RDaSH
Quality Account 2010
3
Contents
Quality Account 2009/10 – Chief Executive’s welcome
Information on the review of services
A look back at the year 2009/10
2009/10 Quality Plans – review 2009/2010 Quality Plans update
Quality Payments 2009/10
Regional Quality Indicators
Local Quality Outcomes Framework (QOF)
Performance against the key national priorities
Care Quality Commission Annual Health Check 2008/09
Core standards declaration 2009/10
Monitor Compliance Framework/risk ratings 2009/2010 Reports from regulators 2009/10
Periodic Reviews
Service Reviews
Safeguarding children declaration
Clinical audits and national confidential enquiries
Other highlights from the RDaSH year
• RDaSH features as CQC case study
• Concordat risk summit
• Delivering same sex accommodation
• NHS Litigation Authority Assessment
• Health and Safety Executive Visits
• Payment by Results
Managing the transition 2009/10 – 2010/11
Care Quality Commission Registration procedure
Looking ahead
Leading the Way with Quality (LWQ)
Trust Quality Council (TQC)
Quality priorities for the coming year
Business Division Quality Framework Quality Payments 2010/11
CQUIN (Commissioning for Quality and Innovation) payments for 2010/11
Regional Indicator framework for 2010/11
Local Indicator framework for 2010/11
Feedback from stakeholders
Annex statement How to contact us
Glossary of terms / jargon buster
Appendices
4
5
6
7
7
9
10
11
15
15
16
17
19
19
19
19
19
20
23
23
24
24
24
24
24
26
26
26
26
27
27
30
31
32
RDaSH
4
Chief Executive’s welcome
Part 1. Statement on quality from the Chief Executive of the NHS foundation trust
A statement signed by the Chief Executive summarising the NHS foundation trust’s view of the quality of the NHS services that it
provided or sub- contracted during 2009/10. The statement must outline that to the best of that person’s knowledge the information
in the document is accurate, as demonstrated in the RDaSH statement below.
Welcome to our first dedicated Quality
Account which emphasises the quality and
standard of the care and services that we
provide to our service users.
As the Chief Executive of Rotherham
Doncaster and South Humber Mental
Health NHS Foundation Trust, I can
confirm that, to the best of my knowledge,
the information contained within this
document is accurate.
This document builds on the work outlined
in our Quality Report which was produced
in 2009. Its aim is to illustrate how
important quality is to our work and how
it underpins all that we do. It also outlines
our progress, where we have responded
to challenges, and our aspirations for the
future.
Throughout this journey, we have
engaged with and involved our Council of
Governors, the Trust User Carer Partnership
Council and the Trust Quality Council. We
have enjoyed and benefited from working
in partnership with Overview and Scrutiny
Committees, Local Information Networks
(LINks) and local NHS commissioners
(PCTs). Quality improvement is fundamental
to our core business and by providing a
Quality Account each year we will remain
accountable to our local communities.
Going forward, the quality of Trust
services will be increasingly defined at
an operational level through the Trust’s
Business Divisions, with service user, carer
and stakeholder involvement rather than
following a corporately driven quality
agenda.
Of course, quality has always been central
to our work and it was key to our success
RDaSH
in achieving Foundation Trust status in
2007. Since then our commitment to
maintaining those high standards has
been reflected in the achievement of
an ‘excellent’ rating for the quality of
our services each year, supported by an
‘excellent’ rating for use of resources for
two years in a row.
In addition, last year the Trust was judged
to have ‘fully met’ the Government’s core
standards for the year and, for the fourth
successive year, was scored as ‘excellent’ in
the new national targets.
our quality and also outline what our
priorities will be in the coming year as we
roll out our Leading the Way with Quality
initiative throughout the Trust.
We will be working with our staff, our
service users and their carers, our partners
and stakeholders and our members as
we move into a challenging period where
the quality agenda will be essential to our
continuing success as a leading provider of
health and care services.
As well as the assessment and rating of
our services by regulatory bodies, the Trust
places high importance on the views of the
people who actually use them.
One way we receive feedback is through
the National Patient Survey, which
systematically gathers the views of service
users about the care they have recently
received. Also, the Trust will soon be
involved in the national mental health pilot
of Patient Opinion, which offers service
users the opportunity to share their own
opinion and gain support from others.
This demonstrates our commitment
to providing service users with easily
accessible and straightforward ways for
them to share their opinions with us,
according to their individual needs.
In addition to those patient experience
measures that we have identified for the
coming year in this Quality Account, we
will be working hard to identify additional
measures of patient experience for the
future.
The following pages show how we are
performing against targets set to measure
Chief Executive
Our annual report 2009/10 contains
further information about our
performance over the past year, as well
as a summary of our financial accounts.
For more details please contact the
Communications Department on phone
01302 796204/6282/8134 or email
RDaSHCommunications@rdash.nhs.uk.
5
Information on the review of services:
During 2009/10 Rotherham Doncaster and South Humber
Mental Health NHS Foundation Trust provided and/or subcontracted 84 NHS services.
Rotherham Doncaster and South Humber Mental Health NHS
Foundation Trust has reviewed all the data available to them on
the quality of care in all 84 of these NHS services.
The income generated by the NHS services reviewed in
2009/10 represents 100% per cent of the total income
generated from the provision of NHS services by Rotherham
Doncaster and South Humber Mental Health NHS Foundation
Trust for 2009/10.
Further details of the services provided/sub contracted by
Rotherham Doncaster and South Humber Mental Health NHS
Foundation Trust are provided on the trust’s website at: http://
www.rdash.nhs.uk/information-for-the-public/services/servicedirectory/
RDaSH
6
A look back at the year 2009/10
2009/10 Quality Plans – review
2009/2010 Quality Plans update
At the start of 2009/10 year we set out
to engage fully with our key stakeholders
and involve them in discussions around the
quality agenda. We worked with our staff
and patients, our User Carer Partnership
Council, Council of Governors and our
Commissioners to agree the details of how
we should demonstrate our commitment
to quality, and above and beyond those
areas identified as aspirations for quality
improvement which are set out below:
In 2009 the Trust produced its first Quality
Report which emphasised the importance
placed on the quality of the treatment and
care we provide to our service users.
• Safety and cleanliness
• Engagement with ethnic and minority
groups
• Improving the provision of physical
healthcare
The 2009/2010 Quality Objectives were
based on two key requirements. Over time,
they will help us to illustrate our progress
towards achieving our identified priority
areas.
They were based on clear local, regional or
national definitions which should facilitate
benchmarking between organisations in
future years.
(We have made good progress and the
indicator set is regularly updated with a
view to the 2010 Quality Account being
agreed locally and published by June 2010).
All of the quality objectives we set for
2009/10 are reported on here. It is also
important that our progress in these areas
continues in the future. In 2010/11 all of
the identified priorities remain important
and will be routinely progress monitored
through different mechanisms. More detail
about how this will happen is included
alongside the 2009/10 Quality Plans
update.
(N.B The work related to the local Quality
Outcomes Framework (QOF) is referred to
in detail on page 11)
• Independent living
• Social inclusion.
These themes are strong within our
identified priorities.
In addition, our priorities reflected those
of the 2009/10 NHS Operating Framework
which included a focus on ‘keeping
adults and children well, improving their
health and reducing health inequalities’;
‘improving patient experience’; and
‘improving cleanliness and reducing
healthcare acquired infections’.
Staff and volunteers with some seasonal produce grown in the Walled Garden.
RDaSH
7
2009/10 Quality Plans update
Safety
Source
2008/09
2009/10
Year end outcome
During 2009/10 the Trust
recorded 649 incidents of
physical restraint, of which
412 were low level/passive,
177 full restraint and 13
rapid tranquilisation.
N National Patient Safety Agency
(NPSA) and Department of Health
target. Delivering Race Equality
(DRE) dashboard. *
Incidents of
physical restraint.
In 2008/09 the Trust
recorded 693 incidents of
physical restraint of which
421 were low level/passive,
219 full restraint and 18
rapid tranquilisation.
The use of physical restraint
is an important concern for
users and carers. The Trust
aims to minimise its use but
also to accurately report
incidents, to enhance the
learning culture within the
services.
N NPSA and Department of Health
target. Delivering Race Equality
(DRE) dashboard. *
Incidents of
seclusion.
In 2008/09 the Trust
recorded 31 incidents of
seclusion.
In 2009/10 the Trust
The use of seclusion is also
recorded 16 incidents of
a concern for users and
seclusion.
carers. Similarly, the Trust
will continue to develop and
improve its reporting and
learning culture.
N NPSA and Department of Health
target. **
Infection control.
In 2008/09 we reported six
outbreaks of diarrhoea and
vomiting, two of C Diff and
zero MRSA.
Infection control Is a
priority to the Trust and
we will work to improve
our standards again in
2009/10.
During 2009/10 the Trust
reported zero cases of
hospital acquired infection
of MRSA.
N NPSA and Department of Health
target. (NHS Staff Survey). **
Availability of hand In 2008 the staff survey
washing facilities.
result showed that 70% of
staff, and 60% of service
users thought that hot
water, soap, paper towels,
or alcohol rubs were
available when needed. This
was an improvement from
2007 when the results were
62% and 56% respectively.
Hygiene and infection
control are a priority to
the Trust and we will work
to improve our standards
again in 2009/10.
In 2009 the staff survey
results showed that 68%
of staff and 61% of service
users thought that hot
water, soap, paper towels
or alcohol rubs were
available when needed.
The staff figure was a slight
reduction on the 2008
results and this will be an
area of focus in the 2010
staff survey.
*These priority areas are taken forward in the 2010/11 Regional CQUIN scheme (see page 33)
**The priority areas continue to be addressed through the Trust’s Essence of Care initiative, more details of which are included on page 20)
RDaSH
8
2009/10 Quality Plans update
Source
2008/09
2009/10
Year end outcome
R/N
Commissioning for Quality and
Improvement and Department of
Health target. *
Vulnerable
These quality outcomes
people achieving
have not previously been
independent living. measured routinely.
The aim this year was to
Improve the reporting and
data quality in respect of
the employment status of
specialist mental health
service users.
The Trust established a
low baseline position in
2009/10. This is a priority
area for improvement in
2010/11.
R/N
Commissioning for Quality and
Improvement and Department of
Health target. *
Vulnerable
These quality outcomes
people achieving
have not previously been
independent living. measured routinely.
In tandem with the above
work, improvements to
data quality were also
made in respect of the
housing status of mental
health service users.
The Trust established a
low baseline position in
2009/10. This is a priority
area for improvement in
2010/11.
Improvements have
been made to the Trust’s
engagement with under
represented groups,
particularly within Assertive
Outreach and Early
Intervention services.
Work to improve diet
(nutritional intake)
continues within early
intervention and 100% of
service users in Assertive
Outreach have the
service engagement scale
completed at the point of
accepted referral. Excellent
progress has been made
with the Productive Mental
Health Ward - Releasing
Time to Care with all of the
Trust’s 21 inpatient areas
having embarked on the
programme.
L
Local Quality outcome
Service
Framework (QOF) Delivering Race engagement.
Equality (DRE) dashboard.
Local quality initiatives
have been agreed around
engaging with hard to
reach minority groups in
specific services.
clinical effectiveness
The Productive Mental
Health Ward - Releasing
Time to Care.
L/R
/N
Monitor, Commissioning for
Quality and Improvement,
Care Quality Commission and
Department of Health target. **
R/N Commissioning for Quality and
Improvement and Department of
Health target. ***
The Productive Mental
Health Ward - Releasing
Time to Care.
Follow up after
discharge.
In 2008/09 98.45% of
those discharged from
inpatient care were
followed up in seven days.
The provision of face to
face or telephone follow up
within seven days of hospital
discharge helps identify and
minimise risks at this critical
period.
During 2009/10 99.7%
of patients were followed
up within seven days of
discharge.
Readmissions.
In 2008/09 we reported
a total of 107, 28 day
readmissions within our
adult services and 25 with
our older people’s services.
Action plans are in place
to provide exception
reporting and we will
continue to work with
service users where
appropriate around areas
identified contributing to
readmissions.
During 2009/10 the Trust
reported a total of 67
readmissions within adult
services and a total of
22 within older people’s
services.
*Included in local authority RAP (Referrals, Assessments and Packages of Care) targets 2010/11.
**Prompt follow-up continues to be a governance indicator for the independent regulator, Monitor, in 2010/11.
***Readmission rates continue to be monitored and are a focus area for improvement in the remodelling of our adult mental health services.
RDaSH
9
2009/10 Quality Plans update
patient experience
Source
2008/09
2009/10
Year end outcome
R/N
Commissioning for Quality and
Improvement and Department of
Health target. *
Patient
Environment
Action Team
(PEAT).
In 2008 the NPSA rated
the Trust’s inpatient
areas as having “good”
environments and “good
or excellent” standards of
food. Results are awaited
for 2009. An action plan
was developed to address
the Rotherham mental
health unit rating of
“acceptable”.
We know that the quality
of the hospital environment
is important. In 2009/10
we propose to further
improve our patient
feedback to Board and
recognise its contribution
to improving the quality of
services we provide.
The 2009 assessments
rated the Trust’s inpatient
areas as having ‘Good’ or
‘Excellent’ standards for
food and environment.
R/N
Department of Health target. *
Complaints.
In 2008/2009, 43 out of
59 complaints (73%) were
resolved within the national
target of 25 days.
As the complaints process
changes, we will continue
to improve our learning
outcomes from patient
comments and complaints
to further improve services
for patients.
The Trust received a total
of 86 complaints during
2009/10. Sixty were
resolved within 25 days,
19 were resolved after the
target period, 7 were still
within the target period to
be resolved.
Local Quality Outcome
Framework (QOF).
Productive Mental
Health Ward Releasing Time to
Care.
In 2008/2009 two pilots of
the nationally established
The Productive Mental
Health Ward - Releasing
Time to Care were
implemented.
The Productive Mental
Health Ward - Releasing
Time to Care pilot projects
are to be further developed
which increase clinical time
in inpatient areas.
The Productive Mental
Health Ward - Releasing
Time to Care was
successfully rolled out to
all 21 inpatient areas of
the Trust.
Commissioning for Quality and
Improvement and Department of
Health target. **
Meeting the health These quality outcomes
have not previously been
needs of people
measured routinely.
with a learning
disability.
The use of health and
wellbeing plans will increase
our focus on the higher
than average physical health
needs of this service user
group.
Primary Care are driving
forward action plans and
the LD Partnership Board
have appointed a health
action plan facilitator
(employed by RDaSH) who
is developing health action
planning and a supporting
database. This database
will link closely to where
an individual has complex
health needs and the
Community Team Learning
Disability supports them
with planning. During
2009/10 100% of service
users in our inpatient
services were provided with
health and wellbeing plans.
L
L/R
/N
*These key indicators of quality continue to be monitored in 2010/11 through the Trust’s Integrated Performance and Assurance Report.
**This priority area is taken forward in the 2010/11 Regional CQUIN scheme (see page 36)
Key
L = Local Commissioner, Referrals, Assessments and Packages of Care Project (RAP) or Quality Outcome Framework (QoF)
R = Regional, Commissioning for Quality and Innovation (CQuin)
N = National Quality Indicators from Department of Health
RDaSH
10
Quality Payments 2009/10
Regional Quality Indicators
A proportion of RDaSH’s income in 2009/10 was conditional upon achieving quality improvement and innovation goals agreed
between RDaSH and any person or body they entered into a contract, agreement 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 set out below.
In 2009/10 the Trust earned payments
from the Commissioning for Quality and
Innovation (CQUIN) at the rate of 0.5% of
contract value (£397,000), as defined in the
NHS Operating Framework. RDaSH was
required to produce and submit quarterly
data to measure the quality indicators.
The scheme covered three quality domains
of Patient Safety, Effectiveness of Care and
Patient Experience, taking into account
some of the objectives identified for mental
health and learning disabilities in Healthy
Ambitions. The standards were monitored/
measured on a regular basis, using clear
information which can be understood by
all and which can be shared easily across
the system.
Indicator A
Improving Access to assessment for people
experiencing acute mental health problems
Indicator B
Improving Access to assessment for people
experiencing non-acute mental health problems Indicator C
Improving health outcomes for service
users from Black and Minority Ethnic (BME)
backgrounds
Indicator D
Improving standards of care and compassion in
the older people’s service
Indicator E
Meeting the health needs of people with a
Learning Disability
Indicator F
Meeting the needs of children and young people
(Further detailed information available in Appendix A)
The standards and their method of
measurement are evidence-based and
demonstrated the quality improvement
and value added, such as improvements in
health outcomes or use of resources.
During the year the Trust began to
report on indicators A to F, shown on the
following table.
The Trust expects to make further progress
in these areas in 2010/11 through the
revised CQUIN scheme, detailed on page
25.
RDaSH
Attendees at the 2009 Annual Meeting of the RDASH User Carer Partnership
Council
11
Local Quality Outcomes Framework (QOF)
During 2008/09 RDaSH became an
early adopter of the Quality Outcomes
Framework (QOF) and worked in
partnership with NHS Doncaster to
introduce quality indicators for groups of
service users with similar needs.
The QOF is a mechanism to improve
quality in areas identified locally rather than
regionally or nationally and is specifically
designed for aspirational rather than core
indicators (e.g. those set down by the Care
Quality Commission).
It enables the Trust to work in a collaborative
way with stakeholders to determine a local
approach in enabling quality improvement.
Ward Programme, Releasing Time to
Care.
The Trust received an additional £380,000
in achieving those outcomes.
RDaSH and NHS Doncaster worked
together for a second year on a set of local
quality indicators, including ‘stretch targets’
to make further quality improvements to
the outcomes listed previously for 2008/09,
mainly in relation to the work of the Early
Intervention in Psychosis Team and the
Assertive Outreach Team. These were
monitored throughout the year:
The Trust put in place a process to engage
with service users, carers, staff and
commissioners and identified outcomes and
measures of quality for service users with a
particular set of needs (for example those
experiencing a first episode of psychosis).
In 2008/09 this resulted in the development
and scoping of the following quality
outcomes:
• Engagement with ethnic and minority
groups in Early Intervention in Psychosis
Services
• Improving nutritional intake in Early
Intervention in Psychosis Services
Early Intervention in Psychosis Service.
• To improve engagement of service users
in Assertive Outreach Services
• To expand the Productive Mental Health
RDaSH
12
Local QOF Outcomes for the Early Intervention in Psychosis and Assertive Outreach teams
2009/10
The Early Intervention and Assertive
Outreach teams are services provided
from the Adults of Working Age Business
Division. Although the funding for the
Indicator
local QOF initiatives was only for 2009/10,
improving the outcomes for service users
against the set of indicators will continue
to be a priority. Choice and Access will
be monitored by the Business Divisions.
Health and wellbeing outcomes are being
addressed through the introduction of a
new service model in Adult Mental Health.
Target
Year end outcomes
Compare BME (Black and Minority Ethnic)
profile of geographic population in comparison
to team BME profile. Formulate an action plan
to raise awareness in under represented groups
in conjunction with Community Development
Workers (CDWs).
A comparison exercise and an action plan
were implemented to raise awareness in under
represented groups.
Agreement was reached with CDWs from NHS
Doncaster regarding which BME services and
groups to target.
An experienced BME worker was recruited to
the team, resulting in improved representation
of this sector of the population within the team
caseload.
Choice and Access
100% of service users will have the service
engagement scale completed at the point
of accepted referral and at Care Programme
Approach review (minimum six months) from
August 2009 to February 2010.
Funding was used to provide additional capacity
within the team to undertake this additional
task. When combining the new referrals and
CPA reviews the overall percentage was 57%
(the agreed targets were 50% - 70%).
Sustained/improved levels for engagement with Training in the service engagement scale
service users. All staff in service to be trained by was completed by 16 July 2009. This was
anticipated to have a positive impact on
July 2009.
staff awareness regarding monitoring and
maintaining service user engagement.
To improve diet (nutritional intake) of service
users with first episode psychosis. The Trust to
be in a position to offer dietary assessment to
100% of service users by July 2009, although
reporting on this indicator was not scheduled to
start until August 2009 to allow the Trust time
to develop the capacity to meet this indicator.
RDaSH
The target of offering nutritional assessment
to 100% of newly accepted referrals was met
consistently from August 2009
A Health and Wellbeing Practitioner was
appointed, with key responsibility of assessment
and nutritional treatment of all services users
accepted by the Doncaster Early Intervention
Service. This post was funded for 12 months
on a non-recurrent basis through the Quality
Outcomes Framework (QOF) initiative.
13
Indicator
Target
Year end outcomes
To progress towards care delivery via electronic
care pathways for cluster 10 patients and to
develop an evidence-based care pathway for
cluster 10, the content of which is suitable for
clinical and commissioning purposes.
The Trust’s Early Intervention in Psychosis
team leaders and service manager worked
on the task and shared information and
good practice between the four geographical
areas of the Trust, with a particular focus on
quality indicators and qualitative rather than
quantitative measurement. This resulted in
an early draft pathway which, over the final
quarter was finalised and discussed to ensure it
met commissioners’ expectations
(Cluster 10 is the grouping within the Summary
Assessment of Risk and Need [SARN] identified
with those individuals with a mental health
needs profile suggesting a first episode of
psychosis)
Engagement of service users in clozapine clinics. The clinic consistently met its 100% target and
100% of cluster 17 (Assertive Outreach profile) lessons are being learned for other areas of the
Trust.
service users receiving clozapine will attend
their follow up clinic appointments.
Health and Wellbeing
Engagement of service users in clozapine clinics. The clozapine clinic staff were all trained in the
use of the electronic patient record, Maracis.
Make necessary IT and system changes to
New clinic profiles were included on the system
provide routine performance reports.
and all attendances, Do Not Attends and Can
Not Attends were routinely recorded. As data is
collated, this allowed a richer picture to emerge
about the service provided.
Engagement of service users in clozapine
clinics. Annual report to be provided on 100%
of service users receiving clozapine from 1 July
2009.
This information will be available from 23 April
2010.
Progress towards care delivery via electronic
care pathways for cluster 17 patients.
Development of an evidence based care
pathway for cluster 17, the content for which
is suitable for both clinical and commissioning
purposes.
The Trust’s Assertive Outreach team leaders
and service manager worked on the task,
resulting in an early draft pathway which was
finalised over the final quarter and discussed to
ensure it met commissioners’ needs.
RDaSH
14
Indicator
Patient experience
Target
Year end outcomes
The Productive Mental Health Ward - Releasing
Time to Care. Begin the programme on six
wards by March 2010.
Excellent progress was made on the Productive
Mental Health Ward Programme which was
successfully rolled out to all of the Trust’s 21
inpatient areas.
Care delivery via electronic care pathways.
Develop capacity to commission and work
with IT company to develop Maracis system
capabilities in order to support the use of
electronic care pathways.
This outcome was agreed at the end of
May 2009. A small group of experienced
clinical staff who regularly use Maracis met
with the software company to produce
a specification for the new system. This
group will continue to regularly review the
development at key milestones in order
to ensure the Maracis system will support
the use of care pathways that have clinical
and commissioner utility. Functionality is on
schedule to be in the test system for the
end of the financial year. It was agreed that
due to wider technical implications, wider
release into the live system would follow at
the next available system upgrade in 2010.
Develop a validated way to assess service user
needs by March 2010 for use from April 2010.
Produce a validated report on how many
service users used the assessment in 2009/10.
Work continued to develop a validated
assessment of service user needs by March
2010 for further use during 2010/11.
Clinical Effectiveness
User experience
A validation report was developed to provide
evidence of the service user needs assessments
achieved during 2009/10.
For 2010/11 locally determined CQUIN (Commissioning for Quality and Innovation) indicators will replace QOF. See Looking Ahead
section on Page 22 for this information.
RDaSH
15
Performance against the key national priorities
Care Quality Commission Annual
Health Check 2008/09
In October 2009, RDaSH achieved a double
‘Excellent’ rating from the Care Quality
Commission in the NHS annual health check
ratings for the quality of its services and the
use of its financial resources.
It was the fourth consecutive year for the
Trust to receive an ‘excellent’ rating for
quality of services - every year since the
annual health check came into being and the second year in a row to be rated
excellent for use of financial resources.
In addition, the Trust was judged to have
‘fully met’ the Government’s core standards
for the year and, for the fourth successive
year, scored ‘excellent’ in the new national
targets.
The quality of services section covers a range
of areas, including, standard of care, safety
and cleanliness, dignity and respect, keeping
the public healthy, waiting to be seen and
good management.
The use of resources aspect of the health
check is measured against how well a trust
manages its finances and achieves value
for money. RDaSH has shown consistently
good progress, from a ‘fair’ rating in 2006,
‘good’ in 2007, and ‘excellent’ for the past
two years.
The ‘under achieved’ target relating to Child
and Adolescent Mental Health Services
(CAMHS) in the table remained the subject
of an action plan with the intention of
achieving this priority in 2009/10.
Healthcare Commission Annual Health Check 2008/2009
Rotherham Doncaster and South Humber Mental Health NHS Foundation Trust
Quality of Services
Excellent
Core Standards
Fully met
National Priorities
Excellent
CPA 7 day follow up
Achieved
Delayed transfers of care
Achieved
Experience of patients
Satisfactory
Drug users in effective treatment
Achieved
Data quality on ethnic group
Achieved
Access to crisis resolution
Achieved
Patterns of care from MHMDS
Achieved
Completeness of the MHMDS
Achieved
Child and adolescent MH services
Under Achieved
Green light toolkit
Achieved
NHS staff satisfaction
Satisfactory
Number of people with a care plan
Achieved
Campus provision
Data not available
Quality of Financial Management
Excellent
Information on the quality of data statement
RDaSH 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: 97.12% for admitted patient
care; 96.96% for outpatient care; and
0%*for accident and emergency care.
-which included the patient’s valid General
Practitioner Registration Code was: 91.31%
for admitted patient care; 93.7% for
outpatient care; and 0%* for accident and
emergency care.
* RDaSH does not provide accident and
emergency care
RDaSH
16
Core standards declaration 2009/10
The annual health check was replaced with
‘periodic reviews’ of commissioners and
providers by the Care Quality Commission
(CQC).
The CQC took over from the three health
and social care regulators (the Healthcare
Commission, The Commission for Social
Care Inspection and the Mental Health Act
Commission) on 1 April 2009.
As a result, the performance of RDaSH
was assessed against Standards for Better
Health mid-year, instead of the end of the
year.
The Trust’s Core Standards Declaration
was submitted to the Care Quality
Commission to meet the 7 December
deadline following agreement by the
RDaSH Board of Directors that the Trust
was fully compliant with all core standards.
This was a mid-year declaration made
Artwork on display at Great Oaks in North Lincolnshire.
RDaSH
both retrospectively and prospectively to
cover the whole of the year. The Board
of Directors, at its April 2010 meeting,
reviewed the full year’s compliance
position as Core Standards were replaced
by the Care Quality Commission (CQC)
registration process.
17
Monitor Compliance Framework/
risk ratings 2009/2010
• Compliance with their constitution
The Trust submits quarterly declarations
to Monitor for Finance, Governance and
Mandatory Services. Monitor reviews the
declaration and issues a quarterly risk rating
for each element.
• Maintaining appropriate Board
structures
The Finance rating is based on the Trust’s
financial performance in the quarter
against the Annual Plan. The risk rating
is on a scale of 1 to 5 with 5 being the
lowest risk.
The Governance rating (Red, Amber
or Green) is based on the Trust’s self
declaration against the following areas:
• Growing a representative membership
• Co-operating with other NHS bodies
• Risk Management
• Service performance and continuing
improvement in clinical quality
The Mandatory Services rating (Red,
Amber or Green) is based on the Trust
providing the services listed in its Terms
of Authorisation. In 2010/2011, Monitor’s
governance ratings system will change to
Red, Amber/Red, Amber/Green, Green.
The Trust is confident that its Monitor risk
ratings at the end of the 2009/10 year will
be:
Finance
4
Governance
Green
Mandatory Services
Green
The following table reflects the Trust’s
anticipated 2009/10 year end position for
the Mental Health indicators.
Targets 2009/2010
Threshold
Year End Outcome
100% enhanced CPA patients receiving follow-up contact within 7
days of discharge from hospital
95%
100%
No more than 7.5%
3.52% ‘achieved’.
90%
99.5%
4.1
4.1 Forecast as ‘achieved’
Per standard
Fully compliant
Minimising delayed transfers of care
Admissions to inpatient services had access to crisis resolution home
treatment teams
Maintain level of crisis resolution teams set in 03/06 planning round (or
subsequently contracted with PCT)
To meet all core standards
Governance Risk Rating
GREEN
RDaSH
18
The tables below show detailed analyses
of the quarterly reporting to Monitor, as
referred to in the text. They are featured
for comparison purposes as required by
Monitor.
Table 1 features ratings for the four
quarters of 2008/09, compared with the
Trust’s expectation at the beginning of the
year in the Annual Plan. Similarly, Table 2
provides quarterly ratings for 2009/10, plus
the expectation in the Annual Plan.
Table 1
Annual Plan
2008/09
Quarter 1
2008/09
Quarter 2
2008/09
Quarter 3
2008/09
Quarter 4
2008/09
Financial risk rating
4
4
4
4
4
Governance risk rating
A
A
G
G
G
Mandatory services
G
G
G
G
G
Annual Plan
2009/10
Quarter 1
2009/10
Quarter 2
2009/10
Quarter 3
2009/10
Quarter 4
2009/10
Financial risk rating
3
3
4
4
4
Governance risk rating
G
G
G
G
G
Mandatory services
G
G
G
G
G
Table 2
In the 2009/10 plan submitted to Monitor,
the Trust forecast a financial risk rating of ‘3’.
This was on the basis that the Trust
retained a risk reserve to manage the risk
of not achieving efficiency targets and not
managing other cost pressures. During
the year, the Trust has managed these risks
without accessing the risk reserves which
had enabled it to move to a projected risk
rating of ‘4’.
RDaSH
Monitor’s new categories of risk rating are::
• Green No material concerns
• Amber-green
Emerging concerns
• Amber-red
Potential future
significant breach if
not rectified
• Red
Likely or actual
significant breach
19
Reports from regulators 2009/10
Periodic Reviews
RDaSH was not subject to periodic
review by the Care Quality Commission
during the reporting period.
Service Reviews
RDaSH did not participate in any special
reviews or investigations by the CQC
during the reporting period.
However, the Trust completed the data
collection for the Healthcare Commission
(now the Care Quality commission)
Safeguarding Children Review.
Safeguarding Children Declaration
Every NHS Trust is required to publish a
declaration to ensure they are compliant
with the relevant arrangements relating
to Safeguarding Children. RDaSH is fully
compliant with all 11 of the specific criteria
relating to provider trusts.
Information Quality and Records
Management
RDaSH’s score for 2009/2010 for
Information Quality and Records
Management, assessed using the
Information Governance Toolkit was
80% for the period 2009/2010 .
Clinical audits and national confidential enquiries
During 2009/10, RDaSH was eligible to participate in five national clinical audits and one
national confidential enquiry which related to NHS services that RDaSH provides. During
2009/10, RDaSH participated in 100% of the national clinical audits and 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 enquiries that RDaSH was eligible to
participate in during 2009/10 were:
• Prescribing Observatory for Mental Health (POMH UK) – Medicines Reconciliation
• Prescribing Observatory for Mental Health (POMH UK) –Use of Antipsychotic
Medication in People with a Learning Disability
• Prescribing Observatory for Mental Health (POMH UK) – Assessment of Side
Effects of Depot Antipsychotics
• Prescribing Observatory for Mental Health (POMH UK) – Supplementary Follow-up
of High Dose and Combination Antipsychotic Prescribing
• National Confidential Enquiry into Suicide and Homicide by People with a Mental
Illness
Royal College of Physicians – National Clinical Audit of Continence Care
The above audit aimed to evaluate the quality of Continence Services, as well as the
assessment and management of people with incontinence in England, Wales, Northern
Ireland and the Channel Islands. The information was collected for use in individual site reports
looking at the quality of continence care provided and whether national guidelines are being
followed.
The audit covered inpatients from January 2008 to December 2009 in Adult, Older People’s
Mental Health Services, Rehabilitation and Learning Disabilities Services across the three main
areas of Doncaster, Rotherham and North Lincolnshire in which the Trust provides services.
The deadline for submission of data was the end of March 2010 and the results are due to be
published in July/August 2010.
The reports of five national clinical audits were reviewed by RDaSH in 2009/10 and RDaSH
intends to take the following actions to improve the quality of healthcare provided:
All clinical audit results will have agreed risk ratings and where appropriate be entered
onto the relevant Trust Business Division risk register. The monitoring and implementation
of recommendations will be undertaken by the Business Division Quality Group and this
procedure will be overseen through the Trust’s governance processes.
Information on participation in clinical research
The number of patients receiving NHS services provided or sub-contracted by RDaSH that were
recruited during that period to participate in research approved by a research ethics committee
was 349.
RDaSH
20
Other highlights from the RDaSH year
RDaSH features as CQC case study
organisations.
RDaSH was featured as an example of best
practice in the Care Quality Commission’s
first annual report to parliament on the
state of health care and adult social care.
All NHS trusts in the Yorkshire and Humber
Strategic Health Authority (SHA) region
were subject to the review meetings which
explored the following areas:
In a DVD commissioned by the CQC, Chief
Executive Christine Boswell talked about
the importance of person-centred care in
mental health planning.
• Ensuring the safety, quality and effective
use of resources in NHS organisations
She was followed by service user Ally, who
talked of her experience of using mental
health services centred on her needs.
She shared her personal story about how
joined-up care and the Wellness and
Recovery Action Plan (WRAP) programme
have supported her through a crisis and
allowed her to get on with her life.
• Targeting and co-ordinating regulatory
and performance management activities
to reduce duplication
•
Agreeing a collective, organisational risk
profile and prospective shared
regulatory plan (dependent on those
organisations best placed to intervene)
that is aligned and co-ordinated with
performance management plans, with
the overall aim of supporting
improvement.
DSSA Posters
The posters match the leaflets and are placed in prominent places on
the wards
Watch the DVD at: http://www.cqc.org.uk/
stateofcare/joined-upcare/allysstory.cfm
Concordat risk summit
For the second successive year it was
concluded that there were no areas of
concern relating to the Trust following a
Concordat risk summit, also known as a
‘planned collaborative review’, hosted by
the Care Quality Commission in December
2009. The Trust underwent a similar review
in January 2009.
The process involved the bringing together
of regulators, audit and review bodies and
Strategic Health Authorities to support
a common approach to risk assessment
and co-ordination of actions with NHS
RDaSH
Delivering Same Sex Accommodation posters. See next page for information about the
scheme.
21
Delivering Same Sex Accommodation
(DSSA)
Delivering Same Sex Accommodation, whilst
not a new concept, has had an increased
profile over the past two years. Recent
guidance includes:
The NHS Constitution states that all patients
should feel that their privacy and dignity are
respected while they are in hospital. High
Quality Care for All (2008), Lord Darzi’s
review of the NHS, identifies the need to
organise care around the individual, ‘not just
clinically but in terms of dignity and respect’.
In December 2009 and February 2010,
further guidance on definitions of same sex
accommodation and what Trusts should do
to achieve this was published. Also included
was the need to provide key information
regarding trust activity and to publish a
declaration regarding achievement of same
sex accommodation on the Trust public
website.
The Trust has engaged in a detailed
programme of work to develop Same Sex
Accommodation. This has included:
Ward estates survey
The Trust has completed all ward estates
surveys and indicated that the wards
are compliant with Delivering Same Sex
Accommodation.
Information leaflets and posters
Posters and information leaflets particular
to the Trust inpatient provision have been
developed. Posters are in key places on
all wards and the information leaflets are
available and issued to all service users and
carers on admission.
regard to same sex accommodation, safety
and privacy and feeling safe during their
inpatient stay
The posters and leaflets indicate what
the service user can expect with regard to
accommodation that is available on the
ward to which they are being admitted. It
also highlights what they should do if they
find that they do not receive the level of care
with regard to Same Sex Accommodation
that is expected or if they have any
concerns, queries or questions.
Essence of Care
Signage
The information on posters and leaflets is
supported by new signage that has been
put in place on each ward.
All wards within RDaSH have a dedicated
and signed ‘Women only lounge’. With the
exception of Amber Lodge which is a male
only ward.
Training Pack
In order to support the above and to
highlight key messages around dignity and
respect along with delivering Same Sex
Accommodation, an educational training
pack was formulated. Following the initial
training to the ward managers and modern
matrons, it was then cascaded to all teams
on each ward across RDaSH.
Service user survey
The Trust is completing the final one of
three service users surveys specifically
focused on service user experience with
The Trust Essence of Care group has
completed an Essence of Care privacy and
dignity audit across all the inpatient wards.
In December 2009 NHS Yorkshire and
Humber published their Delivering Same
Sex Accommodation Privacy and Dignity
Challenge Fund Report, highlighted within
this report and illustrated was the ongoing
working around information undertaken by
the Trust.
The Trust has completed a self assessment
checklist and as a result has declared
compliance with Delivering Same Sex
Accommodation; this was posted on the
Trust public website by the end of March
2010. The Trust has an approved Delivering
Same Sex Accommodation policy published
on its website and all staff across the
inpatient wards work to this policy.
The Trust works closely with its PCT
commissioners with regard to Delivering
Same Sex Accommodation and was invited
to both host and present its developmental
work at the SHA Regional Delivering Same
Sex Accommodation PCT led forum held on
10th March 2010, sharing the agenda with
the Department of Health who took the
opportunity to launch the Delivering Same
Sex Accommodation facilitators’ training
tool.
RDaSH
22
NHS Litigation Authority Assessment
The Trust successfully ‘achieved’ Level 1
of the NHS Litigation Authority (NHSLA)
Mental Health and Learning Disability Risk
Management Standards following a twoday Level 1 independent assessment by the
NHSLA in March 2009.
The risk management standards cover
five key risk domains, with each domain
containing 10 criteria:
1. Governance
2. Competent and Capable Workforce
3. Safe Environment
4. Clinical Care
5. Learning from Experience
Planning for the assessment was undertaken
over a substantial period of time by a crossdirectorate group, charged with revising
approximately 50 Trust policies to ensure
compliance with the NHSLA standards.
During the two-day assessment, the Trust’s
Risk Management Framework and policies
were reviewed by the assessor and a
number of key staff were interviewed.
The Trust is required to be reassessed
against the Level 1 standards no later
than the fourth quarter of 2010 (JanuaryMarch 2011) and may apply for a higher
level of assessment between mandatory
assessments. In order to ensure that
systems are embedded, organisations are
advised to wait at least two years before
being assessed at the next level. The Trust
is expecting an informal visit from the
NHSLA in September 2010, with a Level 1
reassessment in February 2011. Notification
of the new 2010/11 NHSLA Standards was
received on 12 January 2010 and these
will now be mapped against the 2008/09
standards so that the new requirements can
be reflected in existing Trust policies and any
new policies required can be developed.
Looking ahead to the 2010/2011 year, the
Trust is currently working to an action plan
in order to meet the requirements of the
NHSLA’s Level 2 assessment process, which
would take place following a successful
reassessment at Level 1.
Health and Safety Executive Visits
There were no Health and Safety
Executive visits to the Trust during the
2009/10 year.
Payment by Results
RDaSH was not subject to the Payment
by Results clinical coding audit during
the reporting period by the Audit
Commission.
The Trust received complimentary feedback
from the NHSLA assessor about the well
organised assessment visit, appreciation of
the time that Trust staff had set aside to
meet with the assessor, and the excellent
overall outcome.
Pampering session at the Staff Wellbeing Day.
RDaSH
23
Managing the transition 2009/10 – 2010/11
Care Quality Commission Registration
procedure
RDaSH is required to register with the
Care Quality Commission and its current
registration status is ‘registered without
conditions’. The Care Quality Commission
did not take enforcement action against
RDaSH during 2009/10.
From April 2010, all health and adult social care providers who
provide regulated activities were required by law to be registered
with the Care Quality Commission. To register, NHS organisations
were required to show that they were meeting the new essential
standards of quality and safety across all of the regulated
activities they provide. There are now 28 outcomes which relate
to the Health and Social Care Act 2008 (Regulated Activities)
Regulations 2009 and are grouped into six main headings:
• Involvement and information
•
Complete registration application and declare compliance/
non compliance against Essential Standards of quality and
safety for each registered location and regulated activities
provided at each location.
• Establish ongoing monitoring processes to monitor
compliance with the Essential Standards of quality and safety.
The Trust applied to register with the CQC on 28 January 2010 in
preparation for registration from 1 April 2010 and was registered
without conditions by the CQC.
• Personalised care, treatment and support
• Safeguarding and safety
• Suitability of staffing
• Quality and management
• Suitability of management
This new system was designed to ensure that people can expect
services to meet essential standards of quality and safety that
respect their dignity and protect their rights. The new system
focuses on outcomes, rather than systems and processes, and
places the views and experiences of people who use services at
the centre.
Trust Registration Process
• Pre-application stage – submission to CQC of Trust locations.
• Establish Trust compliance against Essential Standards of
quality and safety.
Members of the PROP (People Relying on People) Group,
part of the Early Onset Dementia service, enjoying some
outdoor therapy.
RDaSH
24
Looking ahead
Leading the Way with Quality
(LWQ)
During the 2009/10 year RDaSH embarked
on a transformational organisational
development programme called ‘Leading
the Way with Quality’.
The purpose of the programme, initiated
by the Chief Executive and fully supported
by the RDaSH Board of Directors, remains
to prioritise the Trust’s focus on quality of
service delivery for service users, to support
stronger clinical engagement and to ensure
the Trust was business ready to face the
anticipated challenges of the coming three
years.
Staff were involved in an initial series
of LWQ workshops, led by the Chief
Executive, at the end of 2009 and their
enthusiastic feedback led to the setting up
of a suggestion scheme to enable them
to contribute their innovative ideas to the
ongoing LWQ programme.
Based on the success of phase one, a
second series of workshops was held
during April and May 2010 to update
staff on progress and give them a further
opportunity to have direct input into the
development of the LWQ programme.
Trust Quality Council (TQC)
The Trust Quality Council was established
in July 2009 as a major strand in the Trust’s
‘Leading the Way with Quality’ initiative.
The TQC, which meets monthly, is
supported via the Senior Leadership Team
(SLT) and the Board of Directors where it
reports and advises on the quality of the
Trust’s services.
The TQC was created to bring about and
RDaSH
maintain a hold on quality, sponsored
and supported by the Trust’s clinical staff,
and with an emphasis on understanding,
sharing and learning lessons derived from
patient safety, clinical effectiveness and
patient experience.
Based on the philosophy of the patient
experience being central to the theme of
‘Putting Quality at the Heart of Everything
We Do’ the TQC’s role is to turn those
words into reality, with specific emphasis
on the above three areas.
Research and innovation work are also
areas that the Council is supporting and
encouraging among staff, along with
providing opportunities to share trust-wide
examples of best practice.
Quality priorities for the coming
year
Once again the Trust has taken into
account the priorities for the NHS
outlined in the Operating Framework
for 2010/11. For the Trust the
following have particular significance:
• Improving cleanliness and
reducing healthcare-associated
infections
The Trust will continue to maintain
focus on cleanliness and safety in all
of its service areas
• Keeping adults and children
well, improving their health and
reducing health inequalities
The Trust has a well developed and
successful health, wellbeing and
recovery strategy. The Trust remains
committed to improving the overall
experience of service users while
they are with RDaSH services and
is equally committed to helping
people move on or back to more
independent living
• Improving patient experience
and staff satisfaction and
engagement
Through the Business Division
Quality Framework the Trust has
identified a number of specific
areas for quality that contribute
directly towards improving patient
experience, staff satisfaction and
engagement.
For the 2010/11 year there will
be three main priorities for quality
improvement for the Trust within
the areas of Patient Safety, Clinical
Effectiveness and Patient Experience:
• Learning from and evolving
from untoward incidents and
investigations
• Ensuring access to our services to
support the ethos ‘every patient
contact every time’
• Involving service users and carers
and drawing on their experiences to
inform every aspect of care.
Business Division Quality
Framework
The Business Division Quality Framework
is a key element of the seven developing
business divisions of the Trust, comprising
the operational services of the Trust:
•
•
•
•
Adult Mental Health Services
Older Adult Services
Young Persons’ Services
Community Learning Disability Services
25
• Psychological Therapies
• Substance Misuse Services
• Forensic Services.
The business division development process
has been designed as a stepped process,
whereby business divisions increasingly take
more responsibility for their performance,
governance and financial balance. At Level
One of this process, each business division
is expected to perform satisfactorily and
provide evidence against a prescribed
Quality Framework. This framework is
constructed of four domains: a mandatory
set of core quality fields and a selection
of twenty quality fields across the three
recognised quality domains of patient
experience, patient effectiveness and
safety. From the twenty fields across these
three quality domains, for Level One,
each business division has been required
to select nine quality fields to work to,
alongside the mandatory set of quality
fields, on the basis of three fields chosen
from each of the three domains.
This work will be coordinated by a
quality committee, established by each
of the business divisions, drawing on the
expertise and support of the Trust’s central
governance functions and including input
from the division’s stakeholders, notably
including service users and carers. A key
success factor for the business divisions in
this work will be the further development
of the divisions’ management teams and
clinical leaders, to drive forward the quality
programme and engender a culture of
continuous improvement within each
division.
One of the strengths of the business
division approach is the relative shift from
a position whereby the agenda and work
plan was previously established largely at
a corporate, strategic level, to a position
where the needs of the operational services
increasingly set the agenda and identify
the work plan priorities. In respect of
service quality, the business divisions will
increasingly identify, in close collaboration
with service users, carers and other key
stakeholders, the distinct quality issues
that are the priority for those who use
the services of each business division,
rather than following a corporate driven
quality agenda. Whilst some quality issues
will be common to all divisions, many of
the key quality issues will be particular to
the different divisions. The key issues, for
example, of those receiving Young Persons’
Services are likely to be different to those
receiving Learning Disability Services.
As business divisions progress in their
development process, these emerging
distinctions in the quality agenda, and the
reporting of our success in improving these
areas, will be reflected in future quality
accounts.
Details of the Business Division Quality
Framework indicators are provided below: Patient Safety
1
Untoward incidents are reported and investigated according to policy at level (SUI/internal
review) appropriate to their severity
2
Investigations produce action plans that are owned by clinical services and are achievable
3
There is evidence of learning through changes in practice/procedure through
implementation of action plans
Clinical Effectiveness
1
Evidence that all clinical staff (including consultants) have access to clinical supervision
appropriate to their seniority and development needs and that this is routinely monitored
2
Evidence that services are available within a reasonable time and there are no unacceptable
waiting lists. Where waiting lists occur, clinical staff are involved in prioritisation and are
attempting to manage the list
3
Evidence of systematic monitoring of the physical health of all inpatients at agreed
minimum intervals with particular regard to vulnerable groups (e.g. high dose medication,
lithium etc.)
4
Clinical practice is influenced by NICE guidance/national guidelines (NSF etc)
Patient Experience
1
Evidence that, within each business division staff collaborate with patients to ensure the
latter have access to privacy and are treated with dignity and respect
2
Evidence that information about services and treatment is available to patients in all areas
3
Evidence that staff collate positive and negative feedback and use this information to
improve delivery of care
4
Evidence that staff involve patients and carers in activities to develop services and decisions
are influenced by their views.
RDaSH
26
Quality payments
CQUIN (Commissioning for Quality
and Innovation) payments for
2010/11
As a result of in-depth work with our
strategic health authority and our
commissioners to develop regional and
local indicators for the 2010/11 CQUIN
scheme that would work towards
delivering good quality care for patients
and service users, it was decided in January
2010 that the following allocations would
be made available to the Trust:
Regional CQUIN 0.5%
Local CQUIN 1.0%
The Trust’s progress towards achieving
these indicators is monitored on a quarterly
basis and the results will be published in
next year’s Quality Account. During the
year, regular updates will be reported at
both the Board of Directors and Council of
Governors meetings.
Regional Indicator framework for 2010/11
Indicator 1
Improving access to assessment for adults of working age services experiencing acute mental health problems
Indicator 2
Improving access for service users experiencing non acute mental health problems – adults of working age
Indicator 3
Improving outcomes for BME service users
Indicator 4
Improving standards of care and compassion – Nutrition achieving best practice standards set out in Essence of Care –
Inpatients. Note: Older People’s Mental Health only, to be confirmed
Indicator 5
Improving standards of care and compassion – Pressure Sores achieving best practice standards set out in the consultation
document (DH 2009) “Essence of Care” – Inpatients only
Indicator 6
Meeting the needs of service users with a learning disability
Indicator 7
Dementia – development and implementation of an integrated dementia pathway. (This is a new indicator to replace the previous
CAMHS indicator and focuses on the implementation of the National Dementia Strategy.)
(further detailed information relating to this framework is available in Appendix B)
Local CQUIN indicator framework for 2010/11
Indicator 1
Improving access to assessment for people experiencing non-acute mental health problems
Older people only – to establish the average waiting times
Indicator 2
Inpatient service users will self-report satisfaction with treatment received
Indicator 3
To assess the provider’s readiness for the introduction of PbR (payment by results) in the requirement to cluster clients appropriately
To monitor the provider’s readiness for the introduction of PbR with the % of clients being allocated a SARN score and cluster(s)
Provider utilising SARN will publish quarterly data on the % of clients with a SARN score (or equivalent) and cluster allocation
within the quarter (Adults of working age and older people)
Indicator 4
Promoting healthy lifestyle by training staff. Advice to be provided to patients on:
• Smoking
• Diet
• Exercise
(further detailed information relating to this framework is available in Appendix C)
RDaSH
27
Feedback from stakeholders
Annex Statement
The Quality Account illustrates some of the
ways the Trust is contributing to the delivery
of the World Class Commissioning priorities
of its lead commissioning primary care trusts
(see Appendix D).
Annex. Statements from primary care trusts,
Local Involvement Networks and Overview
and Scrutiny Committees.
NHS foundation trusts must send copies of
their Quality Reports to their relevant lead
commissioning primary care trusts (PCTs),
Local Involvement Networks (LINks) and
Overview and Scrutiny Committees (OSCs)
for comment prior to publication, and should
include these comments in their published
Quality Reports.
For RDaSH, these are NHS Rotherham, NHS
Doncaster, NHS North Lincolnshire (statutory
requirement for comments), Rotherham,
Doncaster and North Lincolnshire OSCs
and Rotherham, Doncaster and North
Lincolnshire LINks (optional requirement for
comments).
Doncaster Metropolitan Borough
Council
It has been agreed with Doncaster
Metropolitan Borough Council to hold
a meeting/workshop with the Healthier
Communities and Vulnerable People
(HCVP) OSC, LINk, the PCT and local
healthcare providers when it reforms
in June 2010, to determine the extent
to which the OSC and LINk will be
involved, and with the possibility of
RDaSH presenting its published Quality
Account at that time. RDaSH has offered to
provide both a mid-year (end Q2) update,
either through a formal meeting or via
correspondence and pick up any questions
that may arise.
NHS Doncaster
NHS Doncaster is one of the lead
commissioners for RDaSH and we are
pleased to be able to review and comment
on the 2009/2010 Quality Account and the
work that RDaSH has undertaken to ensure
the delivery of safe effective, high quality
services for patients and service users.
NHS Doncaster’s objectives are to promote
public health and reduce inequalities
through prevention, investment,
partnerships and the commissioning
of high quality, accessible services. We
continue to work in partnership with
RDaSH to ensure that services delivered
reflect this vision. We are pleased to
acknowledge the priority and investment
that RDaSH has placed on the quality of
the services they deliver.
The lead commissioning PCTs will have a
legal obligation to review and comment,
while LINks and OSCs will be offered the
opportunity to comment on a voluntary
basis. There are specific timeframes for
seeking and receiving responses. Please
note this section has been renamed Annex
to be consistent with the Quality Accounts
regulations.
A member of the Productive Mental Health Ward - Releasing Time to Care
programme relaxing with a service user.
RDaSH
28
In particular we recognise:
•
The achievement towards the quality
goals NHS Doncaster established as part of our ‘Quality and Outcomes
Framework’.This was a scheme to
reward joint quality goals agreed with
NHS Doncaster. Achievements include:
• Productive ward series, all 21
inpatient areas have implemented
this programme
• The rollout of the nutritional
assessment for all service users with
first episode psychosis
• The engagement of service users in
clozapine clinics
• The progress in the development of
the electronic evidence based care
pathway for cluster 17 patients
• RDaSH were able to declare full
compliance against the core standards
within Standards for Better Health
• RDaSH achieved an ‘excellent’ in both
use of resource and quality of services in
the annual NHS Health Check.
• The work and progress achieved in the
‘Delivering Same Sex Accommodation’
•
That RDaSH Board has established the
transformational leadership
development programme, ‘Leading the
way with quality’.
NHS Doncaster looks forward to continuing
working alongside RDaSH, striving towards
the delivery of high quality, safe, and cost
effective care and services for all.
RDaSH
NHS North Lincolnshire
NHS North Lincolnshire is pleased to
be able to review and comment on the
2009/10 Quality Account for Rotherham
Doncaster and South Humber Mental
Health NHS Foundation Trust (RDaSH) and
the work that they have undertaken to
provide high quality safe provision for their
service users.
NHS North Lincolnshire considers that
the information presented in the Quality
Account accurately reflects the work of
RDaSH. Furthermore, we support the
framework for the future development of
quality, as set out in their transformational
leadership development programme
‘Leading the Way with Quality’.
NHS North Lincolnshire’s vision is to
commission integrated health and social
care services that promote health and
well being and empower people to
make healthier lifestyle choices, ensuring
care is constantly improved, responsive,
convenient and delivered in the most
appropriate setting. We continue to work
in partnership with RDaSH to ensure that
services delivered reflect this vision.
We are pleased to acknowledge the priority
and investment that RDaSH has placed on
the quality of the services they deliver.
In particular we recognise:• The participation of RDaSH (as an early
adopter) in the Local Quality Outcomes
Framework, that has seen them working
collaboratively with local stakeholders to
promote effective outcomes including:
• Improving nutritional intake in Early
Intervention in Psychosis Services
• Improving the engagement of service
users in Assertive Outreach Services
• Expansion of the productive mental
health ward programme, ‘Releasing
Time to Care’
• That RDaSH declared full compliance
against the core standards with
Standards for Better Health
•
The achievement of an excellent rating
for quality of services from the Care
Quality Commission (for the fourth
consecutive year) alongside an excellent
rating for use of resources
NHS North Lincolnshire looks forward to
continuing working alongside RDaSH in its
continued commitment to developing high
quality, effective, safe and cost effective
services for all.
North Lincolnshire Overview and
Scrutiny Panel
North Lincolnshire Council’s relevant
scrutiny panels welcome the opportunity
to comment as part of Rotherham
Doncaster and South Humber Mental
Health NHS Foundation Trust’s (RDaSH)
Quality Account. RDaSH are a key partner
and provider of local services, and we are
aware of their excellent performance and
reputation, as judged at both local and
national level. Members examined NHS
North Lincolnshire’s (as lead commissioners)
most recent Corporate Performance
Report (March 2010) and noted that all key
29
indicators and targets were highlighted in
their “traffic light” methodology as green.
We are aware of real progress on issues
such as alcohol misuse and dementia,
although we share RDASH’s view that
further work is required. A previous report
by the council’s Children and Young People
Scrutiny Panel on CAMHS highlighted
some areas of concern, such as long
waiting lists and engagement with schools.
Whilst we note that some progress has
been made since the panel’s report, in
partnership with NHS North Lincolnshire,
we believe that further work on this
important issue is required.
On work-related issues, every contact with
RDaSH in recent years has resulted in a
positive response, and it is clear to us that it
is an organisation that is open, accountable
and committed to providing excellent
services to local people.
NHS Rotherham
NHS Rotherham welcomes the opportunity
to comment on the RDaSH Quality Account
and notes that it appears comprehensive
and detailed.
NHS Rotherham is pleased to note that
RDaSH has provided feedback on NHS
Rotherham’s comments on last year’s
report, which had been taken into
consideration when producing this year’s
version and that user/public opinion
had been sought when producing this
document, the User/Carer partnership
having a wide and varied membership.
NHS Rotherham acknowledges the high
standards of care delivered by RDaSH
and would welcome the opportunity to
comment on future Quality Accounts.
Joint Commentary LINkrotherham
and Adult Services and Health
Scrutiny Panel.
Rotherham Doncaster and South Humber
Mental Health NHS Foundation Trust
(RDaSH) have demonstrated throughout
the year that they are committed to patient
care .
They have actively engaged in patient
involvement and joint working with
stakeholders.
Dementia Event
Representatives from RDaSH attended a
joint Adult Services and Health Scrutiny
Panel and LINkrotherham event to talk
about the support in place for people
with dementia. They demonstrated their
commitment to a holistic approach to
patients with dementia.
Quality Accounts Event
RDaSH also attended a joint event to share
the content of their draft Quality Account.
We look forward to working closely with
RDaSH in 2010 /2011.
RDaSH
30
How to contact us
Let us know what you think
Check out our website
Hopefully, our quality account has been
informative and interesting to you and
we welcome your feedback, along with
any suggestions you may have for next
year’s publication. Please contact our
communications team at:
The RDaSH website provides
comprehensive details of the Trust’s
services and where they are provided,
information about mental health and
learning disabilities, what to do in a crisis
situation, updates on Trust initiatives and
links to other useful websites.
St Catherine’s House
Tickhill Road
Balby
Doncaster
DN4 8QN
Email: rdashcommunications@rdash.nhs.uk
Telephone: 01302 796204/796282/798134
Join us as a member and have a
say in our future plans
A representative and meaningful
membership is important to the success
of the Trust and provides members of
our local communities the opportunity
to be involved in how the Trust and its
services are developed and improved.
Membership is free and the extent to
which our members are involved is entirely
up to them. Some are happy to receive
a newsletter twice a year while others
are keen to be involved in consultations
and come along to meetings. Some have
even become members of our Council of
Governors. For further information please
contact our Foundation Trust Office on:
Freephone 0800 015 0370
Email: ftmembership@rdash.nhs.uk
RDaSH
There is also a section about Foundation
Trust membership under the ‘Information
for the Public’ heading, where there is an
opportunity to sign up online.
Visit www.rdash.nhs.uk to find out more.
This Quality Account can be found on the
NHS Choices website at www.nhs.uk . By
publishing the report with NHS Choices,
RDaSH complies with the Quality Accounts
Regulations.
This report can be made available in a
variety of formats, available on request.
31
Glossary of terms/jargon buster
This section aims to explain some of the
terms used in the Quality Account. It is not
an exhaustive list but hopefully will help to
clarify the meaning of the NHS jargon used
in these pages.
Annual Plan: this document sets out the
Trust’s annual financial forecasts, strategic
plans, key risks and priorities
BME: Black and Minority Ethnic
CAMHS: Child and Adolescent Mental
Health Service
CDW: Community Development Worker
CGAS: Children’s Global Assessment Scale
CPA: Care Programme Approach - the
framework for good practice in delivering
mental health services. CPA aims to ensure
that services work closely together to meet
service users’ identified needs and support
them in their recovery.
Cluster: a group of service users with
similar diagnoses and needs.
CQC: Care Quality Commission
CQUIN: Commissioning for Quality and
Innovation
Dashboard: summary overview of key
areas of performance
DRE: Delivering Race Equality
DSSA: Delivering Same Sex
Accommodation
Essence of Care: the government’s
strategy to improve the quality of the
fundamental aspects of nursing care.
FT: Foundation Trust
LD: Learning Disability
QOF: Quality Outcome Framework
LINks: Local involvement networks
Quarter 1: April, May, June.
LWQ: Leading the Way with Quality
Quarter 2: July, August, September.
Maracis: A computerised system used to
keep service user profiles and records.
Quarter 3: October, November,
December.
MHMDS: Mental Health Minimum Data
Set
Quarter 4: January, February, March.
Monitor: Independent regulator for
foundation trusts
RAP: Referrals, Assessments and Packages
of Care
NPSA: National Patient Safety Agency
Sapphire: Learning Disabilities Assessment
and Treatment Unit.
NHSLA: National Health Service Litigation
Authority
SARN: Summary Assessment of Risk and
Needs
NICE: National Institute for Health and
Clinical Excellence
SHA: Strategic Health Authority
NSF: National Service Framework
OPMHS: Older People’s Mental Health
Service
OSC: Overview and Scrutiny Committee –
a local authority body which scrutinises and
makes recommendations regarding public
services provided by the Trust. PEAT: Patient Environment Action Team
PbR: Payment by Results
PCT: Primary Care Trust
Productive Mental Health Ward
Programme: a programme of positive
changes to ward processes such as
handovers and mealtimes, incorporating
service user feedback and participation
which have been sustained and embedded
into practice.
SUI: Serious untoward incident – an
unexpected occurrence requiring
investigation
Service engagement scale: an
assessment to help improve the level of
service user engagement with services e.g.
attending appointments.
TBD: Trust Business Division
Tool/Toolkit: A package of information
and written guidance
Standards for Better Health: A set of
core and developmental standards covering
NHS healthcare provided for NHS patients
in England
TQC: Trust Quality Council
Validate: prove valid, declare, provide
evidence for.
QIPP: Quality, innovation, productivity and
prevention
RDaSH
32
Appendices
Appendix A:
The following tables give information for services in Doncaster, Rotherham and North Lincolnshire. There may be some
variations to the overall submission from the Trust due to contractual out of area arrangements.
Regional Quality Indicators 2009/2010 for Doncaster
Indicator A) Improving Access to assessment for people experiencing acute mental health problems. (from Q2)
Quarter 1
Total
Seen in 4 Hours %
Quarter 2
Quarter 3
Quarter 4
Total Seen in 4 Hours %
Total Seen in 4 Hours %
Total Seen in 4 Hours %
474
282
a & b) Total referrals to crisis and those assessed within 4 hours
453
Quarter 1
Total
No gate kept
260
57
Quarter 2
%
Total
237
50
Quarter 3
No gate kept
%
Total
150
53
Quarter 4
No gate kept
%
Total
No gate kept
%
100
110
110
100
assessment
%
c&d) Total number of admissions to adult acute inpatients gate kept within the quarter
94
92
98
96
96
Indicator B) Improving Access to assessment for people experiencing non-acute mental health problems. (from Q2)
Quarter 1
refs
assessment
Quarter 2
%
refs
Quarter 3
assessment
%
refs
Quarter 4
assessment
%
refs
a & b) Total number of referrals requiring non-urgent assessment in the quarter offered an assessment within 14 calendar days of
date of ref.
700 LD
128
10
8
135
0
0
197
9
5
710 Adult
1698
446
26
1520
410
27
1347
469
35
715 MHSOP
747
240
32
779
210
27
747
234
31
Quarter 1
refs
Quarter 2
%
refs
Nos in treatment %
Quarter 3
Quarter 4
refs
refs
Nos in treatment %
Nos in treatment %
c&d) Total number of referrals requiring non urgent assessment who in the quarter received appropriate first treatment within 28
days.
700 LD
128
10
8%
135
8
5%
197
6
710 Adult
1698
99
5%
1520
91
5%
1347
143
11%
715 MHSOP
747
84
11%
779
46
5%
747
57
8%
RDaSH
3%
33
Indicator B) Improving Access to assessment for people experiencing non-acute mental health problems. (from Q2)
Quarter 1
No
Quarter 2
No with score Cluster No
Quarter 3
No with score Cluster No
Quarter 4
No with score %
No
assessment
0
674
0
Cluster
g, h, i) number of unique service users and those with a SARN score and subsequent cluster allocation
0
674
0
1739
541
3930
1811
653
3920
1895
833
338
9
2837
605
23
2888
797
55
700
754
0
710
4386
715
2755
Quarter 1
total
employ
Quarter 2
accomm total
employ
Quarter 3
accomm total
0
Quarter 4
employ
accomm total
employ
accomm
J, k, l) Total number of service users and those who are in paid employment, and those who are in settled accommodation (MHMDS)
18 - 64
3479
65+
2899
255
2000
3513
272
2032
479
2899
5
858
RDaSH
34
Indicator C) Improving health outcomes for BME clients (a,b,c,d,e) total number of service users into any service in the quarter. (due for Q2)
Quarter 1
total
Psych Th CRHT
AOT
Quarter 2
EIP
White British
total
5727
Psych Th CRHT
AOT
EIP
237
320
122
120
White Irish
35
3
3
0
1
Other White
191
5
3
2
2
White and Black Caribbean
19
2
1
3
2
White and Black African
7
0
1
1
1
White and Asian
5
0
0
0
0
Other mixed
17
2
1
1
0
Indian
24
2
1
1
0
Pakistani
21
1
3
1
2
Bangladeshi
0
1
0
0
0
Other Asian
24
0
4
1
1
Caribbean
10
0
1
1
0
African
17
0
1
0
3
Other Black
23
0
0
2
3
Chinese
1
0
0
0
0
Any other ethnic group
32
0
1
0
2
Not stated
733
15
7
0
0
Not known
906
14
40
1
3
Quarter 3
total
White British
Psych Th CRHT
AOT
Quarter 4
EIP
total
Psych Th CRHT
AOT
EIP
5279
496
320
130
129
5276
510
370
133
141
White Irish
36
1
5
0
1
37
1
6
0
1
Other White
187
12
11
2
3
199
17
16
3
3
White and Black Caribbean
20
3
4
3
2
19
3
3
2
2
White and Black African
7
2
0
1
1
9
2
1
1
1
White and Asian
3
0
0
0
0
4
0
0
0
0
Other mixed
13
4
1
1
0
14
3
2
3
0
Indian
25
2
1
1
0
24
2
1
1
0
Pakistani
21
6
0
1
2
22
4
1
1
3
Bangladeshi
1
0
0
0
0
0
0
0
0
0
Other Asian
23
2
3
1
1
22
1
4
1
1
Caribbean
9
2
0
1
0
10
3
0
1
0
African
17
1
3
0
3
15
1
2
0
2
Other Black
21
1
2
1
2
20
2
2
1
2
Chinese
1
0
0
0
0
1
0
0
0
0
Any other ethnic group
23
2
2
0
2
26
2
5
0
2
Not stated
660
20
9
0
0
622
26
7
0
0
Not known
954
20
37
0
2
1018
40
36
0
2
RDaSH
Legend: Psych Ther : Psychological Therapies
CRHT: Crisis Resolution and Home Treatment
AOT: Assertive Outreach Team
EIP: Early Intervention in Psychosis
35
Indicator C) Improving health outcomes for BME clients (f, i,j) (inclusive of LD as well as rehab and recovery)
Quarter 1
Admissions
Discharge
Quarter 2
ALoS
White British
Admissions
Discharge
ALoS
228
133
70
White Irish
4
1
36
Other White
4
2
16
White and Black Caribbean
1
0
0
White and Black African
1
3
68
White and Asian
0
0
0
Other mixed
0
0
0
Indian
0
0
0
Pakistani
2
2
109
Bangladeshi
0
0
0
Other Asian
3
1
5
Caribbean
2
0
0
African
1
1
60
Other Black
0
0
0
Chinese
0
0
0
Any other ethnic group
0
0
0
Not stated
0
0
0
Not known
6
4
27
Quarter 3
Admissions
White British
Discharge
Quarter 4
ALoS
Admissions
Discharge
ALoS
231
127
71
243
152
72
White Irish
4
3
47
1
0
0
Other White
6
4
14
6
3
14
White and Black Caribbean
2
1
2
2
1
3
White and Black African
0
0
0
2
2
6
White and Asian
0
0
0
1
0
0
Other mixed
1
1
15
0
1
18
Indian
0
0
0
0
0
0
Pakistani
1
1
39
1
0
0
Bangladeshi
0
0
0
0
0
0
Other Asian
2
2
135
0
0
0
Caribbean
2
1
140
1
0
0
African
1
0
0
3
2
7
Other Black
1
1
20
1
1
7
Chinese
0
0
0
0
0
0
Any other ethnic group
2
1
13
2
2
38
Not stated
0
0
0
1
1
68
Not known
3
1
56
3
4
30
Legend: ALoS : Average length of stay
LD: Learning Disabilities
MHSOP: Mental Health Services for Older People
RDaSH
36
Indicator C) Improving health outcomes for BME clients - (total number of service users newly detained and total number of service users
subject to seclusion) (g,h)
Quarter 1
Detained
Quarter 2
Seclusion
Detained
Seclusion
White British
28
0
White Irish
0
0
Other White
1
0
White and Black Caribbean
0
0
White and Black African
0
0
White and Asian
0
0
Other mixed
0
0
Indian
0
0
Pakistani
0
0
Bangladeshi
0
0
Other Asian
2
0
Caribbean
1
2
African
0
0
Other Black
0
0
Chinese
0
0
Any other ethnic group
0
0
Not stated
0
0
Not Given
0
0
Quarter 3
Quarter 4
Detained
Seclusion
Detained
Seclusion
White British
30
0
33
2
White Irish
0
0
0
0
Other White
0
0
1
0
White and Black Caribbean
1
0
0
0
White and Black African
0
0
0
0
White and Asian
0
0
0
0
Other mixed
0
0
0
0
Indian
0
0
0
0
Pakistani
1
0
0
0
Bangladeshi
0
0
0
0
Other Asian
0
0
0
0
Caribbean
0
0
0
2
African
0
0
1
0
Other Black
0
0
0
0
Chinese
0
0
0
0
Any other ethnic group
1
0
0
0
Not stated
0
0
0
0
Not Given
2
0
0
0
RDaSH
37
Indicator D) Improving standards of care and compassion (MHSOP) Quarter 2 only
Quarter 1
Admitted
Quarter 2
Administered
Admitted
Administered
700 LD
3
0
710 Adult
78
0
715 MHSOP
16
16
a,b,c,d,e inpatients who had a nutritional screening tool administered during the quarter
Quarter 3
Admitted
Quarter 4
Administered
Admitted
Administered
a,b,c,d,e inpatients who had a nutritional screening tool administered during the quarter
700 LD
710 Adult
715 MHSOP
The NUTRITION SUPPORT POLICY FOR IN-PATIENT SERVICES was submitted. The policy is compliant with the NICE Clinical Guideline ‘Nutrition
Support in Adults’ (NICE, 2006) and has been developed with our Dietetic Service providers.
The policy contains the Malnutrition Universal Screening Tool (MUST) at Appendix 5. Training has been provided in the use of both tools, and screening implemented Trust wide in In-patient services for older people. As agreed with the
SHA and Commissioners, nutritional screening will be rolled out through an agreed training programme.
Indicator D) Improving standards of care and compassion (MHSOP) pressure sore prevalence survey
Pressure Sore Prevalence Survey
Age bandings
65-69
70-74
75-79
80-84
85-89
90+
No. single pressure sore
0
0
0
0
0
0
No. more than one pressure sore
0
0
0
0
0
0
No. with a EPUAP grading of 1
0
0
0
0
0
0
No. with a EPUAP grading of 2
0
0
0
0
0
0
No. with a EPUAP grading of 3
0
0
0
0
0
0
No. with a EPUAP grading of 4
0
0
0
0
0
0
The audit of 50 patients during the week beginning 29 June 2009 showed no patients with pressure sores.
RDaSH
38
Indicator E) Meeting the health needs of people with a Learning Disability (from Q2)
Admission protocols were in place for Learning Disability service users requiring assessment and treatment beds as well as those requiring psychiatric
inpatient services. Appropriate care pathways were jointly agreed with both adult and older adult services.
Dedicated resources were placed within the local acute hospital trust in the form of an LD liaison nursing post who works with the general medical
service provider on care pathways, education, training and awareness.
Quarter 1
No
Quarter 2
Quarter 3
Quarter 4
H & W Plan
e&f) total number of learning disability service users, and those with a documented health and wellbeing plan. (health action plan)
683
683
678
678
I,j) total number of service users for whom a quality of life review, or equivalent has been undertaken and documented.
8
Quarter 1
total
Quarter 2
employ accomm
total
8
8
Quarter 3
employ accomm
total
8
Quarter 4
employ accomm
total
employ accomm
M,n) Total number of service users and those who are in paid employment, and those who are in settled accommodation (MHMDS)
18-64
603
65+
75
1
454
603
43
72
Indicator E) Meeting the health needs of people with a Learning Disability (from Q2)
Quarter 1
Quarter 2
Quarter 3
Quarter 4
g) total number of learning disability service users occupying assessment and treatment beds at the end of the quarter.
Sapphire
6
8
8
Zero
Zero
3
h) delays in transfer of care.
Sapphire
1
RDaSH
3
443
42
39
Regional Quality Indicators 2009/2010 for Rotherham
Indicator A) Improving Access to assessment for people experiencing acute mental health problems. (from Q2)
Quarter 1
Total
Seen in 4 Hours %
Quarter 2
Quarter 3
Quarter 4
Total Seen in 4 Hours %
Total Seen in 4 Hours %
Total Seen in 4 Hours %
478
258
a & b) Total referrals to crisis and those assessed within 4 hours
477
Quarter 1
Total
No gate kept
290
61
Quarter 2
%
Total
264
55
Quarter 3
No gate kept
%
Total
165
64
Quarter 4
No gate kept
%
Total
No gate kept
%
100
115
115
100
assessment
%
c&d) Total number of admissions to adult acute inpatients gate kept within the quarter
114
113
127
127
Indicator B) Improving Access to assessment for people experiencing non-acute mental health problems. (from Q2)
Quarter 1
refs
assessment
Quarter 2
%
refs
Quarter 3
assessment
%
refs
Quarter 4
assessment
%
refs
a & b) Total number of referrals requiring non-urgent assessment in the quarter offered an assessment within 14 calendar days of
date of ref.
700 LD
1
0
0
4
0
0
1
0
710 Adult
1174
459
39
1375
470
34
1070
432
40
715 MHSOP
1025
164
16
786
124
16
875
165
19
Quarter 3
Quarter 4
Nos in treatment %
refs
Nos in treatment %
refs
Quarter 1
refs
Quarter 2
%
refs
Nos in treatment %
c) Total number of referrals requiring non urgent assessment who in the quarter received appropriate first treatment within 28 days.
700 LD
1
0
0
4
710 Adult
1174
99
8
1375
715 MHSOP
1025
2
0
786
1
0
0
20
1
1070
37
3
1
0
875
0
0
RDaSH
40
Indicator B) Improving Access to assessment for people experiencing non-acute mental health problems. (from Q2)
Quarter 1
No
Quarter 2
No with score Cluster No
Quarter 3
No with score Cluster No
Quarter 4
No with score %
No
assessment
14
0
Cluster
g, h, i) number of unique service users and those with a SARN score and subsequent cluster allocation
700
12
710
4699
1308
715
2865
14
Quarter 1
total
employ
0
Quarter 2
accomm total
employ
0
13
232
4659
1408
0
2887
41
428
4746
1556
729
1
2936
211
3
Quarter 3
accomm total
0
Quarter 4
employ
accomm total
employ
accomm
J, k, l) Total number of service users and those who are in paid employment, and those who are in settled accommodation (MHMDS)
18 - 64
4201
65+
2739
RDaSH
123
1265
4324
73
2770
167
1544
94
41
Indicator C) Improving health outcomes for BME clients (a,b,c,d,e) total number of service users into any service in the quarter. (from Q2)
Quarter 1
total
Psych Th CRHT
AOT
Quarter 2
EIP
White British
total
Psych Th CRHT
13
White Irish
14
1
3
0
0
Other White
411
0
16
0
7
White and Black Caribbean
10
0
2
3
2
White and Black African
1
0
0
0
0
White and Asian
5
0
0
0
0
Other mixed
7
0
1
0
0
Indian
4
0
1
0
0
Pakistani
79
0
7
2
14
Bangladeshi
1
0
0
0
0
Other Asian
40
0
3
1
4
Caribbean
3
0
0
0
0
African
7
0
1
0
1
Other Black
13
0
5
0
0
Chinese
5
0
0
0
1
Any other ethnic group
9
0
1
0
1
Not stated
698
0
13
0
0
Not known
691
1
56
0
4
total
White British
Psych Th CRHT
5450
240
335
White Irish
12
2
1
Other White
380
12
12
AOT
101
112
Quarter 4
EIP
106
total
Psych Th CRHT
AOT
EIP
5626
257
360
103
112
12
2
1
0
0
6
369
15
20
1
6
2
White and Black Caribbean
11
2
11
0
1
4
2
White and Black African
1
1
2
0
0
0
0
White and Asian
5
1
5
0
0
0
0
Other mixed
7
7
0
0
0
0
Indian
4
Pakistani
75
Bangladeshi
1
Other Asian
38
Caribbean
3
3
9
3
101
EIP
5435
Quarter 3
301
AOT
2
14
1
1
5
1
4
1
African
8
1
1
Other Black
12
1
2
Chinese
4
1
Any other ethnic group
8
1
2
4
0
0
0
0
81
2
13
2
13
1
0
0
0
0
39
1
3
1
7
6
0
1
0
0
8
1
1
0
2
14
1
3
0
1
1
4
1
0
0
1
1
7
0
2
0
0
Not stated
654
13
19
1
614
12
14
0
1
Not known
729
56
99
10
748
76
53
0
11
RDaSH
42
Indicator C) Improving health outcomes for BME clients (f, i,j)
Quarter 1
Admissions
Discharge
Quarter 2
ALoS
White British
Admissions
Discharge
ALoS
214
142
72
White Irish
1
0
0
Other White
5
3
43
White and Black Caribbean
2
1
188
White and Black African
0
0
0
White and Asian
0
0
0
Other mixed
1
1
47
Indian
1
1
18
Pakistani
5
3
25
Bangladeshi
0
0
0
Other Asian
2
0
0
Caribbean
0
0
0
African
0
0
0
Other Black
1
1
3
Chinese
0
0
0
Any other ethnic group
1
1
44
Not stated
3
3
29
Not known
7
6
18
Quarter 3
Admissions
White British
Discharge
Quarter 4
ALoS
Admissions
Discharge
ALoS
231
127
71
208
127
76
White Irish
1
1
94
0
0
0
Other White
4
3
350
4
2
133
White and Black Caribbean
2
1
1126
1
1
28
White and Black African
0
0
0
0
0
0
White and Asian
2
2
7
0
0
0
Other mixed
0
0
0
0
0
0
Indian
0
0
0
0
0
0
Pakistani
9
9
35
5
3
343
Bangladeshi
1
1
50
0
0
0
Other Asian
3
2
102
1
1
38
Caribbean
0
0
0
1
1
102
African
0
0
0
0
0
0
Other Black
0
0
0
0
0
0
Chinese
0
0
0
0
0
0
Any other ethnic group
0
0
0
1
1
12
Not stated
6
4
24
2
2
7
Not known
15
11
19
19
16
19
RDaSH
43
Indicator C) Improving health outcomes for BME clients - (total number of service users newly detained and total number of service users
subject to seclusion) (g,h)
Quarter 1
Detained
Quarter 2
Seclusion
Detained
Seclusion
White British
28
2
White Irish
1
0
Other White
2
0
White and Black Caribbean
0
0
White and Black African
0
0
White and Asian
0
0
Other mixed
1
0
Indian
0
0
Pakistani
3
0
Bangladeshi
0
0
Other Asian
1
0
Caribbean
0
2
African
0
0
Other Black
1
0
Chinese
0
0
Any other ethnic group
0
0
Not stated
0
0
Not Given
1
0
Quarter 3
Quarter 4
Detained
Seclusion
Detained
Seclusion
White British
29
4
28
4
White Irish
0
0
0
0
Other White
1
0
2
0
White and Black Caribbean
0
0
0
0
White and Black African
0
0
0
0
White and Asian
0
0
0
0
Other mixed
0
0
0
0
Indian
0
0
0
0
Pakistani
2
0
2
0
Bangladeshi
0
0
0
0
Other Asian
0
0
0
0
Caribbean
0
0
0
0
African
0
0
0
0
Other Black
0
0
0
0
Chinese
0
0
0
0
Any other ethnic group
0
0
0
0
Not stated
4
0
0
0
Not Given
1
0
7
0
RDaSH
44
Indicator D) Improving standards of care and compassion (MHSOP) (Q2 only)
Quarter 1
Admitted
Quarter 2
Administered
Admitted
Administered
700 LD
0
n/a
710 Adult
90
n/a
715 MHSOP
21
21
a,b,c,d,e inpatients who had a nutritional screening tool administered during the quarter
Quarter 3
Admitted
Quarter 4
Administered
Admitted
Administered
a,b,c,d,e inpatients who had a nutritional screening tool administered during the quarter
700 LD
710 Adult
715 MHSOP
The NUTRITION SUPPORT POLICY FOR IN-PATIENT SERVICES was submitted. The policy is compliant with the NICE Clinical Guideline ‘Nutrition
Support in Adults’ (NICE, 2006) and has been developed with our Dietetic Service providers.
The policy contains the Malnutrition Universal Screening Tool (MUST) at Appendix 5. Training has been provided in the use of both tools, and screening implemented Trust wide in In-patient services for older people. As agreed with the
SHA and Commissioners, nutritional screening will be rolled out through an agreed training programme.
Indicator D) Improving standards of care and compassion (MHSOP) pressure sore prevalence survey
Pressure Sore Prevalence Survey
No. single pressure sore
Age bandings
65-69
70-74
75-79
80-84
85-89
90+
0
0
0
0
0
0
No. more than one pressure sore
0
0
0
0
0
0
No. with a EPUAP* grading of 1
0
0
0
0
0
0
No. with a EPUAP grading of 2
0
0
0
0
0
0
No. with a EPUAP grading of 3
0
0
0
0
0
0
No. with a EPUAP grading of 4
0
0
0
0
0
0
The audit of 50 patients during the week beginning 29 June 2009 showed no patients with pressure sores.
* European Pressure Ulcer Advisory Panel.
RDaSH
45
Indicator F) \Meeting the needs of children and young people (from Q3)
Quarter 1
Total
Quarter 2
Plan
%
Total
Quarter 3
Plan
%
Total
Quarter 4
Plan
%
Total
Plan
%
4
2
Plan
%
a,b) Total number of CAMHS service users aged 17.5 at the end of the quarter, and those with a transition plan.
30
Quarter 1
Total
Quarter 2
Plan
%
Total
8
Quarter 3
Plan
%
Total
27
20
Quarter 4
Plan
%
Total
C,d) Total number of CAMHS service users on tier 3 at the beginning of the quarter, who have at their latest assessment in the
quarter an increase in their CGAS score by 10 compared with their CGAS score at first assessment
609
188
31
782
58
RDaSH
7
46
Regional Quality Indicators 2009/2010 for North Lincolnshire
Indicator A) Improving Access to assessment for people experiencing acute mental health problems. (from Q2)
Quarter 1
Total
Seen in 4 Hours %
Quarter 2
Quarter 3
Quarter 4
Total Seen in 4 Hours %
Total Seen in 4 Hours %
Total Seen in 4 Hours %
274
153
a & b) Total referrals to crisis and those assessed within 4 hours
302
Quarter 1
Total
No gate kept
7
Quarter 2
%
Total
189
69
Quarter 3
No gate kept
%
Total
108
70
No gate kept
%
74
100
assessment
%
Quarter 4
No gate kept
%
Total
100
74
c&d) Total number of admissions to adult acute inpatients gate kept within the quarter
109
109
100
98
98
All adult acute inpatient admissions are gatekept via Crisis Team and this is reported to Monitor on a quarterly basis
Indicator B) Improving Access to assessment for people experiencing non-acute mental health problems. (from Q2)
Quarter 1
refs
assessment
Quarter 2
%
refs
Quarter 3
assessment
%
refs
Quarter 4
assessment
%
refs
a & b) Total number of referrals requiring non-urgent assessment in the quarter offered an assessment within 14 calendar days of
date of ref.
0
0
0%
n/a
n/a
0
0
0
710 Adult
1306
51
4
1306
51
4
830
308
37
715 MHSOP
453
0
0
453
0
0
535
115
22
700 LD
Quarter 1
refs
Quarter 2
%
refs
Nos in treatment %
Quarter 3
Quarter 4
refs
refs
Nos in treatment %
0
Nos in treatment %
c) Total number of referrals requiring non-urgent assessment who in the quarter received first treatment within 28 days
0
0
0%
n/a
710 Adult
1306
15
1
1306
715 MHSOP
453
0
0%
453
700 LD
RDaSH
0
0
0
15
1
830
98
12
0
0
535
29
5
47
Indicator B) Improving Access to assessment for people experiencing non-acute mental health problems. (from Q2)
Quarter 1
No
Quarter 2
No with score Cluster No
Quarter 3
No with score Cluster No
Quarter 4
No with score %
No
assessment
Cluster
g, h, i) number of unique service users and those with a SARN score and subsequent cluster allocation
700
710
4140
205
12
4121
367
34
4202
559
64
715
1238
0
0
1219
0
0
1249
18
0
Quarter 1
total
employ
Quarter 2
accomm total
Quarter 3
employ
accomm total
Quarter 4
employ
accomm total
employ
accomm
J, k, l) Total number of service users and those who are in paid employment, and those who are in settled accommodation (MHMDS)
18 - 64
3122
53
262
3105
65+
1731
2
12
1775
55
325
3190
74
583
15
1810
3
401
RDaSH
48
Indicator C) Improving health outcomes for BME clients (a,b,c,d,e) total number of service users into any service in the quarter.
Quarter 1
total
Psych Th CRHT
AOT
Quarter 2
EIP
White British
total
3749
Psych Th CRHT
AOT
EIP
1046
187
70
52
White Irish
35
3
3
0
0
Other White
86
110
3
2
3
White and Black Caribbean
5
1
0
0
0
White and Black African
0
0
0
0
0
White and Asian
2
0
0
0
0
Other mixed
7
2
0
0
0
Indian
14
4
1
1
1
Pakistani
3
3
0
0
0
Bangladeshi
14
3
0
1
1
Other Asian
11
3
1
1
1
Caribbean
2
0
0
0
0
African
0
0
0
0
0
Other Black
6
1
1
1
1
Chinese
3
0
1
0
0
Any other ethnic group
6
0
0
0
0
Not stated
995
109
14
1
6
Not known
264
186
43
1
14
Quarter 3
total
White British
Psych Th CRHT
3787
932
White Irish
35
3
Other White
89
17
White and Black Caribbean
5
157
3
AOT
74
2
Quarter 4
EIP
49
3
White and Black African
total
Psych Th CRHT
AOT
EIP
3930
1262
161
72
64
35
6
1
0
0
90
55
4
2
3
5
2
1
0
0
0
0
0
0
0
White and Asian
2
1
3
1
1
0
0
Other mixed
8
16
6
3
0
0
0
15
2
0
1
1
6
2
1
0
0
14
6
1
1
0
11
1
2
1
1
2
0
0
0
0
1
2
0
0
0
1
1
5
2
2
2
1
4
0
1
0
0
7
0
1
0
0
2
919
129
14
0
2
16
234
304
33
0
6
Indian
14
1
Pakistani
5
3
Bangladeshi
12
2
1
Other Asian
9
3
1
Caribbean
2
African
1
Other Black
6
Chinese
3
Any other ethnic group
7
20
1
Not stated
924
132
8
Not known
259
122
32
RDaSH
1
1
1
2
1
1
1
49
Indicator C) Improving health outcomes for BME clients (f, i,j)
Quarter 1
Admissions
Discharge
Quarter 2
ALoS
White British
Admissions
Discharge
ALoS
109
118
26
White Irish
3
3
11
Other White
7
3
31
White and Black Caribbean
0
0
0
White and Black African
0
0
0
White and Asian
0
0
0
Other mixed
0
0
0
Indian
0
0
0
Pakistani
0
0
0
Bangladeshi
0
0
0
Other Asian
1
1
39
Caribbean
0
0
0
African
0
0
0
Other Black
0
0
0
Chinese
1
1
7
Any other ethnic group
1
1
24
Not stated
10
9
16
Not known
5
4
9
Quarter 3
Admissions
Discharge
Quarter 2
ALoS
Admissions
Discharge
ALoS
White British
91
89
18
92
71
19
White Irish
0
0
0
1
1
14
Other White
4
2
68
3
1
235
White and Black Caribbean
0
0
0
0
0
0
White and Black African
0
0
0
0
0
0
White and Asian
0
0
0
0
0
0
Other mixed
0
0
0
0
0
0
Indian
0
0
0
0
0
0
Pakistani
0
0
0
0
0
0
Bangladeshi
0
0
0
0
0
0
Other Asian
0
0
0
0
0
0
Caribbean
0
0
0
0
0
0
African
1
1
27
0
0
0
Other Black
0
0
0
2
2
16
Chinese
0
0
0
0
0
0
Any other ethnic group
0
0
0
0
0
0
Not stated
2
1
10
2
2
12
Not known
10
10
18
3
3
105
RDaSH
50
Indicator C) Improving health outcomes for BME clients - (total number of service users newly detained and total number of service users
subject to seclusion) (g,h)
Quarter 1
Detained
Quarter 2
Seclusion
Detained
Seclusion
White British
14
0
White Irish
1
0
Other White
0
0
White and Black Caribbean
0
0
White and Black African
0
0
White and Asian
0
0
Other mixed
0
0
Indian
0
0
Pakistani
0
0
Bangladeshi
0
0
Other Asian
0
0
Caribbean
0
0
African
0
0
Other Black
0
0
Chinese
0
0
Any other ethnic group
1
0
Not stated
3
0
Not Given
2
0
Quarter 3
Quarter 4
Detained
Seclusion
Detained
Seclusion
White British
11
0
11
0
White Irish
0
0
0
0
Other White
1
0
2
0
White and Black Caribbean
0
0
0
0
White and Black African
0
0
0
0
White and Asian
0
0
0
0
Other mixed
0
0
0
0
Indian
0
0
0
0
Pakistani
0
0
2
0
Bangladeshi
0
0
0
0
Other Asian
0
0
0
0
Caribbean
0
0
0
0
African
1
0
0
0
Other Black
0
0
0
0
Chinese
0
0
0
0
Any other ethnic group
0
0
0
0
Not stated
1
0
0
0
Not Given
2
0
1
0
RDaSH
51
Indicator D) Improving standards of care and compassion (MHSOP) Q2 only
Quarter 1
Admitted
Quarter 2
Administered
Admitted
Administered
9
9
a,b,c,d,e inpatients who had a nutritional screening tool administered during the quarter
700 LD
710 Adult
715 MHSOP
Quarter 3
Admitted
Quarter 4
Administered
Admitted
Administered
a,b,c,d,e inpatients who had a nutritional screening tool administered during the quarter
700 LD
710 Adult
715 MHSOP
The NUTRITION SUPPORT POLICY FOR IN-PATIENT SERVICES was submitted to Yorkshire and the Humber Strategic Health Authority. The policy is
compliant with the NICE Clinical Guideline ‘Nutrition Support in Adults’ (NICE, 2006) and was developed with our Dietetic Service providers.
The policy contains the Malnutrition Universal Screening Tool (MUST) at Appendix 5. Training has been provided in the use of both tools, and screening implemented Trust wide in In-patient services for older people. As agreed with the
SHA and Commissioners, nutritional screening will be rolled out through an agreed training programme.
Indicator D) Improving standards of care and compassion (MHSOP) pressure sore prevalence survey
Pressure Sore Prevalence Survey
No. single pressure sore
Age bandings
65-69
70-74
75-79
80-84
85-89
90+
1
0
0
0
0
0
No. more than one pressure sore
0
0
0
0
0
0
No. with a EPUAP grading of 1
0
0
0
0
0
0
No. with a EPUAP grading of 2
0
0
0
0
0
0
No. with a EPUAP grading of 3
0
0
0
0
0
0
No. with a EPUAP grading of 4
0
0
0
0
0
0
The total number of pressures sores recorded in the quarter was 1, however this individual was discharged prior to the audit for one week only,
beginning 29 June 2009.
RDaSH
52
Indicator F) \Meeting the needs of children and young people
Quarter 1
Total
Quarter 2
Plan
%
Total
Quarter 3
Plan
%
Total
Quarter 4
Plan
%
Total
Plan
%
a,b) Total number of CAMHS service users aged 17.5 at the end of the quarter, and those with a transition plan.
14
Quarter 1
Total
Quarter 2
Plan
%
Total
1
Quarter 3
Plan
%
Total
28
2
Quarter 4
Plan
%
Total
Plan
%
C,d) Total number of CAMHS service users on tier 3 at the beginning of the quarter, who have at their latest assessment in the
quarter an increase in their CGAS score by 10 compared with their CGAS score at first assessment
246
Action Plans are underway
RDaSH
14
6
308
50
16
53
Appendix B: Summary of Regional CQUIN indicators for 2010 / 2011
Goal
no.
1
Description of goal
Improving access for people
experiencing acute mental
health problems
Quality
Indicator
Domain(s) 1 number2
Experience
Adults of working age only
(16-65)
2
Improving access for people
experiencing non acute mental
health problems
Experience
Adults of working age only
(16-65)
3
Improving outcomes for BME
clients
Experience
Indicator name
1a
Total of all referrals to Intensive
Home Treatment, in the quarter
1b
Total of those in 1a who required
a face to face assessment, in the
quarter
1c
Total of those in 1b who are seen
within four hours, in the quarter
2a
Total number of referrals (by
specialty) requiring a non urgent
assessment in the quarter
2b
Total number of referrals for
non urgent assessment who are
assessed within fourteen days
2c
Total number of referrals (by
specialty) assessed as requiring non
urgent treatment in the quarter
2d
Total number of referrals (by
specialty) assessed as requiring
non urgent treatment who receive
treatment within six weeks in the
quarter
3a
Reduce the average length of stay
within Acute pathways of BME
patients
3b
Reduce number of BME patients
detained under the Mental Health
Act
3c
Reduce number of BME patients
subject to seclusion
3d
Demonstrate annual Equality
Impact assessments on all services
Local or
Regional
indicator3
Indicator
weighting
Regional
Locally
determined
Regional
Locally
determined
Regional
Locally
determined
Safety / Effectiveness / Experience / Innovation
May be several for each goal
3
Nationally mandated / Regionally mandated/ Regionally suggested/ No
1
2
RDaSH
54
4
Improving standards of care and Experience/
compassion
Safety
4a
Number of patients admitted and
remaining for more than 48 hours
during the quarter
achieving best practice
standards set out in Essence of
Care
4b
Number of these patients who
were screened using appropriate
screening tool during the quarter
Inpatients only
4c
Number of these patients who were
screened at discharge during the
quarter
4d
Number of patients admitted who
were at “high” nutritional risk at
discharge during the quarter
4e
Essence of Care action Plan
5a
Providers must reduce the grading
of pressure ulcers setting a
downward trajectory, to be agreed
locally, for NICE grade III and
above.
5b
ii) Providers must undertake 100%
root cause analysis investigations
of pressure ulcers of NICE grade III
and above
5c
Providers must submit Action Plans
to commissioners detailing delivery
of Essence of Care by the end of
quarter 2.
Nutrition-
5
Improving standards of care and Experience/
compassion
Safety
Pressure ulcersachieving best practice
standards set out in Essence of
Care
Inpatients only
RDaSH
Regional
Locally
determined
Regional
Locally
determined
55
6
Meeting the needs of people
with a learning disability
Experience
Development and implementation
of integrated Pathways for all
clients with learning disabilities
requiring mental health services
across all mental health provision:
leading and working on Partnership
Trust elements of the pathway
in partnership with all key
stakeholders.
7
Dementia
Development and implementation
of an integrated Dementia Pathway
across mental health & learning
disability, community and acute
sectors: leading and working on
Partnership Trust elements of the
pathway in partnership with all key
stakeholders
Experience
6a
Participation at a senior level from
clinical and management staff at
steering group meetings
6b
Development of a documented,
agreed, access to mental health
pathways / services, with an
associated dataset and an agreed
action plan for piloting and
implementation
6c
Piloting / auditing of the pathways
with adjustments made where
indicated
6d
Demonstrate that patients with
learning disabilities in the Trust are
following the pathway, and care
is given according to the pathway
(threshold to be agreed)
6e
Mental Health and Learning
Disability awareness training is
commissioned and commenced
across the respective care group
staff as part of the pathway
development
7a
Participation at a senior level from
clinical and management staff
at all multi-sector steering group
meetings
7b
Development of a documented,
agreed, integrated sector pathway
with an associated dataset and
an agreed action plan for piloting
and implementation of the Trusts
elements of the integrated pathway
7c
Piloting of the pathway with
adjustments made where indicated
7d
Demonstrate that patients
with dementia in the Trust are
following the pathway, and care
is given according to the pathway
(threshold to be agreed)
7e
Dementia awareness training
commissioned and commenced as
part of the pathway development
Regional
Locally
determined
Regional
Locally
determined
RDaSH
56
Appendix C: Summary of Local CQUIN goals and indicators for 2010 / 2011
Goal
no.
1a, b, c
&d
Description of goal
Improving access to assessment
for people experiencing nonacute mental health problems
Quality
Domain(s) 1
Indicator
number2
Patient
experience
1a
Effectiveness
To establish the average waiting
times
2a & b
Description of goal
Service users will self report
satisfaction with treatment
received
Total number of referrals (by
specialty) requiring a non-urgent
assessment in the quarter
Local or
Regional
indicator3
Local
Indicator
weighting
0.25
Total number of referrals
(by speciality)for non-urgent
assessment who are assessed
within fourteen days
Older people only
Goal
no.
Indicator name
1b
Average waiting time for nonurgent assessment
1c
Total number of referrals (by
speciality) assessed as requiring
non-urgent treatment who receive
treatment within six weeks of those
identified as requiring non-urgent
treatment
1d
Average wait for treatment
Quality
Indicator
Domain(s) 4 number5
Patient
Experience
2a
Patient Safety
Indicator name
Proportion of users self report
satisfaction of treatment received
when leaving in-patient care based
upon:
Local or
Regional
indicator6
Local
Indicator
weighting
0.4
• Questionnaire on “leaving
hospital” as part of the CQC
Inpatient Survey with respects to
the discharge of care elements of
the service
2b
Proportion of users self report
satisfaction with whether they
have been treated with dignity and
respect within in-patient care
• Questionnaire on “leaving
hospital” as part of the CQC
Inpatient Survey with respects to
whether patients feel they have been
treated with dignity and respect
whilst receiving in patient care
Safety / Effectiveness / Experience / Innovation
4
May be several for each goal
5
Nationally mandated / Regionally mandated/
Regionally suggested/ No
6
1
2
3
RDaSH
Safety / Effectiveness / Experience / Innovation
May be several for each goal
Nationally mandated / Regionally mandated/
Regionally suggested/ No
57
Appendix C: Summary of Local CQUIN goals and indicators for 2010 / 2011
Goal
no.
3a&b
Description of goal
To assess the providers
readiness for the introduction
of PbR in the requirement to
cluster clients appropriately
Quality
Domain(s) 7
Indicator
number8
Clinical
effectiveness
3a
The % of unique service users with
a SARN score (or equivalent) and
cluster allocation
3b
The % of all service users with
a SARN score and subsequent
(second or more) cluster allocation
To monitor the Providers
readiness for the introduction of
PbR with the % of clients being
allocated a SARN score and
cluster(s).
Indicator name
Local or
Regional
indicator9
Indicator
weighting
0.15
Provider utilising SARN will
publish quarterly data on the
percentage of clients with a
SARN score (or equivalent) and
cluster allocation within the
quarter (Adults of working age
and older people)
Goal
no.
4a&b
Description of goal
Promoting healthy lifestyle
by training staff. Advice to be
provided to patients on
Quality
Indicator
Domain(s) 10 number11
Clinical
Effectiveness
Smoking
Diet
Diet
Exercise
Exercise
4b
Indicator
weighting
0.2
The total % of eligible patients
referred to the local:
a) Smoking Cessation Services
b) Weight management Services
Safety / Effectiveness / Experience / Innovation
10
May be several for each goal
11
Nationally mandated / Regionally mandated/
Regionally suggested/ No
12
7
9
Proportion of staff who have
Local
received training in providing advice
to patients in:
Smoking
All staff working within the
acute adult in-patient areas
involved in direct care provision
to be trained in promoting
healthy lifestyles. To identify
and actively promote referral
to local Smoking Cessation
Services and local Weight
Management Services
8
4a
Indicator name
Local or
Regional
indicator12
Safety / Effectiveness / Experience / Innovation
May be several for each goal
Nationally mandated / Regionally mandated/
Regionally suggested/ No
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58
Appendix D: World Class Commissioning outcomes of our lead commissioning Primary Care Trusts
NHS Doncaster
NHS North Lincolnshire
NHS Rotherham
1 Locally lead the NHS
Locally lead the NHS
Locally lead the NHS
2 Work with partners
Work with community partners
Work with community partners
3 Work with patients and public
Engage with public and patients
Work with public and patients
4 Collaborate with clinicians
Collaborate with clinicians
Work with clinicians
5 Knowledge management
Manage knowledge and assess needs
Manage knowledge and assess needs
6 Prioritisation of investment
Prioritise investment
Prioritise investment
7 Stimulate the market
Stimulate the market
Influence the market
8 Improvement and innovation
Promote improvement and innovation
Promote improvement and innovation
9 Secure procurement skills
Secure procurement skills
Secure procurement skills
Manage the local health system
Manage the local health system
10 Manage the local health system
11
RDaSH
Make sound financial investments
Trust Headquarters
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Telephone: 01302 796000
www.rdash.nhs.uk
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