Quality Account
1st April 2009 – 31st March 2010
improving
p
g the
Specialist Mental Health Service for Bury, Rochdale, Oldham, Stockport,ANNUAL
Tameside
and
Glossop 1
REPORT
2009/2010
Contents
Part 1: Statement on Quality from the Chief Executive .............................................. 4
Part 3: Other Information ...................................................................................... 27
Review of Quality Performance in 2009/10
Part 2: Priorities for Improvement and Statements of assurance from the Board ...... 5
Review of Patient Safety Indicators 2009/10 ........................................................................... 29
Performance in 2009/10 against Quality Indicators identified in the 2008/9 Quality Report ...... 5
Absent without leave, absconding, missing
Self-harm
Slips, trips and falls
Medication errors
Physical assaults against staff
Delayed discharges
7 - day follow up
Gatekeeping
Our priorities for Quality Improvement in 2010/11 ..................................................................... 7
A reduction in patients going absent without leave (AWOL) and absconding
A reduction in slips, trips & falls
A reduction in medication errors
Effective gatekeeping
An effective response to complaints
Review of Clinical Quality Indicators 2009/10.......................................................................... 42
Statements of assurance from the Board .................................................................................. 17
Healthcare Acquired Infections
Effective handling of complaints
Delivering single sex accommodation
Delayed discharges
7 - day follow up
Gatekeeping
Review of Patient Experience Indicators 2009/10 .................................................................... 46
Information on participation in clinical audits and national confidential enquiries..................... 18
Information on the use of the CQUIN Framework ....................................................................... 24
Performance against key national priorities and national core standards .................................. 52
Information on registration with the Care Quality Commission................................................... 24
Other additional content relevant to the quality of NHS services ................................................ 54
Information on the quality of data............................................................................................. 26
Annex ................................................................................................................... 56
Statement on Quality Account from Lead Commissioning PCT
2
PENNINE CARE NHS FOUNDATION TRUST
ANNUAL REPORT 2009/2010
2
ANNUAL REPORT 2009/2010
3
Quality Account
Part 1:
Statement on Quality from
the Chief Executive of the
NHS Foundation Trust
This year has been another successful
year for Pennine Care. As outlined in our
Annual Report last year, we have in place
a Quality Improvement Strategy, known as
‘Quality Matters’ which sets out our quality
improvement goals for 2009-2014. At the
heart of this is our commitment to continue
to provide outstanding care to our patients,
whilst remaining financially sound.
High quality and ever improving care has always
been central to what Pennine Care has strived to
achieve and we are proud that for the second year
running we have been rated “Excellent” by the
Care Quality Commission for our services. In our
Quality Strategy, as well as focussing on a number
of key indicators this year for improvement, we
have also looked forward five years to embed
the quality improvement work in our business
planning for the long term. This will include a
fundamental shift in the way the organisation is
managed, implementing service line reporting
and service line management to enable us to
deliver the improvements that we want to make.
The priorities for quality improvement set out in
this Quality Account have been chosen to reflect
our goals to improve patient safety, clinical
effectiveness and the patient experience. They
have been chosen by the Board, and reflect
the themes common in our ongoing and varied
consultations with patients and carers, the
Council of Members, the wider Foundation Trust
membership, and staff.
This year has seen great improvements in
services and important clinical engagement and
4
PENNINE CARE NHS FOUNDATION TRUST
debate in what the Quality Strategy must achieve.
We will work closely with all our staff to continue
to place quality at the heart of what we do and
keep this as a priority for us in the coming year.
To the best of my knowledge, the information in
this document is accurate.
Signed:
John Archer
Chief Executive
8th June 2010
Part 2: Priorities for
Improvement and
Statements of assurance
from the Board
Priority 1:
A reduction in delayed discharges to meet the
Monitor target of no more than 7.5% delayed
discharges.
Priority 2:
Performance in 2009/10
against Quality Indicators
identified in the 2008/9
Quality Report
95% of patients discharged from an inpatient
ward must receive a follow up in the community
within seven days.
Priority 3:
All patients that have an inpatient stay in Pennine
Care would have been assessed through a
gatekeeping function within the Crisis Resolution
and Home Treatment Team.
The Trust identified three quality priorities in
2008/9 which were reported in last year’s
Quality Report.
The Trust achieved the following level of
performance against each of these indicators in
2009/10:
Priority 1: Achieved in all twelve months.
Achievement is ongoing, and monitoring is
in place.
% of delayed discharges
8%
7%
6%
5%
4%
3%
2%
1%
0%
Apr
May
Jun
Jul
Aug
Sept
Oct
<7.5% target
Nov
Dec
Jan
Feb
Mar
2009/10
% of occupied bed days with delays
ANNUAL REPORT 2009/2010
5
Our priorities for Quality
Improvement for 2010/11
Priority 2: Achieved in eleven of the twelve
months. Achievement is ongoing, with monitoring
in place.
% of patients discharged on CPA followed up within seven days
100%
99%
98%
97%
96%
95%
94%
93%
92%
Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec
95% target
Jan
Feb
Mar
2009/10
followed up on CPA
Priority 1:
A 3% reduction in AWOL/Absconds/Missing as a
percentage of all admissions.
Priority 3: Achieved in all twelve months.
Achievement is ongoing, and monitoring is
in place.
Priority 2:
A 3% reduction in slips/trips and falls.
% of admissions assessed through a gatekeeping process
Priority 3:
A 10% reduction in medication error incidents
related to omitted medicines, medicines
recording incidents and the wrong frequency of
administration.
100%
95%
90%
85%
The Trust has undertaken a wide ranging
consultation exercise to determine its quality
priorities for the year. This has included
discussions with the Board, Council of Members,
service users and carers, and our staff. Bearing
in mind their input, the quality indicators used in
previous years, and the priority areas indicated
by Monitor and the Care Quality Commission, the
Trust has identified the following quality priorities
for the year 2010/11, spanning the three quality
themes of Patient Safety, Clinical Quality and
Patient Experience. These indicators also form
part of the indicator-set used in Part 3 of this
Quality Account to report on Quality in 2009/10.
Apr
May
Jun
Jul
Aug
Sept
Oct
90% target
Nov
Dec
Jan
Feb
Mar
2009/10
% admission gatekept by CRHT
Priority 4:
Ensuring that all patients who have an inpatient
stay in Pennine Care are assessed through a
gatekeeping function within the Crisis Resolution
and Home Treatment Team.
Priority 5:
Ensuring an effective response to complaints.
6
PENNINE CARE NHS FOUNDATION TRUST
These priorities have been assessed in terms of
their impact and feasibility, as well as their ability
to address areas of importance identified by all
of our stakeholders. The Council of Members
(the elected body holding the Board to account,
elected from the wider membership) has been
consulted on the Quality Report during its
construction, including on the priorities for Quality
Improvement.
The priorities form an integral part of the Trust’s
Quality Strategy, and have been agreed and
signed off by the Trust’s Chief Executive, John
Archer, and our Chairman John Schofield. Like our
priorities, the Quality Strategy and other quality
improvement work undertaken by the Trust has
involved a wide variety of stakeholders including
clinical and support staff from across all services,
and the Council of Members.
Performance against our identified priorities is
described below:
Priority 1:
A 3% reduction in patients going
absent without leave (AWOL),
absconding and going missing, as a
percentage of all admissions.
Current performance:
The Trust has seen a 28% decrease in the
number of incidents of patients going AWOL,
absconding or going missing in 2009/10
compared to 2008/9 (Table 1). However, this
figure is not an exact like for like comparison due
to a change in the way that data was recorded
which was made this year. As a result, the target
for improvement this year is significantly less,
reflecting a challenging yet realistic target.
ANNUAL REPORT 2009/2010
7
Table 1:
2008/2009
2009/2010
Missing
(community patients)
54
32
AWOL
(detained patients)
462
256
AWOL – not returned from leave
(detained patients)
115
159
Absconded
(non-detained patients)
201
95
Absconded – not returned from leave
(non-detained patients)
21
70
Total
853
612
How will we track improvement?
The Trust will continue to strengthen its own
internal monitoring of absconding and AWOL
events and will set its own benchmarking
standards as opposed to relying on national
average figures. We will aim to reduce AWOL
and absconding incidences by a further 3% in
2010/2011.
The Trust will also analyse the reported data
which will be used to ensure action plans and
recommendations to reduce these incidents are
performance managed within services.
Areas for improvement:
The Trust has identified a number of patient types
who are considered more likely to abscond:
• Absconded during a previous admission –
nine times more likely to abscond
• Refusal of medication in previous 48 hours –
three times more likely to abscond
• 35 years or under – three times more likely to
abscond
8
PENNINE CARE NHS FOUNDATION TRUST
figures. For example, under the previous
reporting system the monthly data may have
been influenced by an unusually low or high
admission rate for the month, or by longterm patients who may go AWOL or abscond
multiple times during a single admission.
• Reporting on the number of events by ward, in
order to ascertain any trends.
• Presenting data detailing the absolute number
of events linked to single individuals. This will
help to both identify patients at increased risk
of going AWOL or absconding and will also
provide extra information based around the
total number of AWOL or absconded patients,
not just the individual incidents themselves.
We will continue to use the metrics identified as
measures of quality in this area, to report in a way
which is consistent in future years.
In the 2009/10 reporting period we have
reported a small increase of 3% from last year.
This is disappointing, and the Trust hopes to
ensure a decrease in future as we implement new
strategies and continue to highlight this key issue.
The Trust identified the reduction of slips, trips
and falls as part of the Patient Safety First
Campaign and Tameside Older People’s Service
has shown significant success in reducing falls
within their inpatient units.
Within the South Division, the Falls Prevention
Strategy Group continues to monitor and work
towards maintaining the safety of patients in
relation to falls.
How will we report this priority?
• Male – two times more likely to abscond
• Diagnosis of schizophrenia – two times more
likely to abscond.
The Trust has targeted efforts to reduce
AWOLs etc. in these target groups. These types
of patients will form the key areas for our
improvement efforts in 2010/11.
The Trust will continue to report this priority
internally to the Board, and externally in the
Quality Account for 2010/11.
Actions planned to improve performance:
Following guidance from the National Patient
Safety Agency (2007), the Trust developed a Falls
Prevention Strategy, which aimed to reduce the
number of falls across the organisation each
year by 3%. Outstanding results were obtained
in 2007/2008 with an 18% decrease in falls
observed compared with 2006/2007. We further
improved on this in 2008/09 when we reported
a 21% decrease in falls compared with 2007/08.
This meant the Trust had achieved an overall
decrease in falls of 35% against the baseline
figure in the two years since our strategy was
initiated, and far exceeded the target identified.
The Trust has a number of initiatives to work on in
the future in order to improve quality in this area.
We will continue to implement the research within
the Anti-Absconding Workbook (City University,
2003) across all wards. We will also report the
data differently to allow us to more effectively
monitor incidences across the Trust. These
measures include:
• Reporting the total number of events as
opposed to displaying them as the percentage
of inpatient admissions as this will prevent
the possible misinterpretation of the total
Priority 2:
A 3% reduction in slips, trips and falls
Current performance:
ANNUAL REPORT 2009/2010
9
Actions planned to improve performance:
We will be reporting data for slips, trips and falls
in a new way so that we can more effectively
monitor incidences in higher risk areas. The new
reporting measures include:
80
60
40
20
Mar 10
Feb 10
Jan 10
Dec 09
Nov 09
Oct 09
Sep 09
Aug 09
Jul 09
Jun 09
May 09
Apr 09
Mar 09
Feb 09
Jan 09
Dec 08
Nov 08
Oct 08
Sept 08
Aug 08
Jul 08
Jun 08
May 08
April 08
0
• Reporting the total number of incidents
instead of displaying them as a percentage
of inpatients. The results presented to the
Board will also be broken down according
to whether they occurred in Adult or Older
People’s Services or if they were actually
staff falls (Figure 2). This will also prevent the
possible misinterpretation of the figures that
could be skewed by multiple incidents being
accountable to a single patient.
• In addition we will also identify any patients
or staff involved in multiple incidents, in order
to determine if there is particular cause for
concern.
Figure 1: Number of slips, trips and falls by month
10
PENNINE CARE NHS FOUNDATION TRUST
80
60
40
20
Dec 09
Nov 09
Oct 09
Sep 09
Aug 09
Jul 09
Jun 09
May 09
Apr 09
Mar 09
Feb 09
Jan 09
Dec 08
Nov 08
Oct 08
Sept 08
Aug 08
0
Jul 08
The Trust will work to track improvement using the
measures currently in place, reporting as detailed
below.
100
Jun 08
Financial implications can include incurred costs
such as those relating to treatment, increased
lengths of inpatients stay, complaints and, in
some cases, litigation.
• To increase staff awareness in relation to falls
prevention
• To reduce the number of slips, trips and falls
by 3% per annum.
A significant proportion of falls occur within the
Older People’s population and as a Trust a clear
priority is to reduce this figure in the coming
year. In addition, we would like to gain a more
comprehensive understanding of staff slips, trips
and falls and would like to reduce the number of
occurrences by 3%.
120
May 08
The Trust has identified the following two goals:
Apr 08
Areas for improvement:
Service user falls can have significant implications
in terms of both human and financial costs.
For individual patients, the consequences can
range from distress and loss of confidence, to
injuries that cause pain and suffering, loss of
independence and occasionally death. These
incidents can also bring about feelings of anxiety
and guilt for the patients’ relatives and hospital
staff.
Number of incidents
How will we track improvement?
65 and over
Under 65
Staff
Mar 10
Number of incidents
100
Feb 10
120
Jan 10
Incidents of slips, trips and falls by month 2009/2010
Figure 2: New reporting mechanism for slips, trips and falls.
ANNUAL REPORT 2009/2010
11
The Trust is working towards providing additional
training on falls prevention throughout the Trust.
This patient safety priority will be monitored
through the Integrated Risk and Clinical
Governance Group and the recently convened
Divisional Governance Groups where information
is provided through a monthly dashboard.
Priority 3:
A 10% reduction in medication
error incidents related to omitted
medicines, medicines recording
incidents and the wrong frequency of
administration.
In addition, the data indicates that the majority of
falls are linked to the Older People’s Services. A
thematic analysis was undertaken in Tameside to
identify factors linked to increased falls in older
people. Following the successful pilot in Tameside,
this thematic analysis will be conducted across
the Trust to gain a comprehensive data set. The
aim of this project is to provide robust information
in relation to those at highest risk to develop a
bespoke risk assessment tool for use in Older
People’s Services.
Medicines are a central component in the delivery
of high quality healthcare and their effective use
contributes significantly to achieving successful
outcomes for patients.
Current performance:
A total of 303 medication error incidents were
recorded by the Trust in 2009-2010. This was a
fall from 510 in 2008-9. Three particularly high
categories in which medication errors occurred
were as follows:
We will also develop an information leaflet for
relatives and carers through the Falls Prevention
Strategy Group to help raise awareness and
supportive preventative action.
• 46 (15.2%) related to Omitted medicines (78)
• 54 (17.8%) related to Medicines Recording
Incidents (161)
• 42 (13.9%) related to Wrong frequency of
administration (158)
How will we report this priority?
How will we track improvement?
This priority will be reported through the Trust’s
Integrated Governance Group as well as at Board
level where appropriate, and through service line,
divisional, borough and team reports as needed.
Medication error incident statistics will be
reviewed on a quarterly basis by the Managing
Prescribing Risk Sub-group of the Drugs
and Therapeutics Committee. This multidisciplinary group looks at individual incidents
and analyses incident trends in order to make
recommendations about risk management or
training issues following each quarterly meeting.
In 2010-11, particular emphasis will be placed on
omitted medicines, medicines recording incidents
and wrong frequency.
A ‘Learning from medication error incidents’
bulletin will continue to be produced on a
quarterly basis and circulated throughout the
Trust in order to disseminate finding and share
learning.
12
PENNINE CARE NHS FOUNDATION TRUST
Areas for improvement:
The medication error incidents specified have
been selected as areas for improvement for the
following reasons:
• Omitted medicines (78)
In February 2010 the National Patient Safety
Agency (NPSA) issued a rapid response report
entitled ‘Reducing harm from omitted and
delayed medicines in hospital’. The Trust is
therefore required to work on reducing the
risks associated with omitted or delayed
medicines.
• Medicines recording incidents (161) and
wrong frequency of administration (158)
In 2009-2011 these two categories of
incidents accounted for the largest percentage
of medication error incidents and hence are
considered a priority.
Actions planned to improve performance:
An assessment of prescribing competence for
all junior medical staff will be formalised and
introduced in 2010 and will form part of the Trust
Medicines Management Induction Process.
Updated medicines management training will
be introduced in early 2010 and this will include
training on the reporting of medication error
incidents and Adverse Drug Reactions.
There will be a review of the uptake and use
of the Registered Nurse Competency Appraisal
Framework for the Safe Administration of
Medicines.
How will we report this priority?
The Managing Prescribing Risk Group will report
on all medication error incidents, but particularly
those in the specified categories, to the Drugs and
Therapeutics Committee and the Risk and Clinical
Governance Committee.
The Learning from Medication Error Incidents
bulletin will focus on the findings and learning
from the specified categories.
An end of year update will be written for the
Quality Account report next year.
A reduction in these categories will form the
basis of our efforts to reduce errors in the future.
Apr 09 - Mar 10
Apr 08 - Mar 09
350
300
250
200
150
100
50
158 - Wrong
Frequency (inc.
giving twice)
161 - Meds
Recording
Incident
78 - Omitted
Medicine/
Ingredient
Other 15
Categories
ANNUAL REPORT 2009/2010
13
Priority 4:
All patients that have an inpatient
stay in Pennine Care would have been
assessed through a gatekeeping
function within the Crisis Resolution
and Home Treatment Team.
Actions planned to improve performance
The Trust’s target is to ensure that 90% of all
admissions are gatekept by Crisis Resolution and
Home Treatment teams. Current performance
over the last year can be seen from the graph
below:
The further development of the Trust’s Access
and Liaison function will create new challenges
for those seeking to ensure gatekeeping for all
patients. It is hoped that work towards a common
single point of entry for the Trust will enhance the
correct protocols are followed and that all activity
is appropriately recorded. The Trust will also
ensure greater efficiency in inpatient beds to
improve the patient experience by offering more
care at home.
% of admissions assessed through a gatekeeping process
100%
95%
Priority 5:
Ensuring an effective response to
complaints to the Trust
Current performance
In 2009/10 the Trust received 147 complaints.
The table below details the percentage of
complaints responded to within timescales
agreed with the complainant during 2009/10:
Complaints responded to within timescales
agreed with complainants:
Quarter 1
93%
Quarter 2
91%
Quarter 3
89%
Quarter 4
89%
90%
85%
Apr
May
Jun
Jul
Aug
Sept
Oct
90% target
How will we track improvement?
This year the Trust has continued the weekly
monitoring of gatekeeping, in order to gain a
fuller understanding of any issues in the quickest
possible time. This has resulted in an increase
in performance this year. The Trust intends to
continue to track improvements in this way.
Identified areas for improvement
The Trust will continue to strive to improve
arrangements for those patients admitted to
Pennine Care wards who reside out of the Trust’s
footprint.
Administrative procedures have been
strengthened within teams to ensure that the
14
PENNINE CARE NHS FOUNDATION TRUST
Nov
Dec
Jan
Feb
Mar
2009/10
% admission gatekept by CRHT
gatekeeping function and improve performance
still further. Increased training will be provided
to staff and managers within teams responsible
for gatekeeping patients to ensure that the
procedures are followed appropriately and that
patients receive the best care.
How will we report this priority?
The Trust will continue to report this priority
through existing Trust structures to ensure that
operational and strategic staff and managers are
aware of issues and can take remedial action
where necessary. This includes Work Programme
Groups, the Trust’s Service Development
Group, borough and team based meetings as
appropriate.
In 2009/10, the complaints response times were
as follows:
Within 10
working days
Percentage
of complaints
responded to
15%
Within between 11
and 25 working days
38%
In over 25
working days
47%
Whilst 91% of the complaints responded to
during 2009/10 have been responded to within
timescales agreed with the complainant, in
some of these cases the Trust has had to agree
extensions to the original timescale due to delays
in the investigation of the complaint. In all cases
though, response times are tracked.
The Complaints Department reports on numbers,
trends and the location to which complaints
relate, including to Board level. These reports are
largely based on the single most prominent issue
raised in a specific complaint and the Borough in
which the service complained of was delivered.
ANNUAL REPORT 2009/2010
15
How will we track improvement?
The Trust will be tracking improvement through
monthly, quarterly and annual reporting into the
integrated governance structure, reporting on the
numbers of complaints received, the main issues
raised in those complaints, themes identified and
the types of recommendations made.
This will be complemented by training offered
Trust wide to staff on how to effectively investigate
complaints and feedback provided to Divisional
Governance Managers on current complaints
status. This will enable a two-way process of
handling complaints, learning from them and
tracking improvements.
Areas for improvement
The Trust has identified two main areas for
improvement in this area:
1) To ensure that all concerns raised by
complainants are dealt with in accordance
with an agreed action plan with the
complainant (which includes timescales and
the form of response) and national legislation.
2) To ensure that the Trust maximises the
opportunity for service improvement
offered by complaints, by investigating and
identifying areas for improvement and making
recommendations to deliver change, and
the effective reporting into the integrated
governance structure.
Specifically, the Trust will strive to meet the
following aims to enable it to meet those areas
for improvement:
• Quicker response times to complaints,
delivered primarily through the timely
investigation of complaints received;
• More effective information reporting, including
more specific information about the issues
raised in complaints, the areas of the Trust
that they relate to and the complaints
16
PENNINE CARE NHS FOUNDATION TRUST
investigation performance of the different
Divisions; and
• Maximising the learning taken from
complaints through the making of
recommendations and the monitoring of their
implementation.
Actions planned to improve performance
Next year, the Trust plans a number of
specificactions to meet the stated aim in relation
to complaints include:
• Training to be revised to emphasise the need
for the timely investigation of complaints and
the making of effective recommendations.
• From April 2010, more precise recording and
reporting of the issues raised in complaints,
including all of the concerns raised in each
complaint, not just the main concern.
• From April 2010 detailed reporting on
Divisional performance in relation to
investigation times. This will include the
reasons for any delays in responding within
the requested timescale, thereby allowing
for the identification of problems and
improvement of response times.
• A review of the Trust’s Complaints Policy to be
undertaken in 2010 to ensure that it reflects
best practice and offers support to Trust
staff in meeting the stated aim in relation to
complaints.
Statements of Assurance from
the Board
During 2009/10 Pennine Care NHS Foundation
Trust provided one NHS service.
Pennine Care NHS Foundation Trust has reviewed
all the data available to us on the quality of care
in one of these NHS services.
The income generated by the NHS services
reviewed in 2009/10 represents 100% of the
total income generated from the provision of NHS
services by the Pennine Care NHS Foundation
Trust for 2009/10.
How will we report this priority?
The Trust will continue to report numbers, reasons
and types of complaints to Board level to allow a
strategic view on quantity. Qualitative responses
will be formulated and reported corporately
through the Trust’s Integrated Governance Group,
and service line groups across the Trust, down to
borough and team level as appropriate.
ANNUAL REPORT 2009/2010
17
Information on participation
in clinical audits and national
confidential enquiries
During 2009/10 five national clinical audits and
no national confidential enquiry covered NHS
services that Pennine Care NHS Foundation Trust
provides.
During that period, Pennine Care NHS Foundation
Trust participated in 100% of national clinical
audits and 100% of national confidential
enquiries of the national clinical audits and
national confidential enquiries which it was
eligible to participate in.
The national clinical audits and national
confidential enquires that Pennine Care NHS
Foundation 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 enquiry.
2009/2010
Number
448
Led by
(Nationally)
Numbers of cases
submitted as a
percentage of
cases required
Notes
National Health
Promotion in
Hospitals (NHPH)
Funded by DOH
N/A
and supported by
Royal College of
Nursing
Audit did
not commence
Privacy and
Dignity
Part of Essence
of Care
N/A
Audited as part
of Essence of
Care programme
POMH Topic 1
Prescribing high
dose and combined
antipsychotics
(82 data sets)
Royal College
of Psychiatrists
100%
82 cases
required,
82 submitted
2009
POMH-UK
Topic 8 Medicines
reconciliation
Royal College
of Psychiatrists
2009 016
POMH Topic 2
Royal College
Assertive outreach of Psychiatrists
screening for side
effects of antipsychotics
N/A
National Audit of
Royal College
Continence Care (NACC) of Physicians
N/A
2009 015
2009 021
18
Title of Audit
PENNINE CARE NHS FOUNDATION TRUST
The reports of two national clinical audits were
reviewed by the provider in 2009/10 and Pennine
Care NHS Foundation Trust intends to take
the following actions to improve the quality of
healthcare provided:
Audit Name: POMH-UK Topic 8 Medicines
The Trust has made ‘Medicines Reconciliation’ a
topic at the recent Quality Matters event that was
held to highlight quality initiatives and priorities.
A workshop was held which informed a variety
of practitioners from across the Trust about
improvements necessary to practice to implement
the necessary changes.
Report not yet
received by Trust
Report not yet
received by Trust
The reports of 25 local clinical audits were
reviewed by the provider in 2009/10 and
Pennine Care NHS Foundation Trust intends to
take actions to improve the quality of healthcare
provided as detailed in the reports, available on
request from Planning and Modernisation,
Trust Headquarters, 225 Old Street,
Ashton-under-Lyne, OL6 7SR.
A selection of actions are detailed below, full
reports are available on request from the above
address.
Progress against this audit is being monitored
through the Trust’s Drugs and Therapeutics
Committee.
Audit Name: POMH Topic 2 Assertive outreach screening for side effects antipsychotics
The report for this audit is to be written externally,
and is not yet due. Once the report is received
Audit Name: Adherence to the NICE Guidelines
for Schizophrenia in relation to CBT and
Family Intervention Audit Number: 405
Action
100%
from the Royal College of Psychiatrists, an action
plan will be developed.
Co-ordinator
Timescale
Feedback results to EIT at team meeting
CPN Care Co-ordinator
to raise awareness of NICE guideline standards
June 2009
Prioritise, assess and offer those clients
identified for CBT and FI
CBT Therapist
September 2009
Develop data front cover for client case notes
Asst. Psychologist
September 2009
Develop audit pro-forma based on updated
NICE guidelines for schizophrenia (2009)
Asst. Psychologist
April 2010
Re-audit based on new criteria
CPN Care Co-ordinator
May 2010
ANNUAL REPORT 2009/2010
19
Audit Name: Clinical Audit of Section 136 of the Mental Health Act
Audit Number: 421
Audit Name: Mental Capacity Act
Audit Number: 446
Action
Co-ordinator
Timescale
Action
Co-ordinator
Timescale
Audit results to be taken to Mental Health Law
Scrutiny Group and Mental Health Law Forums
Mental Health
Law Manager
June 09
Mental Health
Law Manager
December 2009
Police Liaison officers to highlight importance
of recording time of leaving on Part A of the
form to provide data for length of time they
have spent on site
Mental Health
Law Forums
June – July 09
To review the Trust’s Mental Capacity Act
guidance to ensure that staff are appropriately
recording the application of the Mental
Capacity Act.
Re-audit
Mental Health
Law Manager
2010
New Section 136 Policy to be distributed with
audit results
Mental Health
Law Manager
August 2009
Trust to consider using the Royal College of
Psychiatrists Report on Standards of the Use
of Section 136 (CR149) to carry out a pilot
in one borough
Mental Health
Law Manager
November 2009
Re-Audit
Mental Health
Law Manager
August 2010
Audit Name: Clinical Audit of Suicide Prevention:
April 2009 to September 2009
Action
Co-ordinator
Timescale
For a detailed action plan regarding the
standards, see the Suicide Prevention and
Self-Harm Working Group Action Plan
Continue to audit six-monthly
Clinical Audit Department
Ongoing
Changes made to the SPA audit tool after
discussion at the Working Group to update
and simplify the tool to make completion
easier – continue to review and monitor
Clinical Audit Department
Ongoing
Audit Name: Tribunal Service: Mental Health
Audit Number: 447
Action
Co-ordinator
Timescale
Introduce a system for MHL Offices to flag any
tribunals extending beyond an eight week turnaround to the Deputy Mental Health Law Manager
Deputy Mental Health
Law Manager
September 2009
Review the process and deadlines for processing
hearings, include the request to Responsible
Clinicians for dates, offering dates to solicitors
and forwarding these to the Tribunal Office
Deputy Mental Health
Law Manager
November 2009
Review the inputting of hearings on to the
Registers to ensure standardisation across
the Trust
Deputy Mental Health
Law Manager
October 2009
Results to be considered by:
Mental Health Law Scrutiny Group
Mental Health Law Forums
Consultant Groups
Mental Health Law Administrators
Meeting
Mental Health Law Manager/
Governance Managers/
Deputy Mental Health
Law Manager
October 2009
Re-Audit
Mental Health Law Manager
August 2010
The Trust undertakes a programme of local audit on clinical
performance which is reported to the Board of Directors.
20
PENNINE CARE NHS FOUNDATION TRUST
ANNUAL REPORT 2009/2010
21
Information on participation in
clinical research
The number of patients receiving NHS services
provided or sub-contracted by Pennine Care NHS
Foundation Trust in 2009/10 that were recruited
during that period to participate in research
approved by a research ethics committee is
approximately 123.
This figure includes a degree of uncertainty
due to the nature of the research that the Trust
undertakes. Whilst we do keep a record of
locally approved research in accordance with
the Research Governance Framework, we do not
have up-to-date recruitment figures for all of these
projects.
This cause of uncertainty is primarily in the case
of student or other externally managed research,
which constitutes the majority of Pennine Care’s
work. We have been able to provide recruitment
data for approximately 62% of the research
projects recruiting in the 2009/10 period. We feel
this is a fairly proportionate reflection of our total
recruitment for that period.
Pennine Care is, however, currently re-evaluating
its existing research systems and processes and
introducing new, robust ones in order to be better
equipped to provide this and other quantitative
data in the future. This shift in working practices
will also enable us to exceed legislation and
governance requirements and move towards
achieving best practice.
Our new research strategy is to help the Trust
develop as a leader in high-quality mental health
research by engaging with existing and potential
researchers, and promoting research that benefits
our service users. We plan to achieve this by
actively developing relationships with our own
staff who have a research interest, thus enabling
them to first participate in research and ultimately
22
PENNINE CARE NHS FOUNDATION TRUST
develop their own projects. We hope that this
locally initiated research could be a direct driver
for service improvement and patient care, both
in Pennine Care and in the wider mental health
arena.
The Trust is committed to continuous
improvement, and embraces a model of clinical
leadership which uses clinical audit to benchmark
practice and inform change.
Clinical audit has an important role within
the Trust. It is embedded within the clinical
governance structure and is important in ensuring
the quality of services and patient safety across
the Trust. The Trust encourages all healthcare
professionals, including clinicians, nurses,
social workers, psychologists and occupational
therapists, to participate in clinical audits and
provides training to ensure that individuals are
equipped with the skills required to conduct
audits. As part of the clinical audit strategy, the
Trust aims to significantly increase the number of
audits conducted annually by 2010.
Clinical audit is monitored and supported
centrally by the Clinical Audit Department, The
Clinical Audit Department works closely with
all departments within Integrated Governance,
including Pharmacy, Risk and Mental Health
Law and oversees the development of all
audits initiated by the various departments.
In addition, the Trust has nominated Medical
Clinical Audit Leads, supported by the Clinical
Audit Department, within each borough. The Audit
Department also has representation at Divisional
Integrated Governance Meetings held within
each Division and at the Work Programme Group
Meetings at which clinical audit is a standard
agenda item.
Clinical audit quality is of the utmost importance.
All clinical audits conducted within the Trust
must first receive approval from the Clinical
Audit Department. All audits are reviewed in
terms of the applicability to the Trust, robustness
of the proforma, involvement of service users
and adherence to Information Governance
procedures. The Clinical Audit Department has
developed standard templates which must be
used when applying for audit approval and when
writing the subsequent audit report. Written
approval is only given when the Department is
satisfied with all aspects of the proposed audit.
All audits conducted must be written-up as a
formal report using the template provided by the
Clinical Audit Department. An action plan must
be included in the report if areas for improvement
are identified, and audit leads are required to
feedback audit results locally. In addition, all
reports produced in a given year are published in
the Annual Clinical Audit Report which is widely
disseminated and made available on the Trust
intranet.
The clinical audit cycle is not complete until a
re-audit has been conducted as this is used to
determine if improvements in services have been
achieved. The Audit Department ensures that
re-audits are conducted within the timescale
detailed in the audit report action plan.
The Clinical Audit Department also has
responsibility for conducting audits against
National Standards and Guidelines including NICE
Guidelines. Within the Trust, there is a dedicated
NICE and Clinical Effectiveness Panel that reviews
all published guidelines and determines the audit
programme for national guidelines accordingly.
The NICE and Clinical Effectiveness Panel is
chaired by the Medical Director and is facilitated
by the Clinical Effectiveness Manager to ensure
continuity in the conduct of clinical audit.
in addition, the Trust also develops and publishes
an Annual Clinical Audit Programme, which is
managed by the Clinical Audit Department. The
yearly Clinical Audit Programme specifically
addresses national and Trust priorities and
is developed in conjunction with all relevant
departmental managers, Work Programme
Groups and Executive Directors and the Chief
Executive. A number of service user-led audits are
also included within the Annual Programme. Audit
topics are selected at the Service User and Career
Forum Meetings, which are held frequently at the
Trust. The development of the selected audits is
supported by the Clinical Audit Department.
The Trust also participates in and subscribes
to other national initiatives, such as the quality
improvement programmes run by the Prescribing
Observatory for Mental Health (POMH-UK).
The programmes that the Trust participates
in comprise a cycle of clinical audit against
evidence-based standards and bespoke change
interventions, including prompt feedback of
benchmarked data that allow our Trust to
compare their prescribing practice with other
participating Trusts. As a Trust, we are also taking
part in the National Continence Care Audit, led by
the Royal College of Physicians, and the National
Audit of Psychological Therapies for Anxiety
and Depression, led by The Royal College of
Psychiatrists.
The Trust strongly promotes locally led audits
initiated by various healthcare professionals, but
ANNUAL REPORT 2009/2010
23
Information on the use of the
CQUIN Framework
Commissioner Quality schedule
A proportion of Pennine Care NHS Foundation
Trust’s income in 2009/10 was conditional on
achieving quality improvement and innovation
goals agreed between Pennine Care NHS
Foundation Trust and any person or body
they entered into a contract, agreement or
arrangement with for the provision of NHS
services, through the Commissioning for Quality
and Innovation payment framework.
Further details of the agreed goals for 2009/10
and for the following 12 month period are
available on request from the Trust at:
Pennine Care NHS Foundation Trust,
225 Old Street, Ashton-under-Lyne, OL6 7SR.
In 2009/10, £966,122 was contingent on
performance against the range of indicators
below. The Trust received £966,122 as a result
of its performance. Further information on the
financial performance of the Trust is available
within the Annual Accounts.
These standards have been based on quality
indicators outlined in the mental health model
contract and some locally driven indicators. The
areas of focus are outlined below:
• Care Planning – allocated care coordinator,
recorded employment and accommodation
status
• CAMHS service improvements
• Privacy and Dignity and the elimination of
mixed sex accommodation
• Physical Health and Well-being of patients
• Improvements to services for people with
Learning Disabilities
• Improvements to Older People’s Services
24
PENNINE CARE NHS FOUNDATION TRUST
• Increasing Access to Psychological Therapies
• Implementing the Productive Ward
Programme
• Improvement to A&E waiting time performance
• Reduction in voluntary inpatient admissions
• Collaborative service improvements in
conjunction with PCTs
• Improving the service user experience
• Ensuring that wider contractual and
performance improvement measures are
achieved.
Information on registration
with the Care Quality
Commission
Pennine Care NHS Foundation Trust is required
to register with the Care Quality Commission and
its current registration status is “Registered”.
Pennine Care NHS Foundation Trust has no
conditions on registration.
The Care Quality Commission has not taken
enforcement action against Pennine Care NHS
Foundation Trust during 2009/10.
Pennine Care NHS Foundation Trust is subject to
periodic reviews by the Care Quality Commission
and the last review was on 31st March 2009.
The CQC’s assessment of Pennine Care NHS
Foundation Trust following that review in the
Annual healthcheck resulted in the Trust
achieving “Excellent” in Quality of Services and
“Excellent” in Use of Resources.
Pennine Care NHS Foundation Trust intends to
take the following action to address the points
made in the CQC’s assessment:
• Improvements to performance against CAMHS
performance indicators
• Improvements to performance indicators
in the Green Light Toolkit for Learning
Disabilities.
Pennine Care NHS Foundation Trust has made the
following progress by 31st March 2010 in taking
such action:
• Improvements to performance against CAMHS
performance indicators including enhanced
reporting links from CAMHS to Board level
within the Trust, and a greater focus on
highlighted improvement areas.
• Improved scores against the Green Light
toolkit for Learning Disabilities. This has been
achieved through the establishment of a
Trust Learning Disabilities working group, and
through the enhancement of links to local
PCTs for the better provision of LD services.
Pennine Care NHS Foundation Trust has
not participated in any special reviews or
investigations by the CQC during the reporting
period.
Response to regulators
Pennine Care NHS Foundation Trust’s recent
declaration to the Care Quality Commission
indicated our compliance with all of the core
standards in the Annual Health Check and the
regulations required by the registration process.
The latest Healthcare Commission ratings placed
the Trust amongst the top performers for mental
health services in the country, scoring “Excellent”
for quality of services and “Excellent” for Use of
Resources.
Use of the Care Quality Commission’s
Registration and Quality and Risk
profile
This year for the first time, the Trust has to register
its services with the Care Quality Commission,
indicating how it meets 16 regulations from the
Health and Social Care Act.
We have had to register all our services against
the following regulations and assess our own
compliance with the outcomes underpinning each
of these.
Section 1:
Involvement and information
• Respecting and involving people who use
services
• Consent to care and treatment
• Fees etc.
Section 2:
Personalised care, treatment and support
• Care and welfare of people who use services
• Meeting nutritional needs
• Cooperating with other providers.
Section 3:
Safeguarding and safety
• Safeguarding people who use services
from abuse
• Management of medicines
• Safety and suitability of premises
• Safety, availability and suitability of equipment.
Section 4:
Suitability of staffing
• Requirements relating to workers
• Staffing
• Supporting staff.
Section 5:
Quality and management
• Statement of purpose
• Assessing and monitoring the quality of
service provision
• Complaints
• Notification of death of service user
• Notification of death or unauthorised absence
of a service user who is detained or liable to
be detained under the Mental Health Act 1983
• Notification of other incidents
• Records.
ANNUAL REPORT 2009/2010
25
Section 6:
Suitability of management
• Requirements where the service provider is an
individual or partnership
• Requirements where the service provider is a
body other than a partnership
• Requirements relating to registered managers
• Registered person: training
• Financial position
• Notifications - notice of absence
• Notifications - notice of changes.
In addition to these and to support our own
process, the CQC have published a Quality and
Risk profile for the Trust. This indicates where we
are achieving better, average or worse than other
similar organisations against a range of targets,
the patient survey and the staff survey.
The new regulations within the Health and Social
Care Act 2008 have changed the process in
which the Care Quality Commission is assessing
compliance within Pennine Care. Through internal
assessment we believe there are two areas for
improvement in light of the new regulations.
Supporting staff
Information on the quality of data
Pennine Care NHS Foundation Trust submitted
records during 2009/10 to the Secondary Uses
service for inclusion in the Hospital Episode
Statistics which are included in the latest
published data. The percentage of records in the
published data:
• which included the patient’s valid NHS
number was:
- 100% for admitted patient care;
- 99.9% for outpatient care; and
- N/A for accident and emergency care.
The Care Quality Commission’s assessment has
highlighted that the Staff Survey places Pennine
Care slightly below the national average in a small
number of areas. It is believed that Pennine Care
does support its staff but recognises there is
more work to do in communicating with Staff and
providing training plans and monitoring managers
against these plans. Plans are in place to achieve
this, and are detailed within the Trust’s Annual
Report.
• which included the patient’s valid
General Medical Practice Code was:
- 100% for admitted patient care;
- 98% for outpatient care; and
- N/A for accident and emergency care.
Healthcare acquired infection
Pennine Care NHS Foundation Trust was not
subject to the Payment by Results clinical coding
audit during 2009/10 by the Audit Commission.
Following an inspection from the Care Quality
Commission the Trust has implemented a full
review of its processes to inspect the quality
26
of our ward environments. Pennine Care has
made significant progress on hygiene and
cleanliness and has undertaken a programme
of work to ensure that every member of staff is
aware of their responsibilities in this area. The
Care Quality Commission have re-inspected our
wards and agreed that they are now adhere to
the code of conduct. Pennine Care, as part of its
registration declaration, submitted an action plan
of improvement, this is now in place to ensure our
wards are meeting and continue to meet the code
of practice.
PENNINE CARE NHS FOUNDATION TRUST
Pennine Care’s score for 2009/10 for Information
Quality and Records Management, assessed
using the Information Governance Toolkit, was
83%.
Part 3: Other Information
Review of Quality Performance
in 2009/10
Current view of the Trust’s position
and status for quality
During 2009/10, the Trust has made a large
amount of progress with regard to quality. This
has focussed on two key pieces of work, namely
the Integrated Governance Quality Indicators
and the development and agreement of ‘Quality
Matters’ – a quality improvement strategy
2009-14.
Integrated Governance Quality
Indicators
At the beginning of 2009/10, a range of
indicators were agreed by the Board of Directors
as our first ‘quality account’ measures. These
indicators were debated at both clinical and board
level with a range of improvement work streams
attached to them. It was agreed that these would
be monitored on a monthly basis by the Board of
Directors. These indicators are:
Patient Safety
• Patients going absent without leave,
absconding, or going missing
• Self harm incidents
• Slips, trips and falls
• Medication errors
• Physical assaults reported against staff
(PARS).
Clinical quality
• Delayed transfers of care
• CPA seven day follow up
• Crisis Resolution Home Treatment
gatekeeping for all referrals
• Privacy and Dignity Improvement Plan
• Grade 4 and 5 incidents
• Mental Health Act Admissions
• Items on the Trust Risk Register
Patient experience
• Complaints
• Compliments
• Infection Control
• Investigations
• Coroners investigations
• Litigation
For some of these we have generated internal
improvement targets and for others it has been
about improving the data or monitoring trends,
with the expectation that these will inform targets
in the future.
For the purposes of this Quality Account,
the information below indicates the Trust’s
performance against some of these indicators,
covering the themes of Patient Safety, Clinical
Quality and Patient Experience. The indicators
reported this year have changed from last
year. This reflects the Trust’s work to widen the
scope of its quality improvements, reflecting the
consultations that we have had with our partners,
members and other stakeholders. The range of
indicators reported this year is wider than last
year, and is more extensive.
Quality Matters
The second key work stream has been the
development and agreement of our quality
strategy, ‘Quality Matters’. We took a decision
to use this as an opportunity to build on our
clinical engagement work. The development of
the strategy involved a wider range of consultant,
nursing and practitioner staff. A wide range of
service users and carers were also involved
in thinking about and defining which quality
indicators would make a real difference to the
care they received.
ANNUAL REPORT 2009/2010
27
The priorities for 2009 – 2011
in the strategy are:
• Staff Learning and Organisational
Development
• The Productive Ward Programme
• Physical Health and Health Promotion
• Medicines Management
• Standardised Clinical Risk Assessment
The strategy also establishes how future quality
improvement priorities will be developed and link
into the business planning cycle.
• Improving Health and Safety on wards
continues to be a top priority for our wards
and capital programme. A significant
replacement programme of windows across
our estate has been completed to ensure
security, minimal ligature risk and also bring
more natural light into our wards areas.
• The Trust has once again met all of its Core
Standards, and has been scored “Excellent”
for the quality of its services by the Care
Quality Commission.
28
PENNINE CARE NHS FOUNDATION TRUST
Priority 1: Patients going absent
without leave (AWOL), absconding,
and going missing
Description of issue and rationale for
prioritising:
Improvements to the levels of AWOLs has been
identified as a key quality measure for the Trust.
The current measurement of this target includes
a range of people, some of whom genuinely
abscond, but others of whom are late returning
from leave. Work this year has concentrated on
introducing the AWOL toolkits to all wards and
improving the quality of the data.
In addition to the strategies outlined above,
we have also made significant progress on
the following:
• We have continued to make good progress
in improving single-sex wards and gender
separation. The Trust has already invested
significantly in this area and complies with
both single gender and privacy and dignity
standards. The Trust recognises the ongoing
work required to ensure that our patients
receive services in line with this. In order to
support this work, we have also developed
a monthly patient survey on the wards
around patients feeling safe and how gender
separation is being managed.
• Increasing awareness and compliance with
hygiene and hand-washing improvements
have continued across the Trust, supported
by our Infection Control Nurses and Modern
Matrons. Work has also commenced across all
wards to continue to improve cleanliness and
hygiene following a visit by the Care Quality
Commission, which found some areas in need
of improvement. The numbers of infections
continue to remain low, the Board of Directors
receives monthly update on compliance with
the Hygiene Code.
Review of Patient Safety
Indicators 2009/10
At Pennine Care the following definitions are used
to describe incidents of unauthorised absence:
Launch of the Making Connections Not
Assumptions Project, set up to address service
difficulties in meeting the needs of older South
Asian women with mental health problems.
• The term ‘AWOL’ or ‘absent without leave’
refers to any inpatient detained under the
Mental Health Act, who either leaves the ward
without permission or who fails to return to
the ward after a period of leave.
• The term ‘absconding’ refers to any other
inpatient (i.e. not detained under the Mental
Health Act) who either leaves a ward without
permission or who fails to return to a ward
after a period of leave.
• The term ‘missing’ is used to describe
those patients who go missing whilst in the
community.
AWOL and absconding incidences from acute
inpatient psychiatric wards are a significant
clinical problem that can place patients and
others at risk, as well as being burdensome
and anxiety provoking for staff. The negative
consequences of going AWOL or absconding
are numerous and can include violence,
aggression, self neglect, prolonged treatment
time and hospital stays and substantial financial
implications. In addition, research informs us that
about a quarter of inpatients who commit suicide
do so after going AWOL or absconding and on
very rare occasions there have been homicides
by patients in this group (Bowers, 1999). Police
resources must also be considered, as about half
of all these cases are reported to the police, who
then have to invest time and personnel in trying to
return patients to hospital (Bowers, 1999).
Aim/goal
To reduce the level of patients going Absent
Without Leave (AWOL), missing or absconding
during the year.
Current status
AWOL and absconding incidences represent a
key safety and patient experience improvement
area across the Trust. We are committed to
understanding and implementing preventive
initiatives to reduce the rates of such
incidents. We rigorously measure all AWOL and
abscondment events on a monthly basis (Figure
1) across the Trust to ensure that we are able to
detect any increases or abnormalities which we
need to act upon. Currently, we use a national
average abscondment rate derived from The
Healthcare Commission report ‘The Pathway
to Recovery’ to measure our performance at a
national level.
ANNUAL REPORT 2009/2010
29
Figure 1:
Identified areas for improvement
The Trust will continue to strengthen its own
internal monitoring of absconding and AWOL
events and will set its own benchmarking
standards as opposed to relying on national
average figures. We will aim to reduce AWOL
and absconding incidences by 3% in 2010/2011.
AWOL/absconded/missing
40%
30%
20%
10%
0%
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
National average (27%)
Sept
Oct
Nov
Dec
Jan
% of admissions
The Trust will also analyse the reported data
which will be used to ensure action plans and
recommendations to reduce these incidents are
performance managed within services.
Current initiatives
*Data correct as at January 2010
In comparison to 2008/09, in 2009/10 we have observed at 27% decrease in the number of incidents
of patients going AWOL, absconding or going missing (below).
Table 1
30
2008/2009
2009/2010
Missing
(community patients)
54
32
AWOL
(detained patients)
462
256
AWOL – not returned from leave
(detained patients)
115
159
Absconded
(non-detained patients)
201
95
Absconded – not returned from leave
(non-detained patients)
21
70
Total
853
612
PENNINE CARE NHS FOUNDATION TRUST
The Trust has monitored the impact of the
implementation of the toolkit and continues to
manage performance improvement.
Pilot sites have been implementing the AntiAbsconding Workbook (City University, 2003). The
focus has been on awareness of certain high-risk
patient groups:
• Absconded during a previous admission –
nine times more likely to abscond
• Refusal of medication in previous 48 hours –
three times more likely to abscond
• 35 years or under – three times more likely to
abscond
• Male – two times more likely to abscond
• Diagnosis of schizophrenia – two times more
likely to abscond
The outcomes of these initiatives are being
monitored by the Divisional Integrated
Governance Groups and the Integrated
Governance Group.
also report the data differently to allow us to more
effectively monitor incidences across the Trust.
These measures include:
• Reporting the total number of events as
opposed to displaying them as the percentage
of inpatient admissions as this will prevent the
possible misinterpretation of the total figures
(Figure 2). For example, under the previous
reporting system the monthly data may have
been influenced by an unusually low or high
admission rate for the month, or by longterm patients who may go AWOL or abscond
multiple times during a single admission.
• Reporting on the number of events by ward, in
order to ascertain any trends.
• Presenting data detailing the absolute number
of events linked to single individuals. This will
help to both identify patients at increased risk
of going AWOL or absconding and will also
provide extra information based around the
total number of AWOL or absconded patients,
not just the individual incidents themselves.
We will continue to use the metrics identified as
measures of quality in this area, to report in a way
which is consistent in future years.
New initiatives
The Trust has a number of initiatives which it will
work towards in the future in order to improve
quality in this area. We will continue to implement
the research within the Anti-Absconding Workbook
(City University, 2003) across all wards. We will
ANNUAL REPORT 2009/2010
31
Priority 2:
A reduction in self-harm incidents
Incidents of AWOL,
abscondment and missing
Description of issue and rationale for prioritising
Self harm is a very common reason for hospital
presentation; the Registrar General’s figures for
England and Wales for 2003 indicate 170,000
people presented to general hospitals after selfharming. People who have self-harmed represent
4–5% of all A&E attendances, and self harm is
one of the top five causes of acute medical and
surgical admissions in the UK. It is suggested
however that the majority of episodes of self harm
never reach the health service. In addition, self
harm is often linked to mental health conditions
and, as such, is a common occurrence within
secondary mental health services, especially in
adolescent services.
100
90
80
Number of incidents
70
60
50
40
30
20
10
Absconded, non-return from leave (non-detained pt)
Absconded (non-detained pt)
AWOL, non-return from leave (non-detained pt)
Mar 10
Feb 10
Jan 10
Dec 09
Nov 09
Oct 09
Sep 09
Aug 09
Jul 09
Jun 09
May 09
Apr 09
Mar 09
Feb 09
Jan 09
Dec 08
Nov 08
Oct 08
Sept 08
Aug 08
Jul 08
Jun 08
May 08
Apr 08
0
AWOL (detained pt)
Missing (community pt)
Trust target
There is often controversy about the terminology
used to describe an act of self harm as defined
above; disagreements generally revolve around
the degree and kind of intent required. Descriptive
labels found in literature include deliberate selfharm (DSH), parasuicide, parasuicidal behaviour,
non-fatal self-harm, and more pejorative labels
like suicide gestures and manipulative suicide
Note: The ‘non-returned from leave’ category for both detained and non-detained patients was not introduced until
December 2008. Prior to this these incidents were only coded as either AWOL or absconded.
attempts are present. Use of pejorative labels has
been argued to create blame and dislike toward
the service user. For the purpose of this report the
term self-harm will be used.
Pennine Care recognises that it cannot
realistically expect or achieve risk elimination.
However, the Trust expects that all efforts will
be made to achieve risk minimisation and a
reduction in self-harm incidences is a key
Trust priority.
Aim/goal
• To increase staff awareness in relation to selfharm and increase reporting
• To reduce the number of self-harm incidences
Pennine Care NHS Foundation Trust collates the
self-harm figures by including all incidents coded
as a suspected self-harm attempt, attempted
self-harm (no injury), self-harm using medication,
self-harm excluding medication and attempted
suicide. The data is collected and reported
on a monthly basis. The number of self-harm
incidences which occurred between April 2008
and March 2009 vs. April 2009 and March 2010
is depicted in Figure 1.
Trust self harm incidents 2008 - 2010
160
Figure 2: New method of presenting data relating
to AWOL, abscondment and missing patient
incidences.
140
120
100
2008 - 2009
2009 - 2010
80
60
40
20
0
Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Figure 1: The number of self harm incidents in
2008/09 vs. 2009/10 across the Trust
32
PENNINE CARE NHS FOUNDATION TRUST
ANNUAL REPORT 2009/2010
33
34
PENNINE CARE NHS FOUNDATION TRUST
Current status
Following guidance from the National Patient
Safety Agency (2007), the Trust developed a Falls
Prevention Strategy, which aimed to reduce the
number of falls across the organisation each
year by 3%. Outstanding results were obtained
in 2007/2008 with an 18% decrease in falls
observed compared with 2006/2007. We further
improved on this in 2008/09 when we reported
a 21% decrease in falls compared with 2007/08.
Incidents of slips, trips and falls
100
80
60
40
20
Mar 10
Feb 10
Jan 10
Dec 09
Nov 09
Oct 09
Sep 09
Aug 09
Jul 09
Jun 09
May 09
Apr 09
Mar 09
Feb 09
Jan 09
Dec 08
Nov 08
Oct 08
0
Sept 08
All service users who present with threat of, or
incidents of self-harm, receive a full risk and
psychosocial assessment; the findings of risk
assessment of self-harm are documented and an
annual audit will be conducted to ensure 100%
compliance.
• To improve the patient experience for older
people by preventing falls where possible
• To increase staff awareness in relation to falls
prevention
• To reduce the number of slips, trips and falls
by 3% per annum.
120
Aug 08
In order to reduce the incidents of self-harm,
annual ligature assessments are conducted in
inpatient wards across the Trust. This assesses
environmental suicide risks and remedial and
preventative action taken where possible. The
Trust has installed collapsible curtain/shower rails
to reduce ligature points on inpatient units.
Financial implications can include incurred costs
such as those relating to treatment, increased
lengths of inpatients stay, complaints and, in
some cases, litigation.
Jul 08
Current initiatives
• STORM training, which will be continued to be
rolled-out across the Trust.
• The Trust is intending to use information from
a thematic evaluation which was conducted
within CAMHS to identify common themes
in relation to self-harm incidences, e.g. time
of event, place of event etc. to implement a
number of initiatives to try and reduce selfharm incidences. This includes measures
such as introducing various activities for
inpatients at time points that are strongly
correlated to incidence times.
• Guidelines for the Assessment and
Management of self-harm have been
developed and will be ratified in April/May
2010. The purpose of the guidelines is to
ensure that the Trust adopts a systematic
and shared approach to risk assessment
and management of self-harm at individual
practitioner, team and organisational levels.
The new guidelines will be implemented via
the Divisional Integrated Governance Groups
and the governance structure within the
CAMHS Directorate.
Service user falls can have significant implications
in terms of both human and financial costs.
For individual patients, the consequences can
range from distress and loss of confidence, to
injuries that cause pain and suffering, loss of
independence and occasionally death. These
incidents can also bring about feelings of anxiety
and guilt for the patients’ relatives and hospital
staff.
Jun 08
We have made significant progress in relation to
raising awareness of self-harm and increasing
our reporting of incidences. This has been
achieved through internal training and awareness
campaigns. However, a priority moving forward
is to reduce the number of inpatient self-harm
incidences by 5% and community incidences by 3%.
A variety of new initiatives are planned for the
coming year. These include:
Aim/goal
Description of issue and rationale for prioritising
May 08
Identified areas for improvement
New initiatives
Priority 3:
A 3% reduction in slips, trips and falls
April 08
The number of incidences which have occurred
since July 2008 is influenced by the opening of
the Hope Unit. The Hope Unit is a 12-bedded ward
providing acute, short-term intensive, inpatient
assessment and treatment for young people
with severe acute mental illness or psychiatric
disorder, for whom enhanced community
treatment is no longer viable or safe. The target
age group for service users is predominantly
16–17 years old and the service is managed
through the CAMHS Directorate. Due to the nature
of the client population served by this Unit, it is to
be expected that there will be an impact on the
self-harm figures for the Trust. So far there have
been 250 self-harm incidents reported from the
Hope Unit this year, i.e. since March 2009.
Risk assessment is integral to deciding on the
most appropriate level of risk management
and intervention with a service user, where the
assessor aims to make every effort to achieve
harm minimisation. The Trust has introduced
STORM training, which is specific to self harm to
ensure that all relevant staff are competent in
identifying individuals at most risk.
Number of incidents
Factors influencing the number of self-harm
incidences
ANNUAL REPORT 2009/2010
35
Figure 2: New reporting mechanism for slips, trips and falls
Identified areas for improvement
A significant proportion of falls occur within the
Older People’s population and as a Trust, a clear
priority is to reduce this figure in the coming
year. In addition, we would like to gain a more
comprehensive understanding of staff slips, trips
and falls and would like to reduce the number of
occurrences by 3%.
Current initiatives
A thematic analysis was undertaken in the
Tameside Older People’s Unit to identify factors
linked to increased falls in older people. The
information obtained was used to develop a
comprehensive falls prevention training package,
which has been rolled out in many areas of the
Trust.
36
PENNINE CARE NHS FOUNDATION TRUST
100
80
60
40
20
• In addition we will also identify any patients
or staff involved in multiple incidents, in order
to determine if there is particular cause for
concern.
The Trust is working towards providing additional
training on falls prevention throughout the Trust.
This patient safety and experience priority will
be monitored through the Risk and Clinical
Governance Group and the recently convened
Divisional Integrated Governance Groups where
information is provided through a monthly
dashboard.
Mar 10
Feb 10
Jan 10
Dec 09
Nov 09
Oct 09
Sep 09
Aug 09
Jul 09
Jun 09
May 09
Apr 09
Mar 09
Feb 09
Jan 09
Dec 08
Nov 08
Oct 08
Sept 08
Aug 08
Jul 08
0
Jun 08
Within the South Division, the Falls Prevention
Strategy Group continues to monitor and work
towards maintaining the safety of patients in
relation to falls.
• Reporting the total number of incidents
instead of displaying them as a percentage
of inpatients. The results presented to the
Board will also be broken down according
to whether they occurred in Adult or Older
People’s Services or if they were actually
staff falls (Figure 2). This will also prevent the
possible misinterpretation of the figures that
could be skewed by multiple incidents being
accountable to a single patient.
120
May 08
The Trust identified the reduction of slips, trips
and falls as part of the Patient Safety First
Campaign and Tameside Older People’s Service
has shown significant success in reducing falls
within their inpatient units.
65 and over
Under 65
Staff
We will be reporting data for slips, trips and falls
in a new way so that we can more effectively
monitor incidences in higher risk areas. The new
reporting measures include:
Apr 08
In the 2009/10 reporting period we have
projected a small increase of 3% from last year,
based on projected figures for the 11 months
of data available. Whilst it is disappointing not
to have a decrease, the Trust predicts falls will
continue to decrease in future as we implement
new strategies and continue to highlight this key
issue.
New initiatives
Number of incidents
This meant the Trust had achieved an overall
decrease in falls of 35% against the baseline
figure in the two years since our strategy was
initiated, and far exceeded the target identified.
bespoke risk assessment tool for use in Older
People’s Services.
We will also develop an information leaflet for
relatives and carers through the Falls Prevention
Strategy Group to help raise awareness and
supportive preventative action.
A thematic analysis was undertaken in Tameside
to identify factors linked to increased falls in older
people. Following the successful pilot in Tameside,
this thematic analysis will be conducted across
the Trust to gain a comprehensive data set. The
aim of this project is to provide robust information
in relation to those at highest risk to develop a
ANNUAL REPORT 2009/2010
37
Priority 4:
A reduction in medication errors
Description of issue and rationale for prioritising
Medicines are a central component in the delivery
of high-quality healthcare and their effective use
contributes significantly to achieving successful
outcomes for patients. The effective use of
medicines is usually the mainstay of treatment
in patients with severe mental health illness,
and is known to significantly reduce the risk of
relapse and to improve quality of life when used
appropriately.
The Trust needs to be able to demonstrate that
the systems associated with medicines are of
the highest quality and that the staff involved
in medicines processes are trained to a high
standard.
It is important that all clinical staff have a working
knowledge of medicines management and that
this knowledge is used to listen to service users
and carers about the things that concern them.
In-keeping with the above, the Trust has
developed a Competency Appraisal Framework for
Registered Nurses around the safe administration
of medicines. Following implementation this will
be used to improve standards of practice and
quality.
Medication errors are patient safety incidents
involving medicines in which there has been an
error in the process of prescribing, dispensing,
preparing, administering, monitoring, or providing
medicine advice, regardless of whether any harm
occurred.
This is a broad definition and the majority of
medication errors do not result in harm. However,
some do have the potential to cause harm and
are often termed ‘near misses’.
38
PENNINE CARE NHS FOUNDATION TRUST
Reducing medication errors improves the patient
experience and reduces the risk of a patient
being harmed and it is acknowledged that the
complexity of care pathways in mental health
services increased the potential for medication
errors.
An agreed 10% reduction target has been set
for the number of medication error incidents
in specified categories across the Trust and
there will be an on-going programme to reduce
incidents and improve the quality of reporting.
Medication errors
25
20
15
10
5
0
Apr
May
Jun
Jul
Aug
Sept
Oct
Aim/goal
• To optimise the use of medicines by promoting
effective and evidence-based clinical practice
and effective risk management
• To enable patients to make the best possible
use of medicines
• To meet the needs of individual patients,
to increase accessibility and to ensure the
highest possible standards in all aspects of
medicine use.
The Trust’s Medicines Management Strategy
2009-2011 identifies key actions that the Trust
will take to ensure that the goals are met and that
the systems associated with medicines are of a
high quality.
Current status
The three identified categories of medication error
for the year were:
• Category 78 – Omitted Medicines
• Category 152 – Patient Identification
• Category 158 – Wrong frequency or time
Nov
Dec
Jan
Apr 08 - Mar 09
Feb
Mar
Apr 09 - Mar 10
2008/09
16
14
12
10
8
6
4
2
0
Apr 08 May 08 Jun 08 Jul 08 Aug 08 Sept 08 Oct 08
Nov 08 Dec 08 Jan 09 Feb 09 Mar 09
78
152
158
2009/10
10
8
6
4
2
0
Apr 09 May 09 Jun 09 Jul 09 Aug 09 Sept 09 Oct 09 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10
78
152
158
of administration of medicines
At 31st March 2010 the Trust had recorded
103 medication errors against the three codes
concerned. This compared to 169 errors in the
year to 31st March 2009.
ANNUAL REPORT 2009/2010
39
Identified areas for improvement
• Successful implementation and roll out of the
Registered Nurses Competency Assessment
Framework and improved and enhanced
medicines management systems.
• A 10% reduction in medication related
errors within a year of implementation of our
quality improvement strategy in the following
categories:
- Patient identification (code 152)
- Wrong frequency or time of
administration (code 158)
- Omitted medicine (code 78).
Current initiatives
The medication error incident statistics are
reviewed on a quarterly basis by a Sub-group
of the Drugs and Therapeutics Committee.
This multi-disciplinary group looks at individual
incidents and analyses incident trends in order to
make recommendations about risk management
or training issues following each quarterly
meeting.
A ‘Learning from Medication Errors’ bulletin is
produced and circulated in order to disseminate
findings and share learning.
Particular emphasis has been placed on patient
identification, wrong frequency or time and
omitted medicine incidents in 2009.
In 2009, electronic web based incident reporting
was introduced. The system allows coding of
errors by both cause and type ensuring increased
accuracy in coding and hence learning (NRLS).
In 2009, the Trust became a member of the
National Prescribing Observatory for Mental
Health (POMH-UK) whose aim is to help specialist
mental health Trusts to improve their prescribing
practice.
40
PENNINE CARE NHS FOUNDATION TRUST
The Trust will continue to subscribe to the POMHUK national clinical audit programme, which
provides valuable information on our performance
and allows us to bench-mark ourselves against
other mental health Trusts.
In early 2010 quick access to the electronic
British National Formulary (e-BNF) was made
available on all PCs belonging to the Trust
enabling healthcare professionals to use the BNF
more easily.
New initiatives
An assessment of prescribing competence for all
junior medical staff will be finalised in 2010 and
this will form part of Trust Medicines Management
induction.
A review of all medicines management training
will be undertaken which will include training on
reporting medication error incidents and Adverse
Drug Reaction reporting.
A further three categories of medication error
incidents will be selected for a reduction of 10%
during 2010-2011.
For Pennine Care as a specialist mental health
Trust this issue is particularly important. National
figures for 2008/09 show that staff in Mental
Health Trusts are around eight times more likely
to be assaulted than staff in other types of Trust.
Within the 75 Trusts identified as incorporating
mental health, Pennine Care sits in the top
quartile in terms of incidents, although this is
largely due to the reporting mechanisms in place
within the Trust which lead to a higher number of
disclosures.
Physical assaults against NHS staff are a key
priority for every Trust, as all employers have a
statutory duty to protect their staff from workrelated violence and aggression under European
legislation. Whilst there is little data around the
physical and emotional impact on staff, or the
financial impact on Trusts that violent incidents
create, it is clear that is an important issue and
that identifying and reducing the risks of physical
assaults is vital to improving the working lives of
our staff.
Identified areas for improvement
As such Pennine Care has developed strategies
and initiatives as detailed below.
The Trust has identified training and improving
the safety of lone working as key areas where
improvement initiatives should be focused.
Aim/goal
Current initiatives
• To reduce the incidence of physical attacks
against staff
• To improve the working lives of staff by
promoting safer therapeutic practice and
environments.
The Trust is strongly committed to learning from
incidents and carries out an ongoing programme
of training for staff that includes many important
initiatives.
Current status
Pennine Care recorded 804 incidents in
2008/09, an increase of approximately 5% from
Priority 5: A reduction in physical
assaults against staff (via Physical
Assaults Reporting System)
Description of issue and rationale for prioritising
2007/08. This increase reflects the opening of
additional inpatient facilities and also reflects the
Trust’s continuing work to promote the reporting
of all incidents, even those where there has been
no significant injury. In the period 2009/10 we
recorded 790 incidents, which results in a 2%
decrease from 2008/09. The Trust hopes to
continue and improve upon this downward trend
in the future.
There is a focus on the provision of training in the
national course Promoting Safer and Therapeutic
Services. This is a bespoke mental health course
enabling staff to work collaboratively with service
users and cares in determining the causes of
PARS (assaults on staff)
100
80
60
40
20
0
Apr 09
May 09
Jun 09
Jul 09
Aug 09
Sept 09
Oct 09
Nov 09
Dec 09
Jan 10
Feb 10
Mar 10
ANNUAL REPORT 2009/2010
41
violence in the widest sense (service design,
delivery etc).
A primary focus is on safety across all our services
and service delivery environments. There have
been wider issues explored this year in our
primary prevention strategy of the ‘Think’ (safer
place to work) Campaign looking at Diversity
Issues and Lone Working Safety.
A Lone Working Information Strategy has been
produced to support the national roll out and our
local pilot of the lone working assistive devices.
A dedicated training course has now also been
developed for community and lone working
personal safety issues.
The organisation is working in a targeted way to
sensitively develop bespoke training interventions
for areas of higher clinical activity (reporting low
risk but high frequency assaults).
Active working links have been created, and
representation has been given by the Trust on the
CFSMS Expert Reference Group for Non-Physical
Interventions.
New initiatives
The Trust continues to support an ongoing
programme of safety and security improvements.
A major programme of works has been
undertaken across the Trust to provide state-ofthe-art nurse call and staff attack alarm systems.
Funding is allocated each year to maintain and
improve our security systems, including CCTV,
fencing and improvements to lighting. The Trust
funds security guard services as required. The
Trust encourages a proactive security culture,
and we invest in an ongoing programme of
Management of Violence and Aggression (MVA)
training. We offer de-escalation training to prevent
incidents happening in the first place, and meet
42
PENNINE CARE NHS FOUNDATION TRUST
national guidelines on the training of staff in
conflict resolution. The Trust provides staff with
personal attack alarms on request and at no cost.
The ‘Think’ campaign is still actively promoted
and there is a multi-agency protocol in place with
Greater Manchester Police, Crown Prosecution
Services and Greater Manager Trust Chairmen,
which supports legal action being taken against
perpetrators of assaults.
The Trust ensures that staff who are the subject
of physical assault receive immediate assistance,
and support. The impact of an assault can cause
physical and emotional distress for all concerned,
and the Trust aims to provide the right support
to respond to these incidents through its staff
support service and one-to-one counselling where
needed.
Review of Clinical Quality
Indictors for 2009/10
The Trust identified a number of Clinical Quality
indicators for 2009/10, based on Monitor’s
key performance indicators in this area. The
indicators also reflect those reported on in the
Trust’s Quality Report 2008/9.
Priority 1: A reduction in delayed
discharges to meet the Monitor
target of no more than 7.5% delayed
discharges
Description of issue and rationale for prioritising
Improvements to the levels of delayed discharges
has been identified as a key quality measure for
mental health Trusts.
The Trust has worked hard to build on
improvements to discharge arrangements this
year so as to minimise delays for patients, and
ensure that all service users are treated in a
setting appropriate to their needs. Delays in
discharging patients not suited to their present
treatment setting can have a negative effect on
both the patient concerned and the wider ward
environment. As a result, the Trust has worked
hard to develop partnerships with fellow providers
and to tighten discharge arrangements.
Aim/goal
To maintain a level of delayed discharges at or
below 7.5%, and to see an improvement in the
delayed discharge figures year-on-year.
Current initiatives
The Trust has further refined its Trustwide discharge protocol, and has widened
communications throughout the Trust to ensure
that discharge information is communicated more
effectively. We have also continued to work more
effectively with partners to facilitate improved
discharge arrangements.
The implementation of the discharge protocol has
resulted in a much clearer understanding across
all departments of the discharge arrangements
necessary to prevent delays, and how to escalate
problems to ensure their resolution.
Current status
The target has been achieved throughout the
year, and continues to be achieved.
% of delayed discharges
8%
7%
6%
5%
4%
3%
2%
1%
0%
Apr
May
Jun
Jul
Aug
Sept
Oct
<7.5% target
Nov
Dec
Jan
Feb
Mar
2009/10
% of occupied bed days with delays
Identified areas for improvement
New initiatives
The Trust will continue to strengthen its own
internal monitoring of delayed discharges, to
refine processes and further improve. We have
implemented significant changes to discharge
planning recently, and will continue to work to
improve these arrangements.
In the year ahead, the Trust will work to further
relations with external partners such as Specialist
Commissioners to ensure that discharges from
Pennine Care to other providers can take place
without unnecessary delay.
Partnership working is crucial in reducing delays
to discharging patients into the care of partners.
The Trust will continue to work to maintain
and strengthen partnerships with Secure
Commissioners, Local Authorities and others
involved in the continuing care of patients.
In addition, new service structures and the redesign of some clinical practices will facilitate
smoother discharge planning. Once again the
emphasis will be on minimising admissions in the
first place, and on reducing delays to discharges
by planning for discharges from the point of
admission.
ANNUAL REPORT 2009/2010
43
Priority 2: 95% of patients discharged
from an inpatient ward must receive
a follow up in the community within
seven days
Description of issue and rationale for prioritising
Ensuring that patients receive follow-up care after
discharge from an acute ward is crucial to aid
recovery and prevent relapse or harm.
The Trust has prioritised this area again this year
to continue to ensure that effective follow-up care
is provided, thus improving the quality of care for
patients by trying to ensure a seamless transition
from one service to another. Although the patient
pathway traverses several of the Trust’s service
lines, we are aware that patients make no such
distinction, and as a result are striving to perfect
joined up working and ensure that quality of care
remains high at all stages on the pathway.
Aim/goal
To ensure that 95% of all patients discharged
from acute wards receive a follow-up visit within
seven days.
Current status
The target has been achieved in all but one month
of the year. It was missed by a small amount in
April 2009. Progress was made immediately, and
has been maintained since, with the target being
exceeded in every month since this date.
Identified areas for improvement
Effective recording and monitoring of data and
activity will ensure continual improvement in
this measure. The Trust will work closely with
community teams and their managers to ensure
that effective processes are in place to continue
to meet and exceed this target.
Priority 3: All patients that have
an inpatient stay in Pennine Care
would have been assessed through a
gatekeeping function within the Crisis
Resolution and Home Treatment Team
Description of issue and rationale for prioritising
No new initiatives have been implemented in
2009 – 10. The Trust has continued to fulfil
its statutory obligations to record and report
seven-day follow up visits. Response to trends in
performance will continue, targeting increased
support and resources as appropriate.
Crisis Resolution and Home Treatment teams
provide intensive care for patients suffering
acute episodes of mental illness, in their own
home. This reduces the frequency of inpatient
admissions, which is beneficial to the patient
who can remain within the community and in a
familiar setting. It is also beneficial to the Trust
and wider services because acute inpatient beds
are reserved for the most acutely ill, and transfers
between community services and inpatient
services are lowered.
New initiatives
Aim/goal
The Trust will work to improve its performance,
and also to respond to the increasing drive to
ensure a follow-up appointment within a shorter
time-frame than seven days. This will involve the
appropriate training and targeting of resources to
enhance the patient experience.
To ensure that 90% of all admissions are gatekept
by Crisis Resolution and Home Treatment teams.
Current initiatives
Current status
This target has been met in every month of the year.
Identified areas for improvement
The Trust will continue to strive to improve
arrangements for those patients admitted to
Pennine Care wards who reside out of the Trust’s
footprint.
Administrative procedures have been
strengthened within teams to ensure that the
correct protocols are followed and that all activity
is appropriately recorded. This has meant that
only the correct issues have been identified, and
that responses to them are appropriate
New initiatives
The further development of the Trust’s Access
and Liaison function will create new challenges
for those seeking to ensure gatekeeping for all
patients. It is hoped that work towards a common
single point of entry for the Trust will enhance the
gatekeeping function and improve performance
still further.
Increased training will be provided to staff
and managers within teams responsible
for gatekeeping patients to ensure that the
procedures are followed appropriately and that
patients receive the best care.
100%
95%
90%
Apr
May
Jun
Jul
Aug
Sept
Oct
95% target
44
This year the Trust has continued the weekly
monitoring of gatekeeping, in order to gain a
fuller understanding of any issues in the quickest
possible time. This has resulted in an increase in
performance this year.
% of admissions assessed through a gatekeeping process
% of inpatients discharged on CPA followed up within seven days
100%
99%
98%
97%
96%
95%
94%
93%
92%
Current initiatives
PENNINE CARE NHS FOUNDATION TRUST
Nov
Dec
Jan
Feb
Mar
% followed up on CPA
2009/10
85%
Apr
May
Jun
Jul
Aug
Sept
Oct
90% target
Nov
Dec
Jan
Feb
Mar
2009/10
% admission gatekept by CRHT
ANNUAL REPORT 2009/2010
45
Review of Patient Experience
Indicators for 2009/10
The Trust identified a number of Patient
Experience indicators for 2009/10. The indicators
reported here arose after the involvement of all
stakeholders including staff, FT Members, the
Council of Members, and the priorities of our
regulators and partners.
Priority 1: A reduction in Healthcare
Associated Infections
Description of issue and rationale for prioritising
The Trust prioritised the reduction of Healthcare
Associated Infections (HCAI) and incidents in
relation to Infection Prevention and Control. This
was to ensure that we were compliant with Health
and Social Care Act 2008: Code of Practice for
NHS on Prevention and Control of HCAI.
This issue is considered most important to all
stakeholder groups, and is vital to the ongoing
improvements to quality that the Trust wants
to make. Confidence in the cleanliness of the
hospital environment is a vital part of the patient
experience.
Aim/goal
• To continue to reduce the risk of Health Care
Associated Infections.
• To ensure compliance with national standards
such as the HCAI Code of Practice and Trust
Infection Prevention and Control Policies.
• To increase Infection Prevention awareness
amongst staff through training programmes
and so reduce the number of infection control
incidents.
Incidents
Cause Code
2008/09
2009/10
148 – Infection Control Incident
20
7
35 – Contact with Bodily Fluids
3
7
36 – Contact with Harmful Substance – Breakage
1
0
37 – Contact with Harmful Substance – Cleaning
2
5
38 – Contact with Harmful Substance – Other
8
3
80 – Needlestick Injury
26
22
92 – Sharps – Disposal
10
5
94 – Sharps – Misc
21
10
99 – Spillages
0
1
91
60
There were 91 Infection Control incidents
in 2008/09 and 60 in 2009/10, which is a
reduction of 34%.
Current status
Performance in 2009/10 and 2008/09
are as follows:
Needlestick injuries have also reduced by 15%
from last year.
Identified areas for improvement
Infections
2008/09
2009/10
MRSA
5 (skin)
3 (skin)
C. diff
2
2
ESBL
1
1
D&V
6
8 (3 Norovirus confirmed)
There has been a 40% reduction in cases of
MRSA reported, no change in C. diff cases and an
increase of 25% of reported D&V cases.
46
PENNINE CARE NHS FOUNDATION TRUST
A number of areas have been identified that
require improvement:
• Structured audit programme, which includes
cleanliness of equipment and appropriate use
of storage areas
• Cleaning schedules for all equipment
• Monitoring of ward environment on a weekly
basis by ward manager
• Replacement of old equipment
• Audit of hospital mattresses
• Further Infection Prevention and Control
training for staff
• A further reduction in needlestick injuries
Although there has been a significant
improvement in these areas in recent years, there
is still some improvement to be made in practice
across the Trust, particularly in embedding some
of the procedural improvements that have
been made.
Current initiatives
The Trust will continue to improve its monitoring
systems of Infection Prevention and Control by
measuring compliance against The Health and
Social Care Act 2008: Code of Practice for NHS on
prevention and control of HCAI standards and the
Strategic Health Authority Assurance Framework.
Compliance with Pennine Care NHS Foundation
Trust Infection Prevention and Control Policies will
be monitored by internal audits and unannounced
spot-checks of the environment, and matron
walkabouts.
ANNUAL REPORT 2009/2010
47
New initiatives
The Trust has a structured plan in place to
improve the Infection Prevention and Control
Standards and ensure that the environment is
clean, safe and well-maintained. In the coming
year, the following new initiatives will be taking
place:
• Six-monthly audits of inpatient areas
(due July 2010)
• One-yearly audits of community units (as from
April 2010 – due October 2010)
• Ward managers will inspect the environment
and equipment in their wards weekly using a
standardised tool
• Matrons will undertake monthly environment
inspections with Estates and Domestic
Services
• Deputy Director of Nursing & Integrated
Governance will undertake a rolling
programme of unannounced spot checks
of wards
• Infection Control nurses will meet with
matrons, estates and domestics monthly to
ensure action plans are implemented
• Wards will have nominated Infection
Prevention and Control champions
• A Cleaning Schedule has been implemented
for all equipment in inpatient areas, this will
be monitored via the audit programme
• Commode cleaning guidelines have been
introduced
• Training has been implemented for matrons,
champions and mandatory training for
qualified inpatient staff
• Implement needle safety devices across the
Trust.
48
PENNINE CARE NHS FOUNDATION TRUST
Priority 2: Effective handling of
complaints to the Trust
Description of issue and rationale for prioritising
The effective handling of complaints offers the
Trust an opportunity to obtain service user and
carer feedback on services and to identify areas
for improvement within the services provided and
to deliver positive change.
In order for the Trust to take full advantage of
the opportunities that complaints offer, it is
essential that complaints are dealt with in an
effective and timely manner in accordance with
the relevant national legislation. Whilst managing
complaints in this manner, it is also essential that
accurate and detailed information is extracted
from the complaints received to enable productive
reporting into the integrated governance
structure.
The Trust has prioritised this quality indicator
as it gives a clear opportunity to assess areas
of weakness and improve the experiences of
patients. We welcome patient feedback in all
its forms, and encourage complaints if patients,
carers or others feel that care has not met our
high standards. Handling complaints remains a
top priority for the Trust.
recommendations to deliver change, and
the effective reporting into the integrated
governance structure.
Current status
In 2009/10 the Trust received 147 complaints.
The table below details the percentage of
complaints responded to within timescales
agreed with the complainant during 2009/10:
Complaints responded to within timescales
agreed with complainants:
Quarter 1
93%
Quarter 2
91%
Quarter 3
89%
Quarter 4
89%
In 2009/10, the complaints response times were
as follows:
Within 10
working days
Within between 11
and 25 working days
In over 25
working days
Aim/Goal
The aim in relation to the Trust’s handling of
complaints is two-fold:
1) To ensure that concerns raised by
complainants are dealt with in accordance
with an agreed action plan with the
complainant (which includes timescales and
the form of response) and national legislation;
and
2) To ensure that the Trust maximises the
opportunity for service improvement
offered by complaints, by investigating and
identifying areas for improvement and making
Percentage
of complaints
responded to
15%
Whilst 91% of the complaints responded to
during 2009/10 have been responded to within
timescales agreed with the complainant, in
some of these cases the Trust has had to agree
extensions to the original timescale due to delays
in the investigation of the complaint.
38%
47%
The Complaints Department reports on numbers,
trends and the location to which complaints
relate, including to Board level. These reports are
largely based on the single most prominent issue
raised in a specific complaint and the Borough in
which the service complained of was delivered.
ANNUAL REPORT 2009/2010
49
Identified areas for improvements
The following areas for improvements have been
identified:
• Quicker response times to complaints,
delivered primarily through the timely
investigation of complaints received;
• More effective information reporting, including
more specific information about the issues
raised in complaints, the areas of the Trust
that they relate to and the complaints
investigation performance of the different
Divisions; and
• Maximising the learning taken from
complaints through the making of
recommendations and the monitoring
of their implementation.
including all of the concerns raised in each
complaint, not just the main concern.
• From April 2010 detailed reporting on
Divisional performance in relation to
investigation times, including the reasons
for any delays in responding within the
requested timescale, thereby allowing for the
identification of problems and improvement of
response times.
• A review of the Trust’s Complaints Policy to be
undertaken in 2010 to ensure that it reflects
best practice and offers support to Trust
staff in meeting the stated aim in relation to
complaints.
Priority 3: Delivering single sex
accommodation
Description of issue and rationale for prioritising
Current initiatives
Current initiatives to meet the above stated aim
include:
• Monthly, quarterly and annual reporting into
the integrated governance structure, reporting
on the numbers of complaints received,
the main issues raised in those complaints,
themes identified and the types
of recommendations made;
• Training offered Trust wide to staff on how to
effectively investigate complaints; and
• Feedback provided to Divisional Governance
Managers on current complaints status.
New initiatives
New initiatives to meet the stated aim in relation
to complaints include:
• Training to be revised to emphasise the need
for the timely investigation of complaints and
the making of effective recommendations.
• From April 2010, more precise recording and
reporting of the issues raised in complaints,
50
PENNINE CARE NHS FOUNDATION TRUST
Current status
All of our wards are compliant with Delivering
Same-Sex Accommodation and we ensure that
patients will sleep in the following:
• In a same-sex ward, where the whole ward is
occupied by either men or women only
• In a single room, or
• In a mixed ward, where men and women are
in separate bays or rooms.
Identified areas for improvement
Plans are currently being developed to achieve
our desire to have 100% single bedroom
accommodation. 80% of our beds are currently
single bedrooms the majority of these have ensuite bathroom facilities.
The Department of Health have clearly articulated
their desire to have all organisations delivering
the highest standards of privacy and dignity
within all areas of a hospital. One element of this
agenda was to deliver same-sex accommodation.
Pennine Care believe this issue to be of the
utmost importance for our inpatient units and
therefore prioritised this in 2009/10, after
consultation with patients groups, staff and
Members.
By the autumn of 2011 we hope to have 90% of
our accommodation as single bedrooms.
Aim/goal
New initiatives
Patients at Pennine Care NHS Foundation Trust
deserve privacy and they deserve to be treated
with dignity. By making these considerations our
priority, we are on our way to making patients
hospital experience as comfortable as possible,
through delivering the Same-Sex Accommodation
project.
Our goal is to ensure we meet compliance with
Same-Sex standards and develop above and
beyond our statutory requirement.
However, information on performance in 2009/10
against those priorities which were identified in
2008/09 is contained in the Quality Narrative in
Section 1 of this report.
Above: David Heyes MP opens the new
Etherow Unit, Tameside
Current initiatives
In March 2010 we completed the £100,000
Strategic Health Authority project to ensure we
had single-sex accommodation throughout our
wards and to train and communicate out to our
staff. We are pleased that these projects have
been completed and we are now analysing the
impact on service user perception.
Taking this agenda forward, we will develop our
Estates Strategy to incorporate our ward changes
and ensure that we comply with privacy and
dignity agenda and continue to enhance the
patient experience.
Not all of the indicators above are the same as
those indicated in 2008/09. The change is due to
the significant amount of work with stakeholders
and the Board to identify a more complete and
relevant set of indicators giving a better picture of
the true state of quality and improvements across
the Trust.
ANNUAL REPORT 2009/2010
51
National targets and regulatory requirements
Performance against key
national priorities and national
core standards
We have chosen to measure our performance
against the following metrics, in line with last year:
Performance
Measures
2009/10
2008/09 2007/08
Target
National
Average
Peer Group
Average
Number of serious and 706
untoward incidents
734
598
N/A
N/A
N/A
Patients with MRSA
infection/10,000
bed days
2
0
0
0
N/A
N/A
PARS reporting
793
864
803
N/A
N/A
N/A
Patient Safety
Clinical Outcome
Measures
7 day follow-up
98%
98%
97%
95%
N/A
97.4%
Delayed transfer of care 3.1%
5.7%
12.2%
7.5%
8.2%
12.0%
N/A
Gatekeeping
96.9%
99.6%
Performance
Measures (Continued)
2008/09
2007/08 2006/07
90%
N/A
N/A
Target
National
Average
Peer Group
Average
Patient Experience
Measures
Patient treated with
respect and dignity*
97%
99%
98%
98%
Support for carers/
family*
70%
65%
72%
67%
67%
N/A
Quality of care**
60%
58%
58%
58%
58%
N/A
* % of patients that answered “yes definitely” or “yes to some extent”.
** % of patients that answered “Excellent” or “Very Good”.
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PENNINE CARE NHS FOUNDATION TRUST
98%
N/A
Target
2009/10 2008/09
2007/08
Target
National Peer Group
Average Average
The Trust has fully met
the HCC Core Standards
and National Targets
Fully met
Fully met
Fully met
Fully met
Fully met
Fully met
Clostridium difficile
year-on-year reduction
2
1
0
N/A
N/A
N/A
MRSA - Maintaining the
annual number of MRSA
bloodstream infections
at less than half the
2003/04 level
0
0
0
N/A
N/A
N/A
Maintain the level of
crisis resolution teams
set in the 03/06
planning round
9
9
9
9
N/A
N/A
Please note:
The Trust currently does not benchmark SUI and
PARS because of the complexity of the measures.
There are 5 grades of SUI and the focus of the
Trust’s efforts is on reducing the most serious
incidents. Analysis of the increase of SUIs in
2008/09 has found that a major cause has
been an increase in out of area patients and
those requiring seclusion. For PARS reporting the
increase can be attributed to higher reporting
rates as a result of a highly publicised staff
safety campaign to encourage reporting. It is not
believed that there has been a reduction in quality
this year.
National averages and peer group averages
provided for seven day follow-up and delayed
transfers of care were calculated using the
original guidance provided by Monitor so are
based on occupied bed days excluding home
leave.
Gatekeeping monitoring was introduced in April
2008, so data for 2007/08 is not available.
The Trust has its own target of not having any
MRSA bacteraemia. There is no national targets
for mental health Trusts, the acute Trusts have
the targets. Peer wise mental health Trusts would
expect to have very small numbers.
There is no national target for mental health
Trusts for incidents of Clostridium difficule.
Data source:
National average for delayed discharges taken
from the Audit Commission Trust Provider Mental
Health Benchmarking Club for 2007/08.
Peer group average for delayed transfers of care
taken from the North West SHA Mental Health
Providers Benchmarking Report for Q3 2007/08.
Peer group average for seven day follow-up taken
from the North West SHA Mental Health Providers
Benchmarking Report for Q3 2007/08.
National average for patient experience measures
is taken from the 2008/09 Patient Experience
survey, and target based on the National Average.
The Trust has met and exceeded all Monitor
Compliance Framework targets this year, in
relation to Delayed Discharges, seven day followup, gatekeeping and Crisis Resolution Home
Treatment.
The Trust declared compliance with 42 of the
42 Core Standards.
ANNUAL REPORT 2009/2010
53
Other additional content
relevant to the quality of
NHS services
Review of services
The Trust provides services in a range of
specialties/areas. The Board has reviewed the
available data on the quality of care in these
specialties/areas. The board has used the results
of this review to develop a plan for improving the
quality of the Trust’s services, which has formed
the basis for our quality indicators and strategy as
described above.
The Trust has continued with a range of ongoing
initiatives which are designed to increase the
quality of people’s experience of our services
across the Trust.
Our commitment to increasing quality through
innovation has been evidenced through our
re-investment of £1.5m of our surplus into new
projects aimed at increasing service quality.
This use of opportunities afforded to Foundation
Trusts has allowed for over two dozen quality
improvement projects to acquire funds for a year
of work. These projects included:
• Investing in an electronic records
management system
• Improvements to the estate including
refurbished bedrooms
• More clinical pharmacists to provide
medicines management support to services
• Research into services for adult patients with
Asperger’s Syndrome
• Work to better manage the flow of patients
into and out of inpatient beds
• Additional support for early-onset dementia
• A conference for staff with the aim of boosting
the emotional intelligence of the workforce.
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PENNINE CARE NHS FOUNDATION TRUST
Some other examples of our other work to
improve the quality of services include:
• The New Ways of Working project, which has
been successfully implemented in Oldham
and Bury, and which is now being considered
for implementation in Rochdale. The practice
of consultants either being based on inpatient
wards or working within community teams
has seen great benefits for both service
users and staff. Wards have been quieter and
better managed with multi-disciplinary team
meetings each morning to agree discharge
plans.
• Therapeutic programmes have been
introduced across the Trust which have
supported our service users to get involved
in a range educational and leisure activities
and really improved the quality of the stay on
wards to support recovery.
• Community teams have also seen the benefit
of having medical support, advice and
teaching made available through consultants
being within the teams. Work has continued
on integrating our community services with
local authority and third sector opportunities,
where these exist.
• Re-investment in our Community teams has
seen the commencement of a ‘Transforming
Communities’ project aimed at developing
enhanced clinical pathways and improved
interface between services.
• Access to our services has been simplified
and improved with the introduction of a
pilot Mental Health Referral Management
System in Bury. This pilot scheme involved
significant liaison with partners and GPs, will
now be rolled out across the Trust to give a
single point of entry in each borough for all
secondary care mental health services for
adults and older people.
• Service users in Middleton will now have
access to seamless care when required,
as the Trust has addressed a long-standing
service inequality by agreeing with the local
commissioner to provide inpatient services
to that local community. This will in turn allow
for revised community services arrangements
for the whole of Heywood, Middleton and
Rochdale, benefitting patients across the
borough as a whole.
• There have also been improvements to the
quality of specialist service provision this year,
with increased business support to enable
front-line service delivery staff to concentrate
on delivering higher quality services. In
addition, the Trust has been working closely
with colleagues from the North West Specialist
Commissioning Team, and the local PCTs, to
identify those patients currently treated out of
area (OATs). These patients can in many cases
be treated by Pennine Care, closer to home,
resulting in a significant increase in the quality
of care as well as a financial saving.
Throughout our quality reviews of services we
have borne in mind the need to ensure high levels
of patient safety, clinical effectiveness and patient
experience. Our corporate goals and our mission
statement to improve the patient experience
reflect this. Where the amount of data for review
has not enabled quality improvements to take
place at the rate we would like, improvements to
systems and processes have taken place.
Research and innovation
The Trust has an excellent reputation in terms of
the delivery of clinical services and is committed
to achieving the same reputation in relation to
research. The Trust has established a robust
research governance structure to ensure that all
research undertaken is conducted in accordance
with legislation and the Department of Health’s
Research Governance Framework.
The Trust actively participates in Mental Health
Research Network (MHRN) adopted studies and
currently employs two Clinical Study Officers
who are funded by the MHRN. In addition,
during 2008/2009 the Trust has been focusing
on developing internal research that has a
clear benefit for patients and has been actively
supporting individuals wishing to pursue a career
in research. For example, the Trust participates
in the Clinical Scholarship Scheme funded by
NHS North West, which is designed to provide
individuals with the skills required to conduct
research. In addition, the Trust has supported
NIHR MRes and PhD Scholarship applications.
The Trust is host to NIHR Research for Patient
Benefit grants and is the lead Trust for certain
streams of an NIHR Programme Grant linked
to the Personal Social Service Research Unit
(PSSRU).
The Trust is constantly striving towards innovation
and has conducted a number of service
evaluations either to evaluate the effectiveness
of current services or to gain the evidence-base
in relation to the benefit of innovative services.
For example, we are currently evaluating our
service dedicated to supporting people with
dementia, their families and staff in care homes
through a dedicated Community Mental Health
Team (CMHT). Due to the innovative nature
of this CMHT, we are submitting our findings
to the National Care Home Congress and
hope to develop a research bid to explore the
effectiveness of this service further.
As mentioned above, the Trust is working with its
partner commissioners on the CQUIN framework,
and has agreed a set of indicators prior to the
introduction of CQUIN upon which a proportion of
our income is dependent.
ANNUAL REPORT 2009/2010
55
Statement from Commissioning
Primary Care Trust
Statement from NHS Heywood, Middleton &
Rochdale regarding the Pennine Care NHS
Foundation Trust Quality Account 2009/10.
NHS Heywood, Middleton and Rochdale is the
lead commissioning body for Pennine Care NHS
Foundation Trust and as such has led this review
of the Pennine Care Quality Account 2009/10.
The review has compared the accuracy of the
qualitative information and data contained
in the Quality Account with the qualitative
information and data provided by Pennine
Care, as part of its contractual requirements
during the year. The presentation and scrutiny
of this information and data in year has been
facilitated through the Pennine Care/PCT Sector
Quality Group which reports to the Pennine Care
Lead Commissioner Group. The Sector Quality
Group brings together Pennine Care with its five
main commissioners (NHS Bury, NHS Oldham,
NHS Heywood, Middleton and Rochdale, NHS
Tameside & Glossop and NHS Stockport). Pennine
Care has engaged consistently and effectively
with the Sector Quality Group thus enabling
constructive debate to address gaps and risks
and to agree mitigation plans. For example,
inaccuracies in data reporting were recently
reported to the Sector Quality group by a number
of the commissioning organisation members.
The details were debated with Pennine Care
and improvements were agreed and promptly
implemented.
56
PENNINE CARE NHS FOUNDATION TRUST
Pennine Care has also worked with the
commissioners to devise and implement
a bespoke quality schedule in advance of
the introduction of the new National Mental
Health contract. This has proved invaluable in
progressing the quality agenda and has helped
to embed a culture of ongoing quality monitoring
in readiness for the introduction of the new
formal system in 2010/11. The commissioners
look forward to developing more comprehensive
measures of quality and safety with Pennine Care
in 2010/11.
NHS Heywood, Middleton and Rochdale is not
required to check data included in the Quality
Account that is not part of existing contractual/
performance monitoring discussions.
Having considered the contents of this Quality
Account, NHS Heywood, Middleton and Rochdale
confirms that it considers that this Quality Account
contains accurate information in relation to the
services provided to it by Pennine Care during
2009/10.
Date of publication: June10
Ref: 798RP/Central/QualityAccount
© Pennine Care NHS Foundation Trust
Annex
ANNUAL REPORT 2009/2010
57