Quality Account
2009-2010
CONTENTS
Page
Corporate Statement
3
Care Quality Goals
3
Achievements
4
Moving Forward
17
Summary
20
2
Corporate Statement
Partnerships in Care (PiC) aims to be the first choice Independent Sector provider of
specialist mental health hospitals. Within PiC the needs of the patients always come
first.
In order to achieve this we have asked our patients to tell us what is important to
them and from this have developed a set of patient priorities.
We have promised to provide:

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


Safe and secure hospitals
The best clinical care delivered through defined care pathways
Clean hospitals with good access to comfortable facilities
Dignity and respect for patients
Single sex accommodation
We have a transparent and progressive approach in which we are always working to
improve and develop our services.
This Quality Account reports on how PiC has achieved against its stated aims and
aspirations and the ongoing commitment and focus on these goals.
PiC Care Quality Goals
During 2009/10 consistently high quality care has been provided through:

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The continued delivery of high standards of patient safety by achieving the
necessary standards as laid down by the Care Quality Commission (CQC) in
England and those devised by the Quality Network for Forensic Mental
Health Services. We continue to strive to improve our operational
performance and in 2009/10 have declared compliance across all standards.
Our ambition is to achieve year on year improvements
Ensuring patients receive timely care by meeting company targets
Continued retention of low assessment times with the majority of referred
patients being assessed in four days
Providing clean, modern and welcoming environments
Further training to embed the Recovery Approach across all services
Investments made in 2009/10 to refurbish a number of hospitals improving
the physical security environments for patients, staff and the public
3

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Ensuring we always provide patients with the best clinical care by fully
considering the patient journey
The establishment of the Corporate Clinical Governance Group during the
year, which offers support to staff in developing and improving their services
for the benefit of patients
Closer working relationships with commissioners through: a stronger
commissioner-facing team; the launch of an electronic newsletter produced
specifically for commissioners; the development of a new website with
advanced search function for commissioners
Greater focus on recruitment and retention – strengthening the talent pool
Continuing to improve internal communications across the Group, through
centrally disseminated Team Brief an internal newsletters and further
communication as necessary
Establishing corporate departments and improving internal customer
focussed services. A lot of work has been done in the year to review and
adapt our corporate services to ensure that they are fit for purpose and
provide better support to clinical teams. Staff have also worked closely with
both clinical and non-clinical departments, using Lean principles to help
departments work in a more efficient way
Continual learning and development through training and attendance at
relevant conferences
Ensuring a financially sound organisation. PiC achieved a good financial
position despite a challenging year for the majority of its hospitals and its
competitors
Achievements
A number of incidences of significant improvement in performance can be evidenced
as affecting quality of care delivery in positive ways.
Patient Safety
Patient safety is of particular consideration for PiC as a provider of secure care to the
mentally disordered. We are committed to minimising risks and promoting a culture
where improvements and lessons can be learned through experience.
This commitment includes identifying actual and potential areas of risk through the
reporting of adverse events and near misses. We have decided to focus on safety
initiatives in a way that demonstrates improvement.
A suite of ‘Key Safety Indicators’ [Absence without Leave; Seclusion; Self Harm;
Medication Errors; Slips, Trips and Falls] have been identified and evidence is
4
collected, analysed and utilised to understand and improve on the safety of patients,
staff and others in contact with our services.
Chart One sets out number of occurrences against the indicators as compared to
performance in the previous year. Charts Two (a) (b) offer a cumulative total of
incidents but contrasts the numbers of those involving patients with those
experienced by staff.
Commentary
A significant impacting factor on two of the key indicators has been the increased
capacity across our service provision. The improvement of facilities and addition of
bed numbers has seen a number of more disturbed patients coming into PiC care.
The disruption created by the improvement of facilities whilst remaining in operation
would have meant in some cases a change in routines and management approaches
that potentially could have unsettled patients.
The data shows a sizable increase in the number of male patients self harming and
patients overall where seclusion was indicated as the most appropriate management
tool.
A self harm chart outlining staff interventions for patients who swallow objects has
been developed at Arbury Court. This piece of work has been cascaded through the
clinical governance leads at each hospital. Research papers on the ‘Ingestion of
Foreign Objects & Cylindrical Batteries in Psychiatric Settings’ were also circulated.
During 2010 the company is introducing the audit tool from the National Patient
Safety Agency (Preventing Suicide: A toolkit for mental health professionals). This
provides a comprehensive audit relating to ward management as well as addressing
care pathway needs of individual patients.
Medication errors should be an occurrence that can be minimised through good
governance. The fall of incidents to 134 in 2009/10 is noted.
Medication errors are reported as clinical incidents through the company’s incident
reporting framework. These are reviewed locally by clinical and nursing teams and
corrective action is taken to prevent similar incidents from occurring. Themes arising
from clinical incidents are reviewed annually by the Health & Safety Committee.
Each incidence of absence without leave is reported to the various government
departments in accordance with regulation requirements. In addition each incident
facilitates a Serious Untoward Incident review in accordance with company policy.
Lessons to be learned are cascaded through the Corporate Clinical Governance
Committee; Health & Safety Committee and the PiC Group Security Officer.
5
Chart One:
Num bers
Key Safety Indicators
5,270
5,120
4,970
4,820
4,670
4,520
4,370
4,220
4,070
3,920
3,770
3,620
3,470
3,320
3,170
3,020
2,870
2,720
2,570
2,420
2,270
2,120
1,970
1,820
1,670
1,520
1,370
1,220
1,070
920
770
620
470
320
170
20
5,139
4,098
1,439
1,039
414
497
134
172
29
50
2007
2008
2009
2010
Year
Medication Errors
Self Harm
Seclusion
Slips, trips and falls
Escapes and Absconsions
Chart Two: (a)
Incidents
25,000
22,500
22,901
20,000
Numbers
17,500
18,092
15,000
Staff
Patients
12,500
10,000
7,500
5,000
2,500
3,787
3,930
0
2007
2008
2009
2010
Year
6
(b)
Injuries
6,000
5,000
4,773
Numbers
4,000
3,974
Staff
3,000
2,000
Patients
1,956
1,849
1,000
0
2007
2008
2009
2010
Year
Clinical Governance
The inaugural meeting of the Corporate Clinical Governance Committee took place
in September 2009.
Services continue to be encouraged to share best practice initiatives through the
corporate clinical governance newsletter.
Individual units continue to submit minutes of their clinical governance meetings to
the Corporate Clinical Governance Manager. ‘A guide to clinical governance’
continues to be used to assess the structures that underpin clinical governance
activity and benchmark services against statutory, policy and best practice clinical
governance standards. The audit cycle runs from April to March and seven audits
have been completed.
Clinical Governance Newsletter
The first Corporate Clinical Governance Newsletter covered Storytelling (how
patients can use storytelling as part of meaning interaction that develops and
enhances their creative skills) and an Anti- Bullying working party. It also reported on
the Have Your Say patient satisfaction model and national changes including the
introduction of the Care Quality Commission & Mental Health Development Unit as
well as changes to the complaints policy for England.
The second newsletter covered: changes to the Care Quality Commission, the 25
hours activity project, corporate clinical governance developments, bullying
behaviours, clinical audit developments, and initiatives in services for people who
have a personality disorder.
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The third edition included a paper from Dr Pancho Ghatak (PiC Midlands) who cohosted a workshop on ‘Person Centred Planning in Secure Settings’ with Dr Susan
Johnston at the Faculty of Learning Disabilities Annual Conference 2009.
There is also a report on the availability of Multi-lingual leaflets on patients’ rights
under the MHA (England only). These can be accessed through the Clinical
Governance page on the Company’s intranet. Services continue to be encouraged to
share best practice initiatives through this newsletter.
Patient Involvement
Some hospitals took up the offer of a presentation on clinical audit to the patients’
councils that served to standardise understanding.
During 2009/2010 the company introduced a new model for patient surveys. The
model has been benchmarked against national guidelines and also meets some of
the criteria of Part 2 (Service User, Carer and Staff Experience Surveys) of Schedule 3
(Managing Activity and Referrals, Care and Resource Utilisation Techniques and Retention
of Payment Scheme) of the standard NHS multilateral contract for mental health and
learning disability services
Following a period of consultation the patient satisfaction survey ‘Have Your Say’
was finalised during Quarter 2. The model consists of four separate patient
satisfaction questionnaires. Namely:
1.
2.
3.
4.
My CPA Meeting
Your Environment – What I think of where I live
Information - What I have been told
My Care and Treatment
The intention is for these to be completed at different times throughout the
calendar year. This model aims to:

Standardise the patient satisfaction questionnaires across the Company and
all patient groups

Make the questionnaires more service user friendly and more manageable
for patients who have short concentration spans

Increase the profile of patient satisfaction surveys and how feedback can be
used to shape service delivery

Reduce duplication in current reporting systems by using the data presented
through these questionnaires in other linked audit projects, primarily CPA
8

To provide timely feedback to management teams on themes evidenced by
patient experience
Service users, family members and carers involvement
PiC is committed to involving service users, family members and carers in developing
our services. We do this by:
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Holding ward community meetings for patients

Seeking feedback on current issues from patient representatives or councils

Carrying out regular service user satisfaction surveys

Regularly reviewing themes arising from formal complaints

Minutes from patient’s council meetings are reviewed regularly by a senior
governing committee at each hospital and action is taken to address issues
raised
Care Programme Approach (CPA)
The document was designed to focus on the Care Pathway for the patient thus
integrating individual professional reports. The process to evaluate the CPA
document commenced in the last quarter of 2009 with questionnaires designed for
clinical staff, Commissioners and Case Managers being circulated. All completed
questionnaires were returned by 31st January 2010.
There were a total of 113 returned staff questionnaires from 17 units. This ranged
from 14 completed questionnaires at The Spinney with only 1 questionnaire being
returned from Aderyn and Pelham Woods.
Unfortunately only two responses were received from Case Managers and as one of
these had only recently taken up post they did not feel qualified to comment.
Three quarters of respondents felt the CPA document was laid out in a logical way,
although only just over half reported that the document facilitates ease of access to
information when needed and several believed the document to be unwieldy.
A diverse range of responses was recorded on the remaining 16 questions leaving a
number of recommendations for the Corporate Clinical Governance Committee to
consider in completing the evaluation.
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Physical Health check
The Physical Health Check system and associated guidelines developed by Rethink
were circulated through the Medical Directors Forum. It was decided that as all
services have General Practice input that these documents would be made available
to the relevant GP. Physical health promotion is also a component of the clinical
governance audit.
A corporate physical healthcare policy was produced during 2009 and circulated for
comments. This policy was ratified by the CMG early in 2010.
Referrals to Assessments
PiC has set a standard that wherever possible assessments will take place within
three days of referral. This standard was not achieved, which was largely due to the
number of referrals received for people who were in prison. Access to prisons can be
problematic, either through the restriction caused by security-related protocols or
through PiC wishing to maintain its relationship with Commissioners, whereby some
referrals are received without clear indication that they have been agreed by the
Commissioning team. PiC would seek that clarification prior to arranging an
assessment thereby prolonging the period between referral and assessment.
Regardless of the above considerations PiC has still managed to achieve a credible
average time of four days between referral and assessment. Despite the awareness
of some blockages inherent to the process/system, PiC will retain the three days
target during 2010/11 with the intention of addressing known inhibitors and further
reviewing the target in the light of any additional emerging evidence. Targets should
always be meaningful and achievable.
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Chart Three:
Infection Control
The profile of infection control was raised across the company during the outbreak
of swine flu using the 'Catch it, Bin it, Kill it' campaign. This was reinforced at the
corporate Health and Safety meeting in May 2009 as well as the directive that
Primary Nurses should be holding one to one sessions with patients to talk about
general infection control issues.
Some patients and staff within PiC were affected by the first outbreak and it is highly
likely that this will be the case with a second wave expected in 2010.
The strategy for pandemic influenza was circulated to the CMG at the beginning of
the outbreak of swine flu. The strategy was ratified by the Corporate Management
Group in 2009 and reflected 'A National Framework for responding to an influenza
pandemic' as well as Department of Health Guidelines specific to mental health
services. Regional Executive Directors continue to be responsible for overseeing the
implementation of the strategy at a local level.
Research and Audit
The Clinical Governance Audit Tool aims to provide a corporate vision for the
strategic development of Clinical Governance across the Company. It attempts to
achieve this through setting and monitoring performance standards under the seven
pillars of Clinical Governance bringing together a variety of cross company initiatives.
The standards incorporate national guidance on clinical governance, PiCs operational
policy and the Standards for Better Health issued by the Department of Health (DH).
This strategy helps to identify the direction PiC is taking towards the delivery of its
services. It is intended to be a living document and will evolve in response to new
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initiatives and as lessons are learnt through implementation. Each hospital / service
is audited against these standards at a minimum of once per calendar year.
There have been a number of research papers published involving PiC clinical staff
during the year. In addition the company continues to organise, sponsor and attend
a large number and a wide variety of clinical conferences.
Ligature Audit
A ligature audit tool has been drafted and reviewed by the Corporate Clinical
Governance Committee and will be trialled at two sites during 2010.
Infection Control
A self assessment audit tool has been developed for the Health and Social Care Act
2008. The implications for PiC are that all services registered with the CQC meet the
standards in the guidelines by April 2010.
The standards state that PiC will need a Director of Infection Prevention and Control
(DIPC) who reports to the board annually. Initial scoping indicates that the
management of infection control is currently fragmented across the group with non
clinicians in some areas having sole responsibility.
Following discussion it was proposed that infection control should be primarily nurse
led and that the PiC Corporate Director of Nursing would integrate the role of the
Director of Infection Prevention and Control with current responsibilities. This
initiative will be taken forward through the Infection Control Group and fed through
to the Director of Nursing forum.
Patient Involvement
Each hospital holds patient council meetings looking at all aspects of the patient
experience throughout the hospital. Members of the local senior management team
will be party to council meetings reporting their activity to SMT. The minutes and
outcomes of patient council meetings are monitored through the corporate clinical
governance audit.
Seclusion
The use of seclusion as part of managing violent and aggressive patients has been
audited against the standards outlined in The Mental Health Act (1983) Code of
Practice and Violence, and the short-term management of disturbed/violent
behaviour in psychiatric inpatient settings and emergency departments (NICE Clinical
Guideline 25).
12
The audit has been in three parts. Part A considers the physical layout and
specification of rooms / facilities that may be used in the seclusion of patients. Part
B examines the systems in place to support and regulate seclusion at local level, such
as policies, procedures and training and Part C considers the quality of seclusion
interventions and associated documentation, with regard to individual patient
incidents.
Slips, Trips and Falls
Slips, Trips and Falls are reviewed quarterly by the Health and Safety Committee
through the PiC Accident and Incident reporting process.
Policies and Procedures
In accordance with proper governance and in reflection of PiC’s commitment in
responding to patient needs and prevailing evidence a range of policies, practices
and procedures, and guidance notes were promulgated or reviewed during 2009.
These all respect the expectations of its stakeholders. Examples of these are:
1.
Clinical and Corporate Governance

Clinical Audit
January 2009

Legal Policy – Legal Claims
July 2009

Guidance on Contracted Out Services
July 2009

Nursing Patients in Isolation or Seclusion
August 2009

Confidentiality Policy
October 2009

Data Protection Policy
October 2009

Sex & Violence
March 2010

Complaints Policy & Procedure
March 2010
2.
3.
The Patients’ Experience/Journey

Harassment
March 2009

Policy for Working within the
May 2009

Discharge – Leaving the Service
June 2009
Human Resources
13

Retirement Policy
March 2009

Employment of People from Overseas
August 2009

Redundancy Policy
September 2009

Recruitment and Retention Policy
November 2009

Sickness Absence
March 2010

Discipline and Appeals Policy
March 2010
4.
Health and Safety

Control of Substances Hazardous to Health
January 2009

PiC Health, Safety & Environmental Policy Statement
October 2009

Environmental Management & Sustainable Development October 2009

Manual Handling
5.
January 2010
Finance

Company Credit Cards
May 2009

Cheque Destruction Procedures
June 2009

Care First Income Reconciliation Procedures
June 2009

Compliance & Control Standards
for Patient / Resident Monies
August 2009

Finance Department Sage Users - Starters & Leavers
September 2009

Capital Purchasing
January 2010

Capitalisation Policy
January 2010

Procedures for Budgeting & Budget Management
January 2010

Care First Client Billing Procedures
February 2010

Cash Book & Bank Reconciliation Procedures
February 2010

Standing Financial Instructions
March 2010
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Staff Training and Supervision
Governing bodies such as the General Medical Council (GMC), Nursing & Midwifery
Council (NMC) and British Psychological Society (BPS) continue to emphasise that it is
the individual practitioner’s responsibility to maintain their professional knowledge
and competence. This is a requirement for revalidation or re-registration and should
be monitored through the professional supervision and the appraisal process.
Clinical and managerial supervision is an important element of staff development
and PiC aims to see a consistent structured application across all its services. The
vast majority of services have staff supervision programmes in place with others
under direction to make supervision core to staff development. Achieving full uptake
and the improvement of the co-ordination and evaluation captured data is an
objective for PiC during 2010/11.
Complaints
The Company’s annual Complaints meeting involving all hospitals was held at Church
Farm Lodge on Monday 6th April 2009, this is in addition to the meetings held at
each hospital to review complaints handling and management.
From 1st April 2009 the Parliamentary and Health Service Ombudsman and the
Healthcare Commission (now CQC) became the public body for the complainant to
appeal to if they are unhappy with the local resolution. (This only applies in England)
The Ombudsman’s principles are: Getting it right; Being customer focused; Being
open and accountable; Acting fairly and proportionately; Putting things right;
Seeking continuous improvement. The Ombudsmen will adopt these principles when
considering the standard of the complaint handling by the bodies within her
jurisdiction.
There are three publications where these principles are outlined. These are:
1. Principles of Good Administration
2. Principles of Good Complaint Handling
3. Principles for Remedy
Corporate policy has been updated to reflect these changes and to integrate the
standardised paperwork used across the group. In addition a PowerPoint
presentation was drafted to standardise complaint training at the point of induction.
The charts below denote the complaints activity for the year. Four (b) shows the
average time taken to manage the two stages of complaints namely
Acknowledgement (target 3 days) and Closure (target 28 days).
15
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Number of Complaints
Chart Four: (a)
160
150
140
130
120
110
100
90
80
70
60
50
40
30
20
10
0
Complaint
Cate gory of Complaint
Upheld
Partially Upheld
Not upheld
Withdrawn
Not deemed a complaint
Passed To Other
Referred to ward
Ongoing
(b)
Formal complaints are reviewed regularly by the local Senior Management Team and
action is taken to address any themes arising from these. In addition an annual
complaint report is produced by the Company; this is reviewed by the Corporate
Clinical Governance Committee.
16
Moving Forward
PiC has identified nine priority areas for addressing and improving all aspects of care
quality enhancing the patient experience and outcome. In support of these priorities
a provisional list of specific activities has been set out below.
Our Priorities for 2010/11:
1. Improve the patient experience
2. Further, strengthen the management of risk and patient safety – improved
risk management at regional level and national Patient Safety First campaign
launched across the Company
3. Improve clinical outcomes for patients – Quality Accounts established making
information about quality and clinical outcomes available and focussing on
improving the patient experience
4. Contribute to whole system recovery – improving care pathways
5. Improve financial management
6. Increase utilisation of high quality estates and reduced occupancy costs
7. Making better use of facilities
8. Improve Information Management and Technology to support executive
decision making – delivery of the first year of electronic patient records
strategy and benchmarking of service delivery costs to ensure we provide
good value for money
9. Grow our referral base – implement plans to increase out patient base,
improving working relationships with commissioners increasing the number
of those choosing our hospitals
10. Further work with our units in the area of patient involvement, for example
through patient involvement and engagement newsletters
Clinical Engagement
During 2009/10 Regional Services developed their own performance and quality
standards, which include a range of quality indicators relevant to each region. These
will be refined to meet the needs of patients, Commissioners and the NHS contract
for 2010/11.
The regions will receive regular reports on metrics relating to patient safety, patient
experience, clinical effectiveness, use of agency staff and enhanced observation.
The regions will use selected quality indicators to develop programmes for
continuous quality improvement.
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Services Development and Improvement Plan
PiC will work together with the Commissioner to develop the Services Development
and Improvement Plan (the “Plan”). The Plan is separate to the CQUIN scheme
indicators set out in the NHS Contract.
The key areas of the Plan are as follows:




PiC will commence implementation of the DH’s Relational Security
Guidelines (See, Think, Act) by the end of Q1
PiC will reviewing the CPA document to include a recovery plan for each
patient by the end of the Q2
PiC will commence implementation of the electronic patient records by the
end of Q3
PiC will develop a range of information to be distributed to carers for service
improvement by the end of Q4
Medicines Management
Each hospital is required to have in place the following:



There is a policy in place on the Administration of Medication
An up-to-date service level agreement with supplier of pharmaceuticals
Audits
o Lloyds Pharmacy carry out an annual audit on prescribing habits
o Charge Nurse audits the medicine card on a monthly basis
 Proper prescription
 Check compliance with signatures
 Emergency 62 all paperwork
 Levels of use of PRN medication
o Consent :
 T2
 T3

All new employed first level nurses will undergo an eight week drug
assessment prior to administering drugs to patients
All first level nurses will undergo annual drug assessments (NMC)
The Clinical Nurse Managers or equivalent is a member of the local
intelligence network (LIN)
BNF plus Mental Health Act Code of Practice are on each of the ward areas.
Care Quality Commission – standards 2000
o Accountable officer for control drugs. A designated person on site
usually the Registered Manager if a first level nurse
NICE Guidelines
o Prescribing and monitoring of drugs and their side effects including A
Typical Anti-psychotic





18

Error Management
o Database needs to be established to monitor all drug errors (establish
what constitutes a drug error)
o Train and support staff who have made errors prior to reassessment
Secure Patient Activity Charter
Each hospital will have to be able to evidence that their patients are being offered 25
hours of structured and meaningful activity per week.

Each patient should have an individual timetable outlining the sessions offered to
them on a weekly basis. This timetable should be reviewed at internal CPA
meetings to ensure that the sessions are linked to direct patient care and
treatment
 The named “Therapy Manager”, manages the timetable for each ward.
Therefore, any clinician wishing to change or start sessions with individual
patients need to approach this person so that the timetable is formalised
 The Therapy Manager will have an overview of the variety of sessions offered to
the patients on each ward and site and this will be discussed with the Multi
Disciplinary Teams to ensure the sessions are needs led and link to each
individual care plan
 A database needs to be established and available on each of the wards
computers to enable evidencing of sessions offered to the patient group
 All ward staff should have access to this database and be able to use this
database effectively and in particular run off information for any visiting
commissioner requiring information on their patients
 Training and coaching is carried out with staff using the database with the
rationale of embedding this into the hospital culture
 At each CPA meeting including external meetings all data should be run off for
each individual patient as part of the discussion of the patients care and
treatment
 Service Management Teams for each service should be reviewing the level of
activity for individual patients as part of their agenda
 Ideally one database should be used throughout PiC
 The responsible person for patient engagement for each site should carry out an
audit every three months to ensure compliance
Note:
As a guide activity should be offered in the following areas:



30% Treatment
30% Education/Vocation
40% Recreation
19
SUMMARY
The Quality Account represents an accurate reflection of Partnerships in Care’s
achievements and priorities for improvement and progress towards its aspirations
and commitment to the Patient Experience.
Reporting on progress on elements of the account will be by way of the company’s
governance processes as too will any changes in data that may emerge between the
completion of the document and the reporting period.
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