Improve data quality across the
MHMDS and ensure that all that all national change notices are actioned in line with national deadlines
North Staffordshire Combined Healthcare NHS Trust has made the following progress by 31 March 2010 in takings
such action:
•
✓ Crisis Resolution: Achieved the target as 94% of service users admitted in 2009/10 have been admitted via
the gate-keeping process
•
✓ Best practice in mental health services for people with a learning disability: The Trust has fully achieved all
of the standards with a score of 48 of 48, ie 100%
•
✓ Child and adolescent mental health services (CAMHS) service provision: The Trust has fully achieved all of
the standards with a score of 24 of 24, ie 100%
•
X Delayed transfers of care: Action has been progressed in all three areas as outlined above. However, whilst
significant progress has been made throughout the year this is unlikely to result in the Trust achieving the
national target of 7.5% for 2009/10 as the Trust’s delayed rate for 2009/10 is circa 15%. This will continue to be
progressed during 2010/11 to ensure that the targeted rate of 7.5% is achieved.
•
TBC Data quality as assessed by the Mental Health Minimum Data Set (MHMDS): Action has been taken
to ensure that all that all national change notices are actioned in line with national deadlines and this has
been delivered. However, this indicator has changed since 2008/9 and now includes an assessment of the
data quality for an additional four areas. The Trust’s performance has improved significantly throughout the
year and the Trust is awaiting confirmation of national averages to be able to assess whether the Trust has
achieved the new elements of this national indicator in 2009/10.
SPECIAL REVIEWS / INVESTIGATIONS
North Staffordshire Combined Healthcare NHS Trust has not participated in any special reviews or investigations
by the CQC during 2009/10.
18
Quality Account 2009/10
2.9 STATEMENT ON DATA QUALTIY
NHS Number and General Medical Practice Code Validity
North Staffordshire Combined Healthcare NHS Trust submitted records during 2009/10 to the Secondary Users
service for including in the Hospital Episode Statistics which are include in the latest published data.
The percentage of records in the published data which included the service user’s valid NHS number was
• 99.9% for admitted patient care; and
• 99.9% for outpatient care.
The Trust does not provide accident and emergency care.
The percentage of records in the published data which included the service users valid General Medical Practice
Code was
• 100% for admitted patient care; and
• 100% for outpatient care.
The Trust does not provide accident and emergency care
Information Governance Toolkit Attainment Levels
North Staffordshire Combined Healthcare NHS Trust’s score for 2009/10 for Information Quality and Records
Management assessed using the Information Governance Toolkit was 80%.
Clinical Coding Error Rate
North Staffordshire Combined Healthcare NHS Trust was not subject to the Payment by Results clinical coding
audit during 2009/10 by the Audit Commission.
2.10 STATEMENT FROM KEY PARTNERS
ENGAGING OUR PARTNERS AND STAKEHOLDERS
North Staffordshire Combined Healthcare NHS Trust is committed to working collaboratively with a range of
partners and as such has included two key stages in the development and publication of the Trust’s first Quality
Account. It is hoped that both stages will result in real and meaningful involvement in the content of the Quality
Account and will provide key partners with an opportunity for their views and comments to be included and
therefore made available to the public.
At the development stage, the Trust produced a survey to elicit the views of key partners and staff. The survey
provided suggested areas for inclusion but also provided the opportunity for partners and staff to identify
other areas of interest or concern. This approach has proven successful and input has been received from the
following:
•
•
•
•
•
Commissioning Primary Care Trusts
Returns from both commissioners
LINKs
One return
Overview & Scrutiny Committees of Local Authorities
One return
Staff
78 returns
Other
One return
USING THE FEEDBACK
As a result of the survey of stakeholders, a number of items emerged which interested parties wished to be
included in the 2009/10 Quality Account. Part 3 of the Trust’s Quality Account provides an overview of quality
outcomes across a number of key areas and we are pleased to report that these key areas were decided upon
based on the responses to the survey, ie based on what our key stakeholders felt were important to service users,
our staff and the general public. As mentioned at the beginning we would be happy to receive your views about
what information you might like to see included in the future.
North Staffordshire Combined Healthcare Trust’s Quality Account for 2009/10 was shared with key partners as
shown over the page at the draft stage and each key partner has been invited to provide a statement for inclusion
in the Trust’s Quality Account.
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Working to improve the health and wellbeing of our local communities
COMMENTS FROM KEY PARTNERS
The following responses have been received:
NHS North Staffordshire & NHS Stoke - Commissioning Primary Care Trusts
A draft Quality Account was presented to the Commissioning Primary Care Trusts and the following comments
were received:
North Staffordshire Combined Healthcare NHS Trust has produced a comprehensive Quality Account for 200910. They are required for this year to provide a Quality Account that reflects only on the acute inpatient mental
health and learning disabilities services that they provide.
This statement from NHS North Staffordshire as the coordinating commissioning PCT for the North Staffordshire
Combined Healthcare NHS Trust, has reviewed the Quality Account for 2009/10, in line with Department of Health
guidance. This has also been done in partnership with the associate commissioner, NHS Stoke on Trent.
NHS North Staffordshire PCT is content to confirm the accuracy of the information provided within the Quality
Account for services covered by the current service level agreement for acute inpatient services.
NHS North Staffordshire is satisfied that this Quality Account provides a true reflection of the quality of NHS
services purchased from the North Staffordshire Combined Healthcare NHS Trust, for patients across North
Staffordshire and Stoke on Trent.
The Quality Account offers an overview of some of the areas where the organisation is doing well; where
improvements in service quality are required and actions to address them and priorities for improvement for the
coming year.
The Quality Account reflects some of the key performance quality indicators which are monitored monthly along
with the areas for improvement at Quality Review Meetings which are part of the contractual agreement. Both
commissioners, NHS North Staffordshire and NHS Stoke, have developed effective partnership and collaborative
working with North Staffordshire Combined Healthcare NHS Trust. This is a healthy relationship which seeks to
ensure the delivery of the quality agenda and development of quality assurance mechanisms.
Staffordshire Overview & Scrutiny Committee
A draft Quality Account was presented to the Staffordshire Overview & Scrutiny and the following comments
were received:
As this is the first year of Quality Accounts, our approach has been to review the Trust’s draft Account and make
comments for them to consider in finalising the publication. We have been encouraged, by the Department of
Health’s NHS Medical Director, to consider whether such Accounts are representative and give comprehensive
coverage of a provider’s services and if we believe that there are significant omissions of issues of concern.
There are some sections of information that the Trust must include and some sections where they can choose what
to include. We focused on what we might expect to see in the Quality Account, based on what we have learned
about the Trust’s services through health scrutiny activity in the last year.
We also looked at how clearly the Trust’s draft Account explained for a public audience what they are doing well,
where improvement is needed and what will be the priorities for the coming year.
We made various comments which are listed in the Statement of Changes in section 2.11 of the Quality Account.
We are pleased that our comments have all been responded to by the Trust in finalising the publication. We are
aware that, after we provided our commentary, the Trust did further work on trying to make the Quality Account
easier to read ñ we support this effort.
We encourage people to provide feedback to the Trust on the Quality Account as this will help with next year’s
publication. We expect to see, and contribute to, increasing patient and public involvement in the assessment
and improvement of the quality of services that health trusts provide.
Stoke on Trent Overview & Scrutiny Commission
Stoke on Trent Health Overview & Scrutiny Commission was invited to provide a commentary. The response
received is as follows:
Thank you for giving the Overview & Scrutiny Commission (OSC) an opportunity to comment on the quality
accounts. Unfortunately due to the timing of the publication which coincides with the local Elections, the Health
OSC has been left without a Chair and with a reduced membership. The committee will be reappointed at the
end of May which will be too late to consider the accounts.
20
Quality Account 2009/10
Therefore no statement will be provided this year.
We will be working with LINks and developing a system so that we will be in a more informed position next
year.
Staffordshire LINks (Local Involvement Networks)
A draft Quality Account was shared with Staffordshire LINks and the following comments have been received:
Staffordshire LINk was provided with the proposed structure and format of the Quality Account by the Trust with
the request for comments and feedback. The draft Account was distributed to relevant LINk network organisations
and also published on the Staffordshire LINk website for comment by LINk members. Unfortunately, no comments
or feedback were received.
Staffordshire LINk was also provided with the first draft of the Trust’s Quality Account and, again, this was
distributed to relevant LINk network organisations and published on the Staffordshire LINk website for comment
by LINk members. To date, no comments or feedback have been received. It may be that the length and complexity
of the information provided could account for the lack of responses and the LINk would ask that the Trust consider
a more user friendly way of presenting the information next year and, perhaps through a presentation of the
report to a meeting of LINk participants which would be more effective and engaging.
Staffordshire LINk appreciated being sent the draft proposals for comment and feedback, and acknowledges that
this is the first year of a new process for the Quality Accounts and will seek to develop a more robust process for
involving the LINk in the production of future Quality Accounts with the Trust.
Stoke on Trent LINks (Local Involvement Networks)
A draft Quality Account was shared with Stoke on Trent LINks and comments were invited, however, no comments
have been received.
2.11 STATEMENT OF CHANGES
The following key partners have provided suggestions for change as follows:
Comment
Request
responded to
Staffordshire Overview & Scrutiny Committee:
Ensure that the Quality Account is signed and supported by the whole Trust Board
Ensure that the key priorities are clearly attributed to the three domains
Ensure that the statement on assurance is clear about why this is important / relevant to quality
Ensure that sub-contracted services are included (if relevant)
Include information about building capacity with a particular focus on developing the workforce
Ensure that the review of quality provides graphs and other presentational formats to ensure that it is
understood
Ensure that there is clear service user feedback and information regarding complaints
✓
✓
✓
✓
✓
✓
✓
NHS North Staffordshire:
A number of accuracy checks and a number of suggestions for additional content / to help to make the
Quality Account easier to understand. Commissioners have commented that Part 3 is easier to read
than Part 1 and Part 2 and this is something that the Trust will address in future years by working with
Commissioners and service users
✓
Improved descriptions of incidents; SUIs; Never Events; and Infection Types. Commentary regarding
action taken as a result of incidents.
✓
Request for further information regarding the traffic light for Incidents reported to the National
Patient Safety Agency
✓
✓
Request for further information regarding same sex accommodation in the ECT suite
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Working to improve the health and wellbeing of our local communities
PART 3 – REVIEW OF QUALITY PERFORMANCE FOR 2009/10
(LOOKING BACK)
This section of the Quality Account reviews performance against a number of key areas as selected by key
stakeholders. The information is presented under the three main headings of: Patient Safety, Clinical Effectiveness
and Patient Experience. Each section describes the area being reviewed; the metric used to measure performance
including the unique reference code and performance specific to acute inpatient services for Mental Health and
Learning Disabilities, i.e. the areas we are required to include in our Quality Account for 2009/10.
3.1 PATIENT SAFETY
A
Area of Performance:
Metric (Method of
Calculating Performance):
Performance specific to
the services covered by
this Quality Account:
Environments & Cleanliness
Trust Metric: GQ.10 Environments / cleanliness as assessed by the Environment
Action Teams (PEAT)
We are very proud of our record for cleanliness and in 2009/10
we received the following ratings:
Site Name
Environment
Score
Privacy &
Dignity Score
Learning Disabilities Unit Hilton Road
Good
Excellent
Excellent
Excellent
Harplands Hospital
PEAT (Patient Environment Action Teams) is an annual assessment of inpatient healthcare facilities in England
with more than ten beds and is self-assessed, with validation visits to a small number of sites. In 2009, 1,265 sites
from 321 trusts took part in the PEAT assessment. The inspection team assess each site on three elements - the
environment, food, privacy and dignity. They inspect standards across a range of service user services including
food, cleanliness, infection control, and service user environment (bathroom areas, decor, lighting, floors and
service user access). The annual PEAT audit is undertaken by a team made up of Modern Matrons, the Support
Services Manager managing the area audited, Estates Operational Manager, Head of Support Services, Infection
Control nurse and representatives from North Staffs Users and LINks (Local Involvement Network) who represent
the general public.
Bi
Area of Performance:
Metric (Method of
Calculating Performance):
Performance specific to
the services covered by
this Quality Account:
Incidents (Clinical and Non-clinical)
Trust Metric: QIGQ.14 Incidents
General Incidents
1786
Serious
72
Major
6
Fatal
4
Total
1868
The traffic light is shown as amber due to a backlog in reporting of incidents towards the end of the 2009/10
year and whilst progress has been made to address the backlog, this has impacted on our performance rating as
reported to local commissioners. The total numbers of incidents for the services covered by this Quality Account
for 2009/10 is shown in the table above and in the following charts. The charts show the numbers of incidents
reported in the specified acute areas and the number of those incidents that were classified as either serious,
major or fatal.
22
Quality Account 2009/10
We proactively support the recording of incidents and ensure that they are investigated, monitored and reported
both to Committees of the Board and across the Trust as a whole. Incidents are analysed to understand the route
cause and key trends are analysed and disseminated across the Trust to ensure that we are able to learn the
lessons for the future.
Bii
Area of
Performance:
Metric (Method
of Calculating
Performance):
Performance specific
to the services covered
by this Quality Account:
Total incidents relating the services covered by this Quality Account by area
Incidents by type Serious, major and fatal by area
Incidents Reported to the National Patient Safety Agency (NPSA)
Trust Metric: QIGQ.17 Number of Incidents Reported to the National Patient Safety
Agency
There were 234 NPSA incidents reported during 2009/10.
It is important to note that this includes all acute inpatient settings but
also includes the community element of the resource centres. The total
excluding resource centres fully is 173.
Trusts are required to report certain incidents to the National Patient Safety Agency (NPSA). The NPSA describes
these incidents as Patient Safety Incidents which are any unintended or unexpected incidents which could have,
or did, lead to harm for one or more patient receiving NHS funded healthcare. The Trust reported all incidents
meeting this definition to the NPSA within the required timescales. However, the Trust is planning a number of
improvements in 2010/11 both in relation to improved reporting to the Commissioners and in relation to internal
reporting and learning from incidents and as such has assessed overall performance in 2009/10 by an amber traffic
light. The following data shows the number of incidents and their classification which were reported to NPSA
by the Trust in 2009/10 for the services covered by this Quality Account. The first table and chart shows the total
number of incidents reported during 2009/2010 (Note: Results shown are only available from July onwards)
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Working to improve the health and wellbeing of our local communities
Number of incidents reported by area and type:
50
45
44
40
44
41
35
30
25
20
25
24
22
15
10
5
9
11
0
4
4
6
Violent Incident or Self Injury
Tissue Viability
Sudden or Unexpected Death
Slips Trips and Falls
Other
Missing Person
Injury - Cause Unknown
Inappropriate Placement
Healthcare Associated Infection
Food and Nutrition
Drug Error or Issues
Clinical Incident
Accident
Absent Without Leave
118
1
3
75
3
1
1
1
1
1
9
10
9
1
0
Biii
Area of
Performance:
20
40
60
80
100
120
140
‘Never Events’
Trust Metric: QIGQ.15 Never Events
Metric (Method
of Calculating
Performance):
Performance specific
to the services covered
by this Quality Account:
C
Area of
Performance:
Metric (Method
of Calculating
Performance):
Performance specific
to the services covered
by this Quality Account:
A Never Event is a serious, largely preventable, patient safety incident that should
not occur if the available preventative measures have been implemented. An
example would be an inpatient suicide using curtain or shower rails.
There have been no ‘never events’ in the Trust
Serious Untoward Incidents (SUIs) (Clinical and Non-clinical)
Trust Metric: QIGQ.14 Serious Untoward Incidents
During 2009/10 there have been 4 serious untoward incidents in acute
inpatient areas:
Ward 1, Harplands Hospital
1
Ward 2, Harplands Hospital
2
Ward 3, Harplands Hospital
Area of
Performance:
Metric (Method
of Calculating
Performance):
Di
Performance specific
to the services covered
by this Quality Account:
24
1
Healthcare Associated Infection (HCAI): MRSA
Trust Metric: KPI 3.7 MRSA Bacteraemia (numbers)
Nil
We are delighted to report that we have had no Meticillin Resistant
Staphylococcus Aureus (MRSA) bloodstream infections since 2007 which is,
in part, due to the introduction of the MRSA screening programme for all
admissions to hospital inpatient wards and units
Quality Account 2009/10
Dii
Area of
Performance:
Metric (Method
of Calculating
Performance):
Performance specific
to the services covered
by this Quality Account:
Healthcare Associated Infection (HCAI): MRSA Screening
Trust Metric: KPI 3.8 MRSA Screening (%). Elective and emergency hospital
inpatient beds
91% for 2009/10. Assessed as amber as we targeted 100%
We are very proud to achieve a high level of screening throughout
2009/10 with 100% being achieved on many occasions during the second
half of the year.
The Department of Health required the Trust to undertake MRSA screening of elective admissions from 1st April
2009. The percentages are based on admissions reported via clinical information matched against laboratory
reports.
Area of
Performance:
Metric (Method
of Calculating
Performance):
Diii
Performance specific
to the services covered
by this Quality Account:
Healthcare Associated Infection (HCAI): Clostridium Difficile
Trust Metric: KPI 3.9 Clostridium Difficile (numbers)
4 cases for services covered by this Quality Account and 6 cases for the
Trust as a whole.
The Trust’s target was in excess of the Department of Health’s target and
the Trust is pleased to report that it has achieved this target with a further
reduction of 40% in reported Clostridium difficile (CD) cases compared
to the equivalent period last year. Prudent antimicrobial prescribing and
the prompt identification and isolation of cases will have contributed to
consistent year on year improvements.
Infection control and prevention remains a high priority for us and we have strengthened our systems and
procedures further in 2009/10. Senior management have worked with the infection control team to ensure that
this topic remains a priority for all staff particularly amongst clinicians, nurses, therapists and support services.
We are compliant with all six criteria defined by the national indicator and are registered with the Care Quality
Commission (CQC) in relation to healthcare associated infection which has been a legal requirement since April
2009.
Reported infections are monitored through electronic surveillance, a system which allows changes in trends or
emerging threats to be identified through laboratory reports. This data showed that the Trust has sustained a
consistent year on year improvement in healthcare associated infections.
Clean Your Hands Campaign: The Trust was an early implementer of the National Patient Safety Agency (NPSA)
Clean Your Hands Campaign in 2008 and continues to promote World Health Organisation and NPSA messages.
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Working to improve the health and wellbeing of our local communities
3.2 CLINICAL EFFECTIVENESS
E
Area of
Performance:
Metric (Method
of Calculating
Performance):
Trust Performance:
F
Area of
Performance:
Metric (Method
of Calculating
Performance):
Performance specific
to the services
covered by this
Quality Account:
Achieving National Quality Standards
Trust Metric: KPI 7.2 Registration under the Health & Social Care Act 2008
The Trust was very pleased to be registered without conditions for the
first year of this new national process and further information can be
found in section 2.3.
Mental Health Act Activity
QG.43 Mental Health Act Activity
243 people were assessed under Section 136 of the Mental Health Act. Of
these assessments:
• 30 (12.3%) resulted in formal admission under the Mental Health Act
• 46 (18.9%) people were admitted to hospital informally
• 1 (0.4%) person under the age of 18 was assessed
From the data, it can be seen that the vast majority of people who were
assessed under Section 136 were not admitted to hospital. The totals are
167 not admitted. 68.7%
This data shows the number of assessments carried out under Section 136 of the Mental Health Act (police power
to remove a person to a place of safety). The Harplands Hospital Section 136 Assessment Suite is nominated as the
formal place of safety and all service users are assessed there. This data shows the outcome of the assessments in
terms of admission to hospital and the number of cases where the person was under the age of 18 years.
G
Area of
Performance:
Metric (Method
of Calculating
Performance):
Trust Performance:
Delayed Transfers of Care
KPI 3.4 Delays in transfers of care
Using the same calculation as the Care Quality Commission, the Trust’s
rate for delayed transfers of care is just under 15%.
The rate for the full year is just over 17%.
26
Quality Account 2009/10
The Trust’s target is to ensure that service users are discharged home or to another appropriate care provision as
soon as it is appropriate for this to take place. The Trust is measured against a national target of 7.5% and is not
yet achieving this target. The Trust is working with local commissioners to address delays in the transfers of care
across the area as a whole.
H
Area of
Performance:
Metric (Method
of Calculating
Performance):
Trust Performance:
Staff Satisfaction
KPI 5.2: Staff satisfaction as measured by the annual national staff satisfaction
survey
The survey took place in November 2009. The report of the survey results
published by the Care Qualities Commission (CQC) is based on a random
sample of staff. The response rate for the sample was of 47% compared
to an average response rate of 54%.
The Trust’s results were as follows:
• average or above in 21 areas (16 in 2008); and below average in
19 areas (19 in 2008).
Throughout 2009/10 we reviewed, updated and remodelled the five year workforce strategy to support the
development and retention of a first class workforce, in order to improve the mental health and wellbeing of
the local community and to meet our strategic goals. The workforce strategy is underpinned by a leadership and
Organisational Development (OD) Plan, Education and Workforce plan.
I
Area of
Performance:
Metric (Method
of Calculating
Performance):
Trust Performance:
Implementation of Guidance issued by the National Institute of
Clinical Excellence (NICE)
QIGQ.2 Implementation of national guidelines for interventional procedures
QIGQ.3 Implementation of national clinical guidelines
QIGQ.4 Implementation of national technical appraisals
All of the 42 Interventional Procedures issued were reviewed and found to
be not applicable to the Trust
Of the 13 Clinical Guidelines issued, 8 were reviewed and found to be not
applicable, 1 has been adopted, 1 has been distributed for information
and 3 were being assessed for relevance at year end
All of the 17 Technical Appraisals issued were reviewed and found to be
not applicable to the Trust
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Working to improve the health and wellbeing of our local communities
Ji
Area of
Performance:
Metric (Method
of Calculating
Performance):
Trust Performance:
Jii
Area of
Performance:
Metric (Method
of Calculating
Performance):
Trust Performance:
Productivity Improvement and Pathway Programme (PIPP)
KPI 10.1 Productivity Improvement and Pathway Programme Implementation
This target was one of the Trust’s CQUIN targets for 2009/10
This programme is a Trust level programme and no specific targets were
set for inpatient services. The Trust achieved the targets associated with
this programme.
The Productivity Improvement and Pathways Programme contained a
number of targets relating to four different elements of the programme:
• Directory of Services – A full and accurate listing of all services and
the Trust achieved the target by ensuring that Trust level data was
submitted on time;
• Benchmarking Tool - A way of comparing different services and
the Trust achieved the target by ensuring that Trust level data was
submitted on time;
• Time to Care Diary Exercise - A way of understanding how much
time staff spend on different elements of their daily work. This was
completed with selected community teams and the Trust achieved this
target; and
• Pathways - A way of making sure that new service users are allocated
to a care ‘pathway’ in line with their needs. The target was for 50% of
service users to be allocated to a pathway by September 2009 and 90%
by March 2010. Both targets were exceeded and month by month
progress is shown in the chart below:
Physical Health Checks
KPI 10.2 Physical health checks
This target was one of the Trust’s CQUIN targets for 2009/10
Quarter
Quarter 1 2009/10
Quarter 2 2009/10
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Response Rate
86%
Target for % of
Physical Health
Checks
75%
75%
Outcome for
% of Physical
Health Checks
89% ✓
Quarter 3 2009/10
91%
75%
92% ✓
Quarter 4 2009/10
98%
95%
96% ✓
Quality Account 2009/10
K
Area of
Performance:
Metric (Method
of Calculating
Performance):
Performance specific
to the services
covered by this
Quality Account:
Waiting Times
QI GA.9 18 week waiting time targets
Inpatient waiting times
All of our admissions to acute inpatient wards covered by this Quality
Account are planned or emergency admissions and as such do not have
waiting times.
The Trust does record and report waiting times for outpatient
appointments which show the proportion of people on the waiting list for
a service who have been waiting for their first appointment for treatment
for more than 18 weeks, but this year’s Quality Account relates to adult
acute inpatient services only.
L
Area of
Performance:
Performance specific
to the services
covered by this
Quality Account:
Percentage of suicides in receipt of care compared to similar cluster /
national average
There have been no verdicts of suicide for the services covered by this
Quality Account for 2009/10
3.3 Patient Experience
M
Area of
Performance:
Metric (Method
of Calculating
Performance):
Trust Performance:
Patient Experience
KPI 1.2 Patient experience as measured by the annual National Patient Survey
The most recent results were received in the Summer of 2009 and
the Trust was rated overall as ‘about the same as other Trusts’ but as
‘achieved’ in the 2008/9 Annual Health Check.
Of the 47 questions:
• 5 were better than other Trusts (top 20%)
• 42 were about the same as other Trusts (average range)
• None were in the lowest 20%
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Working to improve the health and wellbeing of our local communities
Questionnaires were posted to a random sample of 288 adults who had used our acute services at the Harplands
Hospital between July and September 2009 and the Trust achieved a 38% response rate. Service users were asked
about various aspects of their experiences and key results and a number of comments from those who completed
the survey are shown below:
Questions relating to
Score out of 10
Introduction to the ward
7.2
How this score compares with
other trusts
‘The hospital was very clean.’
About the ward
7.85
‘I was on an all female ward which I found to be safer for me.’
‘The feeling of being safe and secure was prominent.’
Psychiatrists
7.22
Nurses
7.1
‘Certain Nursing and Healthcare Staff made a positive contribution to my care. Small gestures went a long way
in making me feel like I was cared for.’
Medications
4.59
‘Would like more explanations about side effects of medication.’
‘Would like more choices in the treatment and more say in it.’
Care and treatment
6.67
‘I thought the care was fantastic and thank everyone helping me get better. I was given acupuncture during
my stay and this was excellent.’
Talking Therapies
7.12
Activities
4.06
‘Maybe more activities in the evening on the ward.’
Physical Health Checks
7.66
Rights
5.87
‘Could have had mental health sections explained to me more. Left very un-assured about sections etc.’
Leaving hospital
7.48
Overall
6.29
‘I have stayed at the Harplands Hospital on quite a few occasions over the past 15 months and I have noticed a
big improvement in the way service users are treated. The ward I stayed on was well organised and comments
were taken on board and acted on immediately. I look on it as a safe place to stay in a crisis.’
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Quality Account 2009/10
Area of
Performance:
N
Metric (Method
of Calculating
Performance):
Performance specific
to the services
covered by this
Quality Account:
Complaints
QI 1.7 Complaints, Acknowledgements, Responses and Trends
Number of complaints
17
Number acknowledged within
timescale
100%
Number responded to within
timescale
100%
On 1st April 2009, New Complaints Regulations (The Local Authority Social Services
and National Health Service Complaints (England) Regulations 2009) came into force.
The Regulations contain new timescales for responses and new principles of good
complaint handling which are:•
•
•
•
•
•
Getting it right
Being customer focused
Being open and accountable
Acting fairly and proportionately
Putting things right
Seeking continuous improvement
A 16-page booklet, ‘Listening, Responding and Improving’, was published by the PALS
and Complaints team following the introduction of new complaints regulations, which
came into effect at the beginning of April.
O
Area of
Performance:
Metric (Method
of Calculating
Performance):
Performance specific
to the services
covered by this
Quality Account:
Patient Advice and Liaison Service (PALS) & Compliments
QI 1.8 Numbers and types of contacts via PALS and Compliments
During the course of the year the following contacts, requests and issues were received
and addressed from service users within the services detailed in this Quality Account:
Comments
14
Compliments
5
Liaison/Help
46
Information
10
Onward referral
19
There are no specific timescales attached to the PALS service, however, the ethos
is person-centred and staff liaise closely with service users to agree acceptable
outcomes and timeframes. There is a high degree of satisfaction with the service
indicated by both open and anonymous feed-back.
31
Working to improve the health and wellbeing of our local communities
Throughout the year our PALS and Complaints staff have been working more collaboratively
and now offer a single point of contact for service users and the public who have enquiries,
requests for help or information, concerns and complaints. Issues that people bring to
PALS are wide-ranging and include concerns about access to services, appointments,
choice, support needs, communication problems, and requests for quality improvements
in their healthcare.
Patient information publications
The PALS Manager also supports trust teams in the development of service user and
carer information. During the year, PALS helped to produce 18 new publications,
including the popular ‘We’re here to help’ guide to local mental health services, of
which 12,000 copies were distributed throughout North Staffordshire.
P
Area of
Performance:
Metric (Method
of Calculating
Performance):
Performance specific
to the services
covered by this
Quality Account:
Q
Area of
Performance:
Metric (Method
of Calculating
Performance):
Trust Performance:
Food Provision
GQ.10 Food and nutrition as assessed by the Patient Environment Action Teams
(PEAT)
We are very proud of our excellent record for the food provision and in
2009/10 received a rating of ‘excellent’ in all 8 areas assessed
Site Name
Food Score
Learning Disabilities Unit Hilton Road
Excellent
Harplands Hospital
Excellent
Same Sex Accommodation
QI GQ.20 Shared Bedrooms
QI GQ.21 Shared Bathrooms
QI GQ.22 Overall Compliance
We are proud to confirm that mixed sex accommodation has been virtually
eliminated in our trust.
Every service user has the right to receive high quality care that is safe,
effective and respects their privacy and dignity. We are committed to deliver
care with privacy and dignity of which providing every service user with
gender appropriate accommodation is an integral element, because it helps
to safeguard their privacy and dignity when they are often at their most
vulnerable.
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