Ridgeway Partnership
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2009/2010
Oxfordshire Learning Disability NHS Trust is the legal name of Ridgeway Partnership.
The name Ridgeway Partnership has been adopted during the process of becoming a NHS
Foundation Trust and it will become the legal name when the Trust achieves FT status.
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www.ridgeway.nhs.uk
Quality Accounts 2010
Contents
1.
Statement from the Trust Board
2.
Review of Services
2.1 Social Care
2.2 Specialist Health Care
2.3 Community Teams for People with a Learning
Disability– Oxfordshire and Buckinghamshire
2.4 Research and Innovation
2.5 Participation in Clinical Audit
2.6 CQUIN Framework
3.
Review of Quality Performance 2009/2010
3.1 Service User safety
3.2 Effectiveness
3.3 Service User Experience
4.
Priorities for Improvement 2010/11
4.1 Service User safety
4.2 Effectiveness
4.3 Service User Experience
Annex.
What others say about Ridgeway Partnership Data Quality
Appendix 1. Appendix 2. Active Service Evaluations and Clinical Audit 2009/10
CQC Indicators for Learning Disability Trusts
Appendix 3. Statement from Commissioning PCT
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Quality Accounts 2010
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Quality Accounts 2010
1. Statement from the Trust Board
The Trust Board is pleased to welcome you to the first Quality Account from Oxfordshire Learning Disability NHS Trust,
herein after referred to as “Ridgeway Partnership”. The Board and all staff in the Trust are rightly proud of their efforts to
improve services this year and we are delighted to have the opportunity to present an accurate and detailed account of
the quality of those services.
In the following pages we will review our performance in the domains of Service User Safety, Effectiveness and the Service
User Experience. We will describe the scope of services we provide and later in the document we will outline our Priorities
for Improvement for the coming year. We conclude by giving information on our current ratings by external regulators and
statements from our Commissioners.
Our Quality Account has been prepared and presented in line with guidance from the Department of Health. We are
grateful to the service users, carers, staff and partner organisations involved for their ideas, information and support in the
creation and production of this document. We have consulted with service users, carers, staff and key stakeholders on the
draft Quality Account and their comments have been incorporated into this final document. An easy read version, as well
as other formats of this document will be available following publication. The photograph opposite was taken at one of
our consultation events.
During the review of the quality of our services we have taken account of reports received at Trust Board.
These include:
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Monthly Performance Reports
Annual PEAT statements
Internal audit reports
Staff and service user surveys
Quality Strategy review
Single Equality Scheme action plan annual report
Information Governance report
Board Assurance Framework
Strategic Risk Register
Statement of Internal Control
Mental Health Act Commissioners Report
We work hard to put in place necessary actions to ensure we meet the standards required of an NHS organisation. We were
inspected by the Healthcare Commission in 2008/9 and our declaration was revised following the inspection. An action
plan to address areas of improvement was established and implemented. Trust Board are assured that service users are not
placed at risk in any areas. We know that our reporting structures and risk management processes are strong however our
Priorities for Improvement for 2010/11 aim to make them even stronger.
We hope that this Quality Account is useful to you. If you would like further information
or to discuss any aspect presented here, please do not hesitate to contact us by email at
communications@ridgeway.nhs.uk or telephone us on 01865 228040.
John Morgan
Chief Executive
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Quality Accounts 2010
2. Review of Services
In reviewing our services we have taken account of all
of our internal systems for monitoring service delivery
and compliance as well as external requirements to
demonstrate we are meeting the standards required of an
NHS Trust.
We aim to provide high quality, safe and effective services.
We ensure we meet quality standards through a robust
system of audit and review, involving people we support,
their families and external partners as appropriate. We
publish our reports, results and action plans via our website,
and our results are featured on national and regional
websites as appropriate. Results are often reflected in
national reports and we are benchmarked against our
competitors and partners.
The Ridgeway Partnership is an experienced specialist NHS
Trust providing a range of health care and social support
services to people who have a learning disability. The
Trust supports over 3,300 people with the most complex
health care and social support needs across Oxfordshire,
Buckinghamshire, Swindon and Wiltshire.
The Trust is divided into four service divisions which are the
Specialist Health Care, Social Care and Community Teams
for People with a Learning Disability (Oxfordshire
and Buckinghamshire).
2.1 Social Care
The Trust supports over 200 people to live in their own
homes as tenants across Oxfordshire and 9 service users
living in residential care homes. Short term breaks are
provided for people with learning disability in five facilities
in Oxfordshire and Swindon, supporting over 200 people
across these two areas. In addition the Trust’s ‘Vision’ service
provides one-to-one support for people who mainly live
at home with their family who have more complex needs
and/or challenging behaviour. This service supports over 77
people across Oxfordshire. There is also the Albion Centre, an
art and craft centre based in Chipping Norton in Oxfordshire.
This year all of our current Oxfordshire Social Care services
have been subject to tender and we have been successful
in being placed on all six contract frameworks to provide
services in Oxfordshire and the County Council Framework
for Buckinghamshire. We have also been successful for the
first time in winning business to provide social care
in Dorset.
This year we have undertaken a Reviewing our Work (ROW)
project, aiming to improve our efficiency whilst ensuring
support remains person centred and we are working
towards the REACH2 standards.
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2.2 Specialist Health Care
The Trust provides in-patient services in Oxfordshire,
Buckinghamshire, Swindon and Wiltshire which specialise
in assessing and treating people who have learning
disability and challenging behaviour and/or mental health
related problems.
In Oxfordshire the Trust provides the following services;
• A short-term assessment and treatment service for 6
people (plus 1 emergency bed) that have a learning
disability with challenging behaviour and/or mental
health needs.
• An in-patient service for up to 7 people, providing
medium-term rehabilitation.
• A medium secure facility for up to 10 people with a
learning disability and forensic history from Oxfordshire,
Buckinghamshire and Berkshire.
• A Step Down service for up to 4 people which offers
accommodation for service users who have previously
been in secure settings. This service is planned to
expand to 6 beds in 2010/11.
• The Oxfordshire Learning Disability Child and Adolescent
Team which is a community based service providing
support for up to 90 young people up to their 18th
birthday. The service is specifically for young people who
have mental health problems or difficulties with their
behaviour and a moderate to severe learning disability.
In Swindon and Wiltshire the Trust provides the following services;
• A short-term assessment and treatment service for 6
people (plus 1 emergency bed) who have a learning
disability with challenging behaviour and/or mental
health needs
• A medium-term service for up to 6 people in need
of rehabilitation.
• A long term service for 4 people who have learning
disability with challenging behaviour and/or mental
health needs. This service transferred to a social care
provider on 1st March 2010 in order to comply with
national policy to close campus accommodation
by 2010.
• A service for 6 older people with learning disability
with additional physical disabilities who require long
term health care support. This service also transferred
to a social care provider on 1st March 2010 in order
to comply with national policy to close campus
accommodation by 2010.
NB! A campus is
NHS provided long-term care in conjunction with NHS
ownership/management of housing (residents do not
have an independent landlord and housing rights),
commissioned by the NHS, and may include
people who have been in assessment and treatment
services more than one year, who are not compulsorily
detained or undergoing a recognised evidence based
treatment programme
Quality Accounts 2010
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Quality Accounts 2010
In Buckinghamshire the Trust provides the following services;
• A short-term assessment and treatment service for 6
people (plus1 emergency bed) who have a learning
disability with challenging behaviour and/or mental
health needs.
• A long term facility for up to 9 people who have
severe learning disability and challenging behaviour
and/or mental health needs is planned to transfer
to a social care provider in 2010/11. As the Trust is
now an approved provider of social care services in
Buckinghamshire we could be appointed as the provider
for the people currently in these services.
• Specialist Learning Disability Intensive Intervention
Team which is part of the integrated CAMHS service
within Buckinghamshire in partnership with Oxfordshire
and Buckinghamshire Mental Health Foundation Trust.
This multi-disciplinary team holds a small caseload of
the most complex cases, offering rapid assessment
and tailor-made home or placement support packages
to support children, young people families and other
agencies, when behaviour escalates and placement or
relationships become vulnerable.
2.3 Community Teams for people with a Learning
Disability - Oxfordshire and Buckinghamshire
Assessment of needs and provision of community specialist
health care is provided by the Trust through multiprofessional community teams based in Oxfordshire and
Buckinghamshire (excluding Milton Keynes). There are three
teams based in Oxfordshire and three in Buckinghamshire.
In addition an Oxfordshire Assertive Outreach Team
provides long term community health care support to
people who have a learning disability with enduring mental
health needs who have found it difficult to engage with
other services. This service supports 17 people.
We measure the quality of all our services by responding to
reports and feedback from:
• Quality Monitoring Reviews undertaken across all
services by our Commissioners
• Quality visits to all our social care services quarterly by
staff not working within those areas. Quality visits focus
on specific aspects of service delivery and service user
experience.
• Looking@Us reviews and reports on our services and
the experience of those using them, undertaken by
people with a learning disability. These enable us to
respond to changes in support as identified by the real
experts - the people who we support
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In addition the Ridgeway Partnerships Quality Strategy
brings together the following:
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Internal audit providing quarterly reports,
recommendations and advice on Risk Management
and Quality Standards.
Risk Assessments and Risk Management Strategies
Statutory Training undertaken by all staff
Supervision of all staff
Personal Development Plans
Compliments and Complaints
Equality Scheme Action Plans
Workforce reports
Clinical Audits and Service Evaluations
We are monitored as an organisation on our compliance
against national standards of provision which include:
• Care Quality Commission standards, inspections,
reviews, and recommendations across all our services
• National Patient Safety Agency Standards which
includes reviewing accident/incident reporting
• National Health Service Litigation Authority
Inspection reports by the Strategic Health Authority
for Serious Untoward Incidents
• Benchmarking Person Centred Plans (PCP’s) and
Health Action Plans (HAP’s)
Our current CQC ratings and PEAT scores are shown
in theAnnex.
The Ridgeway Partnership is committed to becoming the
leading specialist in the South of England for the provision
of high quality, innovative health and social care services for
people with complex support needs and long term health
conditions. In order to achieve this, it is essential that the
planning, delivery and monitoring of services is based on
best practice and is informed by the best evidence that
is available. To retain its strong reputation as a specialist
provider, the Trust must also innovate and respond
positively to an ever-changing context in health and social
care. This will include valuing knowledge and drawing on
the know-how of all those who work for the Trust as well as
those who use its services.
Quality Accounts 2010
2.4 Research and Innovation
2.5 Participation in Clinical Audits
Ridgeway Partnership has an active Research and
Development programme with participation in projects
from across all areas. For the purposes of the Quality
Account we have demonstrated the number of participants
recruited in the previous year to clinical research.
This is shown in the table below
The Trust was eligible to participate in 1 national audit
during 2009/10. In addition we undertake a programme of
local audit and service evaluation on clinical performance
which is reported to Trust Board. Local research, audit and
evaluation reflects some of the priorities identified within
the Healthcare Quality Improvement Partnership national
audit programme.
Ridgeway Partnership was accepted as a pilot site for using
Experienced Based Design (EBD) within NHS Services. EBD
is an innovative, fully inclusive methodology designed to
bring about significant service improvements at little or no
additional cost. This regional pilot was led by the Institute
of Innovation and Improvement in conjunction with NHS
South Central. Ridgeway Partnership undertook a project
to review the experiences of annual reviews, involving 7
service users with varying levels of learning disabilities,
Care Managers, care staff and family members. As a result
of the project significant improvements have been made
in how annual reviews are planned and facilitated, leading
to a more positive and meaningful engagement of service
users. A second project is being undertaken exploring the
experiences of CPA review meetings.
The Ridgeway Partnership is also one of four national
“Mansell” demonstration pilot sites, exploring issues relating
to the management of behaviours that are traditionally
considered to be challenging. Specialist Health Services
and Community Teams in Oxfordshire are working in
partnership with Oxfordshire County Council
Details of the audits Ridgeway Partnership have undertaken
during 2009/10 are attached to the Appendix.
2.6 Using the Commissioning for Quality and
Innovation Payment Framework (CQUIN)
A proportion of the Ridgeway Partnership’s contracted
income from commissioners of specialist health services for
2009/10 was conditional on achieving quality improvement
and innovation goals agreed between the Trust and its
commissioners through the CQUIN payment framework.
This is equivalent to an additional 0.5% on top of agreed
contract values. The Trust received the full 0.5% available
from all commissioners. Further details of the agreed goals
and outcome can be obtained on written request from
Andrew Hall, Director of Finance and Estates.
Research Project recruiting participants who have a
learning disability
No. of Participants
eligible for the study
No. of Participants
agreeing to take part
A follow-up of discharges from two intellectual disability medium
secure units: an investigation of outcomes.
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Enabling people with learning disabilities to engage in cognitive
behaviour therapy
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A qualitative exploration of factors that promote and facilitate
satisfying intimate relationships between people with a learning
disability
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The psychometric testing of psychological outcome measures
for people with a learning disability
(waiting on final data)
Research Project recruiting participants who are staff
No. of Participants
eligible for the study
No. of Participants
agreeing to take part
Factors that influence learning disability nurses using e-learning in
the Continuing Professional Development
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(6 were selected to
take part)
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Enabling people with learning disabilities to engage in cognitive
behaviour therapy
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1
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Quality Accounts 2010
3. Review of Quality Performance 2009/10 In January 2009 the Trust Board approved a five year
Ridgeway Partnership Quality and Service Governance
Strategy. This document provides a framework for the
continuous improvement of quality throughout the Trust. It
brought together and reflected the ideas of a range of staff,
service users and carers who were asked for their views on
what mattered most to them about Ridgeway Partnership’s
services. Information was also taken from the annual staff
survey and the surveys carried out with service users in our
in-patient facilities. Whereas it is recognised by the Board
that stakeholder engagement in setting priorities for the
strategy was limited, service users and staff were involved
in developing other priorities which were monitored
by the Board throughout the year. This review of quality
performance focuses on progress and key developments in
relation to selected priorities identified within the Quality
and Service Governance Strategy which is available upon
request from John Turnbull, Director of Quality
and Information.
Quality Indicators for the Ridgeway Partnership
3.1 Service User Safety
3.1.1 Analysis of service user safety incidents and
near misses
Trust Board monitors safety events in the following areas;
• Medication errors
• Violence against staff
• Serious Untoward Incidents
• Accidents and incidents
• Infection control
Reduction in medication errors
There is a strong belief in the Trust amongst managers
and staff that all medication errors are avoidable events.
Therefore, in response to an adverse trend in reported
medication errors, this was selected as a priority for
improvement. Throughout 2009/10 managers in the
services have been engaged in reducing medication errors.
Services where medication errors were reported more
frequently were identified and staff in those areas were
retrained in safe and effective administration of medication.
Medication errors are routinely monitored as part of
the Trust Board’s monthly performance report. The Risk
Management and Service Governance Committee (RMSGC)
monitors all accidents and incidents in more detail and
is able to provide Trust Board with an analysis of types,
location and frequency of medication errors. The trend
for medication errors for 2009/10 is shown in the
following graph.
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Medication Errors
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12
10
Trend
8
6
4
2
0
Apr
May June July Aug Sep Oct
Nov Dec
Jan
Feb
Date
Care has been taken to ensure that the Trust maintains
its good reporting rate of accidents and incidents. Staff
continue to be supported in being open and honest in
their daily practice which includes feeling able to continue
to report medication errors.
Violence against Staff
The Trust is committed to the NHS’ zero tolerance campaign
in relation to violence towards staff. However, all incidents
of violence against staff in 2009/10 were classed as having a
clinical basis. Nevertheless, the Trust Board identified a need
to reduce incidents and set a target of an annual reduction
in violence against staff by 10% on the previous year’s
average. Results for 2009/10 show that the average for this
year is 22 per month, compared to a monthly average on
31.5 for 2008/09, which is a 33% reduction.
Serious Untoward Incidents / Accidents and Incidents
The Trust’s overall figures for service user safety incidents
show an average of 132.3 incidents per month. In terms
of severity, over 90% were rated as green (low severity)
or yellow (low to medium severity). Two incidents per
month on average were rated red. The Trust uses National
Patient Safety statistics for Trusts comparable to Ridgeway
Partnership to set targets for the volume of incidents.
The Trust wishes to remain within the second quartile of
statistics for comparable Trusts. The volume of incidents this
year is higher than the Trust’s target of 126 per month. The
increase in volume is thought to be accounted for by the
increase in contracted activity across the Trust. There were
four Serious Untoward Incidents reported in 2009/10.
Infection Control
In 2008/09 the Trust was inspected by the Healthcare
Commission and the Trust’s Standards for Better Health
declaration was modified from compliance to insufficient
assurance in standard C4a relating to the Infection
Control Hygiene Code. This area was also chosen because
all Trusts were required to register with the new Care
Quality Commission in 2009/10 in the specific standard of
Infection Control. The Trust wanted to ensure that it could
be registered without conditions. Throughout 2009/10
managers and staff in the Specialist Health Services have
brought about improvements in the cleanliness of their
facilities in line with National Patient Safety
Agency standards.
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Quality Accounts 2010
The Trust has demonstrated an improvement in National
Scores for Cleanliness (NSC) such that all relevant facilities in
the Trust showed an average of 93.5%, which is 5.5% higher
than the threshold for ‘Good’. This performance is confirmed
by PEAT scores which were shown in the Annex.
NSC scores from managers are collated and presented to
the Trust Board as part of it’s monthly performance report.
Scores for the previous year are shown in the graph below
National Scores for Cleanliness (NSC)
Percentage
100%
80%
60%
40%
20%
0%
Feb Mar Apr May June July Aug Sep Oct Nov Dec Jan Feb
Date
(A score of 87% and above attracts a ‘Good’ rating)
The Trust was also registered in the Infection Control
standard without conditions in 2009/10.
3.1.2 Safety of clinical practice
Aspects of clinical practice that were subject to audit and
review in line with national expectations this year included;
Medical devices and equipment
The Trust has an indicator to ensure that there is a
comprehensive system for the management of medical
devices and equipment. An audit of practice in relation
to the Healthcare Commission’s core standard C4b on
Medical Devices and Equipment in 2008/09 resulted in
the Trust Board deciding to declare insufficient assurance.
In response to this the Trust developed and published a
new Medical Devices and Equipment Policy in 2009/10.
The Trust initiated its first asset register for medical devices
and equipment. This has proven to be a more complex
and extensive project than first thought but significant
progress has been made. Therefore, the Trust Board decided
that further work will be necessary in 2010/11 before the
Trust can declare compliance with the new Care Quality
Commission Registration Regulations. Further work
included improving the quality of information regarding
the training that staff have undertaken to use the medical
devices and equipment, and involving service users in
feedback about the equipment they use.
3.1.3 Implementation of NICE Guidance in relation to
(i) Dementia
What we did:
• A local evaluation of current practice across the
Ridgeway Partnership was undertaken, measuring
current practice against the recommendations of the
NICE Guidelines 42 (2006); Dementia : supporting people
with Dementia and their carers in Health and Social Care.
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What we found:
there were some inconsistencies in how the
guidelines were being implemented across
Oxfordshire, Buckinghamshire and Wiltshire
• each area has their strengths and limitations
• common areas of good practice related specifically
to Diagnosis and Assessment
What has changed in 2009/2010?
• clear actions plans have been developed for each
county in response to the evaluation
• Development of A Dementia Care Pathway within
Buckinghamshire which is currently being audited
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(ii)Violence and Aggression
What we did:
• An audit was undertaken to measure current practice in
relation to the standards of the physical environments
in all Ridgeway Partnership In-Patient Services against
standards recommended in NICE Guidance; Violence:
The Short Term Management of disturbed / violent
behaviour in in-patient psychiatric settings and
emergency departments
What we found:
• In relation to the physical environment, single sex
facilities, opportunities to engage in exercise and
recreational activities, recommended standards were
met in all service areas.
• Some policies and Good Practice Guidance needed to
be updated to make sure they are in line with National
Good Practice (NICE)
What has changed in 2009/2010?
• Individual actions plans have been agreed for each
service area to address areas in need of improvement.
Progress on action plans will be reported to the
Research and Development Committee.
• The Trust policy on levels of observations has been
reviewed and amended in line with National Standards.
This has been disseminated and implemented in all
practice areas. Timescales for amending other polices
and Guidance are in place.
• Intermediate Life Support Training will now be
integrated into existing Physical Interventions Training,
rather than running as a separate course.
(iii) Obsessive Compulsive Disorder, Bi-Polar
Disorder and Anxiety
What we did:
• A service evaluation of prescribing patterns in all InPatient Services (9 units) to identify
(i) How many service users were diagnosed with a specific
mental health disorder / challenging behaviour.
(ii) If service users were prescribed medication that was
licensed for treating their mental health disorder/
challenging behaviour
(iii)if the doses prescribed were within safe BNF limits
What we found:
• The number of service users diagnosed with the
conditions identified above was very low
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Quality Accounts 2010
•
There was clear evidence to demonstrate that practice
in each of these areas was in line with national
recommendations in most cases.
• In all but one case, medication was prescribed within
BNF Limits. The reasons for prescribing outside limits
were provided.
• There is a need for Trust Guidelines on the Physical
Monitoring of Service users prescribed medication
• There is a need for good practice guidance re:
prescribing off license.
• The evaluation highlighted that it was common for
anti-psychotic medication to be prescribed for the
management of challenging behaviour. Although there
may be evidence to suggest that this is safe practice
more specific guidance is required.
What has happened in 2009/2010
• A Drugs and Therapeutic Committee has been
established with Terms of Reference. This group will be
responsible for developing the necessary Good Practice
Guidelines and monitoring safety issues
(iv) Post Traumatic Stress Disorder.
What we did:
• Reviewed NICE Guidance 26 Post Traumatic Stress: The
management of PTSD in adults and children in primary
and secondary care
• The evaluation of Prescribing Patterns referred to above
highlighted that no service users were diagnosed with
PTSD.
What has changed in 2009 / 2010
Development of local Good Practice Guidance on picking
up the signs and symptoms of PTSD in both staff and
service users.
3.2 Effectiveness
3.2.1 Quality of care and support
Monthly monitoring shows that 100% of eligible service
users have a person centred plan that details their support
needs and choices and preferences for how they wish to be
cared for and supported.
In 2009/10 an audit and service evaluation of the
implementation of the Care Programme Approach (CPA)
was undertaken. The results showed that CPA is embedded
as part of Trust practice although there are areas for
improvement. In particular there is a need to improve
• the accessibility of paperwork
• consistency of practice across the Trust.
A CPA project manager was appointed. Together with the
CPA Project Group, the following changes have been made
• the CPA Policy has been updated making sure it is line with new national guidance.
• Clearer guidance has been written, explaining how
CPA works and who is responsible for doing what. This
includes information on how to make sure service users
are included in the process where ever possible.
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•
All CPA paperwork has been simplified making clearer
links between assessments, risk, care plans and relapse
prevention. The revised paperwork will be in place from
1st April 2010.
Monthly monitoring also reveals that 100% of those eligible
have Health Action Plans. An audit of practice in this
area in 2009 revealed that Health Action Planning had
been introduced to the Trust successfully and many basic
components of the process were embedded in the Trust.
However, there was a need to ensure that Health Action
Plans were more clearly linked to other planning systems
such as Person Centred Planning and service development.
3.2.2 Delayed transfers of Care
Where service users have been admitted to In-patient
Services, the Ridgeway Partnership works closely with
primary care organisations and social services to plan the
transfer of their care back to the community as soon as
it is safe to do so. This ensures that service users receive
the right care and support in the right place at the right
time. The 2009/10 NHS Operating Framework emphasises
that delays in the transfer of care must be maintained at a
minimal level and are, therefore carefully monitored.
The average delayed transfer of care attributable to the
health service for the Ridgeway Partnership in 2009 /10 was
0.29%. This falls within the National Target Indicator of 8%
and therefore meets with CQC compliance.
3.2.3 Meeting the Trust’s responsibility to promote
equality
We have a clear commitment to providing equal access to
the information and services we provide and working to
ensure that our services are equitable and responsive to
the diverse needs of people with a learning disability living
within our geographical areas. We are also committed,
wherever practicable, to building a workforce which is
valued and whose diversity reflects the communities
it serves. The Director of Quality and Information is the
board level sponsor of Equality and Diversity and there
is a dedicated Equality and Diversity lead working within
the trust. Our commitment is outlined in our Equal
Opportunities and Diversity Policy, our Disability Policy and
our Dignity at Work Policy. Workforce statistics are published
on the website.
We have had a Single Equality Scheme (SES) in place since
March 2009. The SES is a public commitment of how
we plan to meet the duties placed upon us by equality
legislation and supports us in the implementation of
our Strategic Objectives and the delivery of our Vision
Statement. An important element of the SES is the Action
Plan which sets out the specific areas in which we ensure
equal opportunities are in place for everyone. The Action
Plan is reviewed and updated quarterly by the Trust Board
to ensure equality underpins everything that we do.
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Quality Accounts 2010
The Action Plan is divided into distinct areas covering
service provision, employment and partnership working.
3.3.1 Enhance the service user experience by
respecting their privacy and dignity.
All of our staff receive training on Equality and Diversity
and the Agenda for Change terms and conditions require
NHS employees to work within the Knowledge and Skills
Framework, a core principle of which is Equality and
Diversity. We also offer staff additional training in Cultural
Competency. Senior managers and members of the
Trust board recently took part in an Equality and Diversity
workshop to provide them with training especially targeted
to their roles.
Develop and disseminate a policy on Privacy and
Dignity for the Trust.
In 2008/09 the Trust was inspected by the Healthcare
Commission and the Trust’s Standards for Better Health
declaration was modified from compliance to insufficient
assurance in standard C20b relating to Privacy and Dignity.
In 2009 the Trust published it first policy on privacy and
dignity. The Policy brought together for the first time a
comprehensive set of approaches and actions so that staff
could understand their roles in relation to promoting the
privacy and dignity of people with learning disabilities. It
also clarified for anyone using the Trust’s services or their
relatives exactly what they should expect from staff.
3.3 Service User Experience
“What makes me feel good is knowing that
staff are always there for me. If something is
worrying me or if I’m confused it makes me
feel safe”
Ongoing monitoring of the policy is being carried out by
comparison of practice against the 7 dignity tests which
were published as part of the document. Information on
the outcome of this will only be known in July 2010 when
the policy is reviewed on the anniversary of its publication.
In addition the Trust monitors how the physical
environment of services promotes the privacy and
dignity of service users through the National Patient
Safety Agency’s annual Patient Environment Assessment
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Quality Accounts 2010
Team (PEAT) scores. In the 2009 assessment the Trust was
assessed as follows;
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•
•
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2 areas were rated excellent
4 areas were rated as excellent to good
2 areas were rated as good
1 area was rated as good to acceptable
2010 results are shown in the Annex and reflect an
improvement in the scores
Eliminate mixed sex accommodation.
In 2008/09 the Trust was inspected by the Healthcare
Commission and the Trust’s Standards for Better Health
declaration was modified from compliance to insufficient
assurance in standard C20b relating to Privacy and Dignity.
The Trust was requested to make sure that signs were in
place to distinguish between male and female toilets and
some bathing facilities.
The Trust was successful in making a bid to the Department
of Health’s fund to modernise aspects of the NHS’ estate to
eliminate mixed sex accommodation. The project focused
on upgrading bathing and toilet facilities in John Sharich
House on the Slade site in Oxfordshire.
The project has been subject to regular monitoring by the
Strategic Health Authority and results are communicated
to Trust Board. A summative assessment in January 2010 is
shown in the box below and an Action Plan has
been implemented to address recommendations from
the assessment.
• The review highlighted clear evidence of activities
in most areas and how far the Trust has come in the
journey to delivering same sex accommodation.
• All schemes from the Challenge Funds have been
completed and good progress has been made by the
provision of en-suite facilities in one unit.
• A walk about of John Sharich House, led by one of the
clients, clearly showed that the client group are well
cared for and proud of their facilities in the unit and
that they have good relationships with the staff.
• Detailed personal care plans demonstrated
comprehensive consideration of individual client
needs and wishes.
• Service users can choose to have a same-sex key
worker due to the good management of same sex
staff in all units.
• Regular service user experience surveys are
undertaken to ensure the organisation provides the
necessary change in service need.
3.3.2 Analysis of complaints received by the Trust
in 2009/10
Throughout 2009/10 there have been 24 complaints, the
majority of which have involved a number of complex
issues. Of these, 20 complaints were responded to within
agreed timescales and 4 remain open.
Our policy on complaints is not to assign blame or to
act defensively: rather, we seek to learn from this type of
feedback of our services. It can generally be said that in the
majority of cases, further communication and discussion
with the complainant resolves issues satisfactorily.
For example,
“ A father contacted the complaints department very
unhappy. His son was supported by in-patient services,
and a home visit had been arranged. It had been agreed
that staff would support and transport the service user to a
service station half way between Oxford and Dad’s home. There were a series of events that resulted in the service
user arriving two and a half hours late, and dad receiving a
parking fine. Dad questioned the suitability and training of
staff, and wider internal communications.
An investigation took place. The investigation found that
many factors had contributed to the incident, particularly
around communication. As a result of this complaint, the
role of shift co-ordinator was removed, and the Nurse in
Charge became responsible and accountable for all shift
activity. A protocol was also developed as guidance for
staff supporting service users on long journeys, and a
synopsis of what went wrong was shared with the team
to ensure that lessons were learned. The father concerned
verbally expressed his satisfaction with the outcome of
the complaint”
Additional areas of learning this year have included:-
•
•
•
Better contact between agencies and the sharing of
issues when they arise – more conducive multi-agency
approach
Development in report writing and organisational skills
for staff
Practice changed regarding liaising with parents for
tenant vacancies
As well as collecting information around complaints the
Trust is also interested in recording compliments. Staff
genuinely appreciate it when service users or carers
go out of their way to thank them for their efforts and really
value these words of kindness.
South Central Strategic Health Authority January 2010
15
Quality Accounts 2010
4. Priorities for Improvement 2010/2011
These Priorities for Improvement have been established following consultation with Trust Board, staff and carers. They are
reflected in the Corporate Business Plan for 2010/11 and were agreed by Trust Board in March 2010. Consultation with
service users took place in May 2010 prior to publication of the Quality Account. Quality Indicators for the Priorities are
being developed with Service Line Mangers and will form part of further consultation with service users.
4.1 Service User Safety
Priority: 1
Assess service user care plans and support plans for risk according to the Trust Risk Management
Policy, using the risk management assessment tools identified within the Risk Management Pack.
Rationale
NHSLA and CQC Registration require the Trust to demonstrate how it ensures that the services
provided are safe and effective for people with a learning disability.
Measure
• An annual audit of the quality
of Person Centred Care Plans in
relationship risk using the Trusts
benchmarking tool is undertaken
• Quality visits annually focus
on reviewing service users risk
assessments
• Personal Development Plans
identify additional learning and
development staff need to assess
for risk.
4.2 Effectiveness
Priority: 2
Rationale
Reporting
• Trust Board reports
• Annual reports
• Reports to RMSGC
Discharge all Service users from in-patient services with a Care Plan which is implemented
according to the criteria within the CQC indicators for Learning Disability Trusts: Care Plans and
Delayed Transfers of Care. (Appendix 2)
CQC Registration requirement to ensure Care Plans meet agreed minimum requirements and
national thresholds for Delayed Transfers of Care.
The Trust’s new CPA policy and process which has been developed in response to Refocusing CPA,
DoH 2009, requires each service user to have care plans and relapse prevention strategies which
are responsive to individual need
Measure
• Service user attendance and
participation at CPA meetings
• Annual CPA Policy audit
undertaken and reported to
RMSGC.
• Readmission rates
• Service User satisfaction survey
• Quality visits
16
Monitoring
• Accident Incident Reports
highlight areas of activity related
to risk – reports received monthly
at Risk Management and Service
Governance Committee (RMSGC)
identify any areas of concern and
action plans are developed to
address these.
• Service Line Business Plans and
Performance review meetings
identify each Service Line’s
performance in implementing
the process for assessing care
plans and support plans for risk.
• NHSLA Assessment and Review
identify the Trust’s progress in
achieving Level 1.
• CQC Registration, Inspections
and reports identify the Trust’s
progress in addressing risk
Monitoring
• Action Plans from the Audit will
be monitored by the Operational
Management Group and within
Divisional Service Line Performance
Reviews
• Delayed Transfers of Care figures inform
Commissioners on how efficient and
effective we are at good working
relationships with local health partners
and local social care providers
Reporting
• Performance reports for
Commissioners
• HES and SitRep figures
• Trust Board Reports
Quality Accounts 2010
Priority: 3
Develop all Health Action Plans (HAP) for all eligible service users supported by the Trust using the
Health Action Planning Benchmarking Tool.
Outcomes from Health Action Plans contribute to service development and delivery.
Rationale
The audit undertaken in 2009 identified some aspects of Health Action Planning which needed
to be further developed. The Benchmarking tool provides clear guidance on what should be
included within a HAP.
Outcomes from HAP’s should inform service development and delivery
Measure
• Quality visits annually focus on
reviewing service users Health
Action Plans
• An annual audit of Health
Action Plans using the national
benchmarking tool is undertaken
• Service developments identified via
Service Line Management
Monitoring
• Service Line Business Plans and
Performance review meetings identify
each Service Line’s performance in
implementing the process for each
service user to have a Health Action
Plan
Reporting
• Trust Board Reports
• Performance reports to
Commissioners
• Corporate Business Plan
report
4.3 Service User Experience
Priority: 4
Increase the proportion of service users who report that they contribute to the development of
their care plan and support plan and are able to influence the way support is provided for them.
Rationale
CQC compliance for registration requires the Trust to demonstrate how service users have been
involved in planning their care and how their privacy and dignity is maintained.
A Trust project using Experience Based Design demonstrated the benefits of people being
involved in planning their care.
The Trust’s Single Equality Scheme focuses on providing services which meet individual need.
Measure
• Care Plans produced in accessible
format
• Attendance at care planning
meetings by service users
• Service user satisfaction surveys
• Service user and carer involvement
meetings
• Annual audit of Person Centred
Plans
• Quality visits
• Service user involvement in
recruiting staff members
Monitoring
• Single Equality Scheme Action Plan
Quarterly report
• Service Line Business Plans and
Performance reviews monitor how
each Division is involving people in the
development of their care plan.
• Minutes of Service user and carer
involvement meetings
• Complaints
• Audit report to RMSGC
Reporting
• Trust Management
Executive receive the SES
quarterly report
• Trust Board reports
• Performance Reports
In addition to the above priorities, Service Line Managers are implementing Business plans which reflect the Corporate
objectives for 2010/11. Many of these represent service improvements. There are continual discussions at Trust Board on
the introduction of individualised budgets for service users and the possible expansion of Ridgeway Partnerships services
into more specialised services such as Autistic Spectrum Disorder services and Aquired Brain injury services.
17
Quality Accounts 2010
Annex
What others say about Ridgeway Partnership
•
Patient Environment Action Team Assessments 2010
The following information was received from the NPSA in
April 2010 and reflects an improvement on the 2009 scores.
Care Quality Commission
Site Name
Environment
Score
Food
Score
Privacy
&
Dignity
Score
In 2009 the Trust failed on two national standards as part of
the core Standards for Better Health. In one area the Trust
failed to enter sufficient ethnic codes to finished consultant
episode data to achieve the standard of 80%. In the second
area the Trust did not state that it had discharge plans for
five service users being resettled as part of the national
campus reprovision scheme. An action plan addressed
these areas.
The Chilterns FKA
Win Croke
Excellent
Self
Catering
Excellent
Cressex House,
309 Cressex Road,
Good
Self
Catering
Excellent
Statt (Slade Site)
Excellent
Self
Catering
Excellent
In 2009 / 10 the following CQC Ratings were provided
for Social Care
John Sharich
House
Slade Site
Evenlode Clinic
Excellent
Self
Catering
Excellent
Excellent
Good
Excellent
Postern House
Acceptable
Self
Catering
Good
Lanterns
Acceptable
Self
Catering
Excellent
The Trust registered with the Care Quality Commission
against the Infection Control Standard in 2009/10 and was
registered by them without condition.
No
Domicillary Care Agencies
( locality bases)
5
Short Term Breaks
5
Registered Care Homes
2
Adequate Good
5
2
3
2
In March 2010 the Trust was registered by the Care Quality
Commission without conditions to provide health services
according to the registration and requirements of the CQC.
CQC Registration for Social Care will be assessed in October
2010.
•
National Health Service Litigation Authority
The Trust was assessed against the National Health Service
Litigation Authority’s standards at level 2 in October 2009.
Assessors determined that the Trust had not met the
appropriate level of compliance at levels 1 and 2 and was
designated level 0 status. An action plan is currently being
implemented and the Trust will be reassessed in
October 2010.
•
Statements from key stakeholders
Attached in Appendix 3 is a statement from
Buckinghamshire PCT on behalf of the commissioning PCTs
in South Central Region.
Data Quality
In records submitted to the Secondary Uses System
(SUS) for inclusion in Hospital Episode Statistics (HES) the
percentage of records including patients number is 100%
for Oxfordshire. We are awaiting an output report from
Swindon PCT and Buckinghamshire PCT.
The Ridgeway Partnership does not report clinical coding in
the payment by Results clinical coding audit .
In records submitted to the Secondary Uses System
(SUS) for inclusion in hospital episode statistics (HES) the
percentage of records including the valid patients GP code
was 100%. We are awaiting an output report from Swindon
PCT and Buckinghamshire PCT.
The Trust’s score for Information Quality and Records
Management assessed using the information Governance
Toolkit was 52%
18
Quality Accounts 2010
Appendix
Appendix 11
Active Service Evaluations and Clinical Audit 2009/10
Service Evaluations active in 2009 / 10
“An insight into service-users’ experience of transition through two learning disability service assessment and
treatment units”
Evaluation of Post-Incident Staff Support processes & procedures within the RP In-Patient Services
An Evaluation of the Wallingford Call Centre Project (Assistive Technology)
Evaluating Clinical Outcomes in Routine Practice (Psychology)
Post Community Support Team Discharge Service Evaluation
An evaluation of the outcomes of the Preceptorship Development Programme
Evaluation of the prevalence of alcohol misuse in PWLD across Bucks
To assess the effectiveness of Intensive Interaction Training by the Oxfordshire Facilitators
Prescribing Patterns within In-Patient Services
Exploring Service User experience of CPA
An Evaluation of Total Communication Training for Ridgeway Partnership Supported Lifestyles Directorate
Service Evaluation of Prescribing Practice in view of local and national guidelines on Ridgeway Partnership
wards (Pharmacy)
Well Being and Physical Activity Levels in Older Adults with Learning Disabilities
Evaluation of Major Clinical Incident and Serious Untoward Policy Application
Views and Experiences of Psychiatrists about DoLs
An Evaluation of the use and findings of the Assessment of Motor and Process Skills (AMPS) carried out by OTs
Audits Active in 2009 / 10
To Evaluate the Effectiveness of Current Recording Forms in Gaining the Appropriate Information Required to
Monitor
Management of epilepsy in learning disability outpatients
Measuring Physical Environments
Medical devices and equipment audit
Audit Care Programme Approach for People with Learning Disability
Re audit of the Mental Health Act: Section 17 leave at Evenlode, JSH and STATT wards
Epilepsy in People with Learning Disability, North Oxfordshire
Management of epilepsy in learning disability outpatients
19
Quality Accounts 2010
Appendix
Appendix 22
CQC Indicators
Care Quality Commission Last updated 17th March 2010
Performance assessment 2009/10
Care plans
Rationale
The 2007 Healthcare Commission’s learning disability audit
highlighted the need for every person with a learning
disability to receive high quality care within NHS inpatient
specialist learning disability services. If people with learning
disabilities are to lead more independent lives following
assessment and treatment, then the planning for this must
be improved, updated frequently and made more relevant
to the individual (Healthcare Commission 2007).
A care plan is a written statement developed for a person
that records any nursing/social/environmental or other
interventions to be undertaken in order to achieve
an improved quality of life including the health/social
outcomes to be achieved and the review of care that will
occur at regular intervals.
Care plans should have a person-centred approach and
be based on a periodic review of care involving the
individual concerned (where possible), the health/social
care professionals involved and the carers. For detained
and specialist inpatients, care plans should be in line with
the care programme approach (CPA). Frequency is to be
determined by the responsible clinician(s), but should not
occur less than every six months.
Numerator
Number of people receiving care for three months or more
within NHS inpatient specialist learning disability services
who have a care plan (as at 31st March 2010).
Denominator
Number of people receiving care for three months or more
within inpatient specialist learning disability services (as at
31st March 2010).
Indicator
Indicator is the numerator divided by the denominator,
expressed as a percentage.
20
Note
Care plan definition - for the purposes of the assessment
against this indicator a care plan is defined as:
An overall care plan that charts progress through specialist
healthcare. The care plan should make reference to and be
consistent with an individual’s person-centred plan and
health action plan, and care programme approach where
appropriate.
Each care plan should demonstrate the following:
a) an evidence based approach for example, care based on
published clinical guidelines
b) a pathway including assessment, planning,
implementation, monitoring and evaluation
c) active involvement of the patient in every part of the
plan and agreed with the patient and/or relevant parties
(with regard to the ‘Mental Capacity Act 2005 Code
of Practice’)
d) a process and schedule for discharge for each patient
which has been agreed with the patient and the key
partners (including local authority). The exceptions may
include patients detained under the Mental Health Act
with or without Home Office restrictions
e) active treatment plans that lead to planned discharge
and improved health and well being
f) meaningful activities such as leisure, therapeutic,
education and occupation.
This indicator has been developed in full consultation with
the Department of Health, the Royal College of Psychiatrists,
the Royal College of Nursing and Mencap.
Data source and period
Care Quality Commission special data collection (as at 31st
March 2010)
Quality Accounts 2010
Appendix
Appendix 33
Statement from Commissioning PCTs
Directorate of Public Health
25th May 2010
Sue Chapman
Head of Quality and Performance
By email only
rd
3 Floor, Rapid House
40 Oxford Road
High Wycombe
Buckinghamshire
HP11 2EE
Tel. 01494 552238
Fax: 01494 522046
Email: jane.mcvea@buckspct.nhs.uk
Dear Sue,
Quality Account Ridgeway Partnership
Thank you for sending me a draft copy of your Quality Account for 2009/10. It was
extremely useful to see all the quality initiatives summarised in one document along with the
trusts vision for the future.
The following is NHS Buckinghamshire’s response for inclusion in the published Quality
Account.
NHS Buckinghamshire has reviewed the Ridgeway Partnership’s Quality Account on behalf
of the PCTs which commission its services within South Central SHA. The Quality Account
provides information across the three domains of quality as set out by Lord Darzi and the
nationally mandated elements of a Quality Account are covered. There is evidence that the
Trust has used both internal and external assurance mechanisms.
The PCT is satisfied as to the accuracy of the data contained in the Account.
The PCTs works with the trust on quality of care in a number of multiagency forums, and
continues to develop good working relationships across the trust.
The PCT notes the trust’s focus on providing a positive patient experience by improving
staff attitude and communication and supports the trust concentrating on this important
area.
The Ridgeway Partnership have identified in their quality account a number of
improvements including the development of dementia services and support for those with
behavioural problems.
The PCT is pleased to note that the Trust is actively involved in clinical research which
establishes the evidence base for areas of care which are often neglected.
I realise how much effort such quality improvements take in terms of engaging clinical staff
Sue
Chapman
2 - in place, for example the information
25th May 2010
and also
in making sure the support systems -are
systems.
Next year will be equally challenging but I am sure with the commitment the trust
has built
…../continued
that we will see further improvements in quality.
Yours sincerely
Chief Executive:
Chair:
Ed Macalister-Smith
Stewart George
Dr Jane O’Grady
Director of Public Health
G:\PCT\Quality\Quality accounts\200910\Letter Ridgeway 200910.doc
21
Quality Accounts 2010
CONTACT DETAILS | HEADQUARTERS, OXFORD
Ridgeway Partnership
(Oxfordshire Learning Disability NHS Trust)
Slade House
Horspath Driftway
Headington, Oxford, OX3 7JH
For further information
If you would like further information about Ridgeway Partnership, please
go to our website at www.ridgeway.nhs.uk
Or contact the Trust’s Communication Department on (01865) 228031
and they will send the information to you by post.
If you require this publication or any of our other information leaflets in a
different language, large print, braille or speaking version you can contact
the Trust’s Communication Department for support on: (01865) 228031.
Telephone:
01865 747455
Fax: 01865
228182
| Email:enquiries@ridgeway.nhs.uk
enquiries@ridgeway.nhs.uk
Telephone:
01865 747455
| Fax:| 01865
228182
| Email:
Ridgeway Partnership (Oxfordshire Learning Disability NHS Trust), August 2009
www.ridgeway.nhs.uk