Quality Report
2010 to 2011
The Second Quality Account of
Somerset Partnership NHS Foundation Trust
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
A report explaining the quality of the care we offer
and how we are seeking to improve
Version Final
Section 1 - Quality narrative
From the Chief Executive
The last twelve months have proved to be very successful for the Somerset
Partnership NHS Foundation Trust and I am grateful for the contribution that
staff and key stakeholders have made to that success.
I am very pleased that the Trust has moved forward in such a pro-active way
with this Quality Account. The Trust has been committed to focus on quality,
and in particular looking at the stories and experiences of our service users,
their carers, relatives and the public at large. We have welcomed the
extension of “Patient Opinion” to our services as we believe that open,
independent feedback is invaluable in helping us provide even more effective
services. The Trust will be using new methods of hearing patient and carer
stories throughout the next year and as a way of evaluating the five priority
areas that we will look at in the Quality Account for 2010-2011.
The Trust is also delighted that Somerset Local Involvement Network (LINKs)
has made such strides in the area of mental health in the past year. We are
fully committed to work in a collaborative way with LINKs and with other
stakeholder organisations. Our Members’ Council has proved an invaluable
way of hearing the views of the various constituencies they represent, be they
patients, carers, staff, organisations, or public members. In our second year
as a Foundation Trust we see the rewards of greater community engagement
in a variety of ways, not least tackling stigma in mental health and involving
the Members’ Council in decisions about our priorities.
The Trust believes that in arriving at the five priority areas for 2010—2011
Quality Account, it has tried to engage in a meaningful way with a wide range
of community organisations to ensure that we look at the areas that really
matter.
In the last year we have seen a number of major developments completed:
the upgrading of Holly Court in Yeovil, the move from Broadway Park and the
opening of our new community base at Glanville House in Bridgwater, and the
bringing together of inpatient and community services at the Cheddon Road
site in Taunton with the opening of Foundation House. We have also
delivered a surplus which has been invested in the redesign of mental health
services in the Wells area which has seen the upgrading of St Andrews Ward
to create the new Beech and Cedar Wards.
The year has also seen us consistently deliver against Monitor’s compliance
targets and governance requirements. We achieved an ‘Excellent’ rating from
the Care Quality Commission (CQC) on meeting national targets and
priorities. We also achieved an ‘Excellent’ rating for the first time for our use
of resources. It was disappointing that we achieved a ‘Good’ rating for the
quality of our services however, it remains my firm view, and that of the Board,
that despite the Care Quality Commissioner’s assessment we continue to
deliver an excellent service to our patients and service users and that we
Quality Account 2010-11
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remain one of the best mental health and learning disabilities Trusts in the
country in terms of service delivery, best practice and innovative working.
This view is supported by the most recent patient survey which placed us in
the top 20% of mental health and learning disability Trusts in the country, and
our staff survey which placed us as the top NHS organisation in the South
West to work in. The Trust has now been registered as a healthcare provider
with the CQC. Our current CQC registration status is for treatment of disease,
disorder or injury and aassessment or medical treatment for persons detained
under the Mental Health Act 1983 and we have no conditions on our
registration.
In 2010 we will be taking forward the work on the Broadway Park
development which will see our Child and Adolescent Mental Health Services
(CAMHS) facility at Orchard Lodge, Cotford St Luke and our Adult
Rehabilitation and Recovery Units at Wyvern Court and Burtons Orchard
being re-provided on Broadway Health Park in Bridgwater. The building work
has already commenced on this project and is due to be completed in
September 2010. We have also been successful in obtaining national funding
from the Department of Health to upgrade patient facilities at Rydon Ward on
the Cheddon Road site in Taunton.
As we move forward to 2011, all of you will be aware of the significant cost
pressures that the Trust and the wider NHS will be facing as a consequence
of the economic downturn and recession. The level of anticipated reductions
in funding is unprecedented in the 60 years of the NHS. We have already
begun to plan for 2011 – the main focus of our efforts over the next twelve
months will be to improve the quality and efficiency of our services so that we
can demonstrate to our commissioners that we are making the best use of our
money and resources.
We will also be looking to how we can further improve the way we deliver our
services and whether services can be provided in different ways and in
different settings. We will continue with our commitment to the ‘recovery
principle’’ of ensuring that patients, their families and carers are fully involved
in decisions about their care and their treatment and how services are
delivered.
The Trust remains committed to supporting patients wherever
possible in the community rather than admitting them to hospital and as part
of our service redesign work we will be looking at opportunities to invest more
resources into our community services. The main focus for this year remains
to further improve the productivity, efficiency and quality of our services.
EDWARD COLGAN
Chief Executive
Somerset Partnership
NHS Foundation Trust
Quality Account 2010-11
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INTRODUCTION
The Trust developed its first Quality Account in 2009 following a consultation
from Monitor. The turnaround time on this work was extremely short and in
effect brought the requirements for NHS Trusts to publish Quality Account
ahead by one year for Foundation Trusts. For the 2010-2011 the Trust
engaged in a fuller consultation process. This was led by the Director of
Nursing Development and Governance and the Performance Manager, with
support from the Clinical Governance Manager and the Clinical Effectiveness
Team.
The Director of Nursing Development and Governance and the Trust
Secretary met with the Users and Carers Group of the Members Council in
August and November 2009 to discuss what might be included within next
year’s quality accounts. In addition letters were sent to each representative of
the Members Council asking for comments and suggestions.
Letters inviting comments and suggestions were also sent to a number of
representative and stakeholder organisations in Somerset, with a particular
focus on hard to reach groups. We were assisted in defining these groups and
making contacts by the Somerset Primary Care Trust (NHS Somerset). The
consultation process was also highlighted on the Trust Website.
In addition the Director of Nursing Development and Governance and the
Performance Manager met with NHS Somerset and the Somerset LINKs to
outline our plans for consultation and to invite suggestions. A written invitation
followed this meeting.
From the responses received a number of suggestions were worked into a
draft form. The Board considered and agreed the priorities for the 2010-2011
Quality Account and further avenues were pursued in terms of final
consultation, including additional discussion with the Users and Carers
Working Group of the Members’ Council, presentation and discussion with the
Trust’s Patient and Carer Experience Group.
Quality Account 2010-11
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Priorities for quality improvement in 2010-2011
The Trust undertook a consultation on the areas to be included in the quality
account in two stages. A range of stakeholders, including service users and
the Members’ Council, were contacted by post. The current priorities were
discussed and people asked to suggest areas for inclusion for the following
year. Responses were then discussed with relevant staff, and additional
information such as audit results and safety recommendations were
considered, resulting in a list of five areas for inclusion being developed. This
was then sent to the board for their approval.
Area 1 - Care Planning
Service users feel involved in the development, delivery and review of
their care.
The primary area that those individuals and organisations consulted on felt
strongly about was the need for service users to feel more involved in the
development, delivery and review of their care, and in particularly the
development and review of their own care plans. The Trust has effectively
monitored the number of service users with care plans and those whose care
has been reviewed. It was felt that there was an opportunity to supplement
numerical information with feedback from service users on their experience.
Care planning remains a core task carried out to support the delivery of
effective care. It applies to all directorates, although the actual plan
developed with service users may vary in design and style, depending on
circumstances.
Monitoring
1.
Level two clients (clients supported within the Care Programme
Approach) have a care plan and the plan is reviewed in line with the
Trust’s Recovery Care Programme Approach (RCPA) guidelines.
2.
Audit of the quality of assessment against RCPA policy and standards
3.
Audit of the quality of care plans against RCPA policy and standards.
4.
Face to face structured interviews of patient involvement in care plan
(audit), to include thematic review and service involvement.
5.
Information given about condition/treatment (national patient
survey/tracker survey).
6.
Involvement in decision making (national patient survey/tracker
survey).
7.
Information on medication and side effects (national patient
survey/tracker survey).
Area 2 - Preventable Suicides
Service users at risk of suicide are provided with care in line with best
practice
Quality Account 2010-11
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This is a key area for Mental Health Trusts, and links in with much of the work
the Trust is already undertaking through the Serious Untoward Event Review
Group, the Seven Steps to Patient Safety and Practice Development Unit
accreditation and other similar initiatives.
Focusing on preventable suicides is timely given the recent publication of the
National Patient Safety Agency (NPSA) Suicide Prevention Toolkit. Preventing
suicide applies to all directorates, and it fits with existing areas within the
clinical audit plan for 2010/11, the rolling out of Clinical Risk Training and the
Root Cause Analysis (RCA) competency framework.
Monitoring:
1.
The NPSA have provided two valuable audit tools, one of which can be
used by Ward Managers.
2.
Clinical audit of risk assessment procedures, care planning and review,
particularly focussing on the use of the risk screen and ensuing plans.
3.
Clinical audit of NICE guidance and key performance indicators such
as seven day follow up, employment support and housing support.
4.
A sample of post discharge semi-structured interviews with service
users who had been identified as being at risk of suicide.
Area 3 – “Healthcare for all”
Improving the care and treatment of people with a Learning Disability
(LD) in mental health settings.
Following the Green Light and Healthcare for All reports, all health services
need to be able to ensure equal access and equal treatment for people with
LD in non- LD health care settings. This includes acute and older people’s
mental health services.
The Trust has an action plan which includes work on premises such as LD
friendly signage, adding disability to core assessments, an LD friendly care
plan format, ensuring that there is a link person from LD services available
every time a person with LD is admitted to our mental health services and
ensuring that staff are properly trained and aware of LD issues.
Monitoring
1.
Progress report of all areas of the action plan in conjunction with LD
service users from Somerset Advocacy.
Area 4 - Physical Health Monitoring
Following national guidance in this area, the Trust has been improving its
processes over the last 18 months. This is reflected in the new service
development plan regarding the importance of physical health. A number of
Quality Account 2010-11
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standards have already been drawn up by the clinical effectiveness team,
such as the definitions of physical health monitoring within core assessments
and the admission checklist. These are reflected in a number of the Local
Quality Improvement Plans (L-QIPs) that teams have identified.
Monitoring
1.
Clinical audits on:
a)
Nurse-led assessment of physical health within 48 hours of admission
b)
Nutritional screening within RiO
2.
Monitoring and reporting of Local Quality Improvement Plans.
3.
Health Action Plans for LD.
4.
Commissioning for Quality and Innovation (CQUIN) target with Primary
Care.
5.
Project with Somerset PCT reporting monthly on baseline access to
health screening within primary care for people with severe and
enduring mental health problems.
Area 5 - Cancelled Appointments
This is an area that is already monitored by the Trust in terms of the
percentage of appointments cancelled by the Trust.
The feedback from service user and carers representatives is that they think
the Trust should now go further and look at a number of patient experience
measures. These should focus on how users are treated when an
appointment is cancelled, rather than just how many appointments we cancel.
Monitoring
1.
Clinical Audit and Patient Feedback Surveys on:
a)
How and when patients are given a further appointment. This should be
within an agreed timescale that is shorter than the time that is taken for
other routine patient appointments.
b)
Was there a clear explanation given regarding the cancelled
appointment?
c)
Was a choice offered of when a further appointment should take place?
Carers involvement
Although there are no specific quality measures contained within the five
areas identified within the Quality Account for 2010-2011 which relate to
carers, carers are implicit to the review of Care Planning and the Recovery
Care Plan Approach. As such there is an intention to involve carers directly
within Area 1 – Care Planning.
Quality Account 2010-11
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Monitoring
These measures will be regularly monitored by the Board as part of a rolling
programme throughout the year. This programme is set out in Appendix 2 of
this report.
Quality Account 2010-11
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The priorities for improving quality in 2009/10 were as follows.
Care Planning
All people using our service will have a care plan in line with their needs that
is reviewed and updated as appropriate
Monitored by
Measure
Target
Outcome
Percentage of care co-ordinated clients
with a care plan
96%
throughout
year
Achieved
throughout
year
97.5% Average
Percentage of care co-ordinated clients
sent a copy of their care plan
95%
throughout
year
Achieved
100% mail out
process
CQUIN Incentive scheme indicator
Recovery based care plans in place for
all Level 2 (new CPA) clients
98% by 31
March 2010
Achieved by
year end
98.5%
CQUIN Incentive scheme indicator
Percentage of care co-ordinated clients
reviewed in the previous year
80% by 31
March 2010
Achieved by
year end
86.2%
Privacy, Dignity and Gender Sensitivity
Men and women will not share bedrooms and women only day areas will be
available throughout the Trust
Monitored by
Measure
Target
Outcome
South West Strategic Health Authority
Standards for Patient Accommodation
Fully compliant
Achieved
Every patient has the right to receive high quality care that is safe, effective
and respects their privacy and dignity. The Somerset Partnership NHS
Foundation Trust is committed to providing every patient with same sex
accommodation, because it helps to safeguard their privacy and dignity when
they are often at their most vulnerable.
The Trust fully supports the requirement for patients to be treated in a high
quality environment that is safe, effective and respects the privacy and dignity
of every patient.
We are proud to confirm that mixed sex accommodation has been virtually
eliminated in our organisation. Patients who are admitted to any of our wards
have either their own rooms or will only share the room where they sleep with
Quality Account 2010-11
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members of the same sex. The toilet and bathroom areas are clearly identified
for each gender and are as close to their own room as possible if their room is
not en-suite.
·
80% of our beds are in single rooms, many with en-suite shower/WCs.
·
Female-only day rooms are provided in each ward.
While the Trust was compliant with the earlier Department of Health guidance,
the more stringent approach taken by the Care Quality Commission (Mental
Health Act Commissioners) in this area has encouraged the Trust to
reconsider its current position. As a result of this, the Trust Board has put into
place a small amount of additional building work to ensure that the grouping of
bedroom accommodation is fully compliant with both the Department of Health
guidance and the more stringent Care Quality Commission approach. This
work will be completed by October 2010
Waiting times
Waiting times from referral to assessment and treatment will be reduced
throughout our Trust ahead of national targets.
Monitored by
Measure
Target
Waiting time from referral to assessment
no more than six weeks
98%
Waiting time from referral to assessment
no more than four weeks
90%
Waiting time from referral to treatment
no more than eight weeks
98%
Access to Psychological Therapy from
referral to treatment start within 18
weeks
95%
Outcome
Achieved
100%
Achieved
93.2%
Achieved
100%
Achieved
100%
Support for Carers
The Trust will work in partnership with the families and carers of people who
experience mental health problems.
Monitored by
Measure
Target
Outcome
Carer’s assessment to be started within
four weeks of service user assessment
100% by 31
March 2010
Initial care plan for identified main carer
to be started within four weeks of
service user assessment.
100% by 31
March 2010
Achieved
100%
Achieved
Quality Account 2010-11
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Develop our Services
Quality improvement is one of the strands that characterises all the service
development plans set out in our Five Year Integrated Business Plan.
Monitored by
Monthly Balanced Scorecards reports to the Board. Quarterly Board Report
setting out progress against the Business Action Plan for 2009/10.
Quality Account 2010-11
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Section 2 - Quality Overview
Statement of assurance from the Board
The Board has regularly monitored the compliance and assurance
mechanisms throughout the year relating to the performance and quality
measures set out within this report for the year 2009-2010. The Board
considers that the information provided is a true and accurate picture of the
Trust’s Quality activities by 31 March 2010.
This section of the report demonstrates progress on a wide range of quality
issues with a focus on patient safety, clinical effectiveness and patient
experience. It also declares progress on national priority indicators including
the Monitor Compliance Framework.
Patient Safety
1. Seven day follow up
Percentage of people receiving face to face
or telephone contact within 7 days of
inpatient discharge
2. Recording of risk
Percentage of clients under our care who
have had a formal assessment of risk and
safety recorded
3. Hospital Falls
Number of falls of patients reported by staff
Clinical Effectiveness
1. Delayed transfers of care
Percentage of in-patient days where a
person’s transfer from inpatient care is
delayed
2. Care plans
Percentage of clients on the care
programme approach with a Recovery Care
Plan
3. Gatekept Admissions
Admissions to inpatient services had access
to crisis resolution/home treatment teams
Patient Experience
1. Cancelled appointments
Percentage of first appointments cancelled
by the Trust
2. Complaints
Number of complaints received by the Trust
Quality Account 2010-11
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Q1
Q2
Q3
Q4
96%
98%
96%
98%
95.6%
95.4%
96.0%
96.2%
141
144
127
139
Q1
Q2
Q3
Q4
2.8%
3.6%
3.9%
2.5%
96.8%
96.2%
98.6%
98.4%
96%
96%
93%
95%
Q1
Q2
Q3
Q4
4.5%
4.2%
3.9%
4.8%
21
17
13
11
3. PALS
Number of enquiries received by the Trust’s
Patient Advice and Liaison Service Officer
4. Compliments
Number of compliments received by the
Trust
151
143
124
193
49
52
56
41
Two measures reported in last year’s quality account have not been included
in this table. Both are addressed elsewhere in this report. Waiting times are
reported in section 1 and are subject to further improvement as part of our
CQUIN target with NHS Somerset. Overall satisfaction of service users was
measured for inpatients in the most recent National Survey. This is therefore
not directly comparable and is not reported by quarter. The National Patient
Survey and our own commissioned community survey was positive about the
care delivered by the Trust. Full details of the findings can be viewed on the
Care Quality Commission website.
Participation in clinical audits
The Trust was eligible to and continues to participate in the national
confidential enquiry into homicides and suicides. Therefore during 2009/2010
Somerset Partnership participated in 100% of National Confidential enquiries
which it was eligible to participate in. There are three national clinical audits as
set out by the Healthcare Quality Improvement Partnership (HQIP) specific to
mental health in development, Dementia, Psychological Therapies and
Treatment Resistant Schizophrenia but none were available for participation
during 2009-10.
The Prescribing Observatory for Mental Health (POMH-UK) runs national
audit based quality improvement programmes open to all specialist mental
health services in the UK. The aim is to help mental health services improve
prescribing practice in discrete areas (‘Topics’). There are a total of 54 Trusts
who subscribe to POMH-UK, and all are invited to participate in projects to
benchmark their performance against other Trusts and the national samples.
In 2009 the Trust took part in five out of the six topics. As such during 2009/10
Somerset Partnership participated in 83% of the National Clinical Audits which
it was eligible to participate in . These were:
•
Screening for side effects of antipsychotic drugs in patients treated by
Assertive Outreach Teams;
•
Prescribing of high dose and combination anti-psychotics in adult
inpatient wards;
•
Monitoring of patients prescribed Lithium;
•
Medicines Reconciliation and
•
Assessment of side effects of depot antipsychotic medication.
During 2010 the Trust will be taking part in another five out of the six topics
with POM-UK. Some of the 2010 projects are re-audits of topics covered in
the previous year. In addition to this, the Trust is taking part in the National
Audit of Continence Care, and the National Audit of the Organisation of
Quality Account 2010-11
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Services for Falls and Bone Health for Older People, both of which have been
commissioned by the Healthcare Quality Improvement Partnership (HQIP) as
part of the National Clinical Audit and Patient Outcomes Programme.
The Trust undertakes a programme of local audit on clinical performance
which is reported to the trust board. Full details of this programme are
available on request.
Section 3 – Research and Innovation
The number of patients receiving NHS services provided by Somerset
Partnership that were recruited during that period to participate in research
approved by a research ethics committee was 366.
0.5% of Somerset Partnership NHS Foundation Trust’s contracted income in
2009-10 was conditional upon achieving quality improvement and innovation
goals agreed between the NHS Somerset and the Trust through the CQUIN
payment framework. The Trust met its CQUIN targets, which related to
waiting times, care planning and reviewing of care and Health Action Plans for
clients with learning disabilities. Further details of the 2009-10 agreed goals
and new goals agreed for 2010-11 are available on request from the Director
of Finance, Information and Performance.
The Trust has been set the following CQUIN targets for 2010-11, accounting
for 1.5% of contracted income.
a) Referral to assessment
b) Referral to treatment
c) wait for psychological therapies
- 3 weeks
- 6 weeks
- 12 weeks
Patients will receive a physical health assessment by a named nurse within
48 hours of admission
Between 8.00pm and 8.30am, assessments at A & E will be provided within
two hours of the request
10% reduction in total occupied bed days for all adult and older people’s
ward compared with the 2009/10 baseline
Increase % of discharged patients within Memory Services with a formal
diagnosis and a care plan to 75%.
Section 4 – What others think
Somerset Partnership is required to register with the Care Quality
Commission and our current registration status is for treatment of disease,
disorder or injury and assessment or medical treatment for persons detained
under the Mental Health Act 1983. The Trust has no conditions on our
registration.
Quality Account 2010-11
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CQC has not taken enforcement action against us since the start of the
reporting year. The most recent Mental Health Act annual statement carried
out by the CQC made the following findings.
•
The constructive response made by the Trust to the recommendations
of the Mental Health Act Commissioner, following each visit, is
appreciated.
•
There were lapses found in the implementation of the Consent to
Treatment provisions. These should have been addressed in the new
training programme.
•
Staff were found to be under extreme pressure on Rydon Acute
Admission Ward, which was impacting on the care of the patients. The
Trust reported that staffing is kept under regular review and undertook
to ensure that regular supervision is given.
•
The Trust undertook to review the support given to staff experiencing
violence and aggression on Wyvern Link.
•
On Pyrland and Holford Wards, patients who were seen by the Mental
Health Act Commissioner were generally happy with their care and felt
treated with dignity and respect.
Somerset Partnership was subject to periodic review of Core Standards by the
Care Quality Commission and made its last declaration of compliance against
Care Quality Commission Core Standards on 2 December 2009 and declared
full compliance.
Prior to this the trust was subject to a standards based, rather than risk based
assessment. Following this the Trust received a qualification against
standards C4c “Decontamination of Medical Devices” and C13a “Dignity and
respect”. This assessment was based on the evidence for the year 20082009. The Trust had already introduced the following measures to address the
concerns raised before the results of this assessment were known. These
were:
i.
The introduction of measures within the Bournemouth University
Practice Development Units accreditation scheme which
demonstrated how patients and carers were treated with dignity and
respect.
ii.
To amend the Trust Decontamination of Medical Devices Policy to
reflect that the lead is our Infection Control Nurse.
iii.
Revised systems for ward based cleaning schedules.
Since 2009 the Trust has further:
i.
Put in place an End of Life Policy
ii.
Put in place a Dignity and Respect Policy
iii.
Amended its Transfer of Patients Policy to include specific mention
of patients with dementia.
iv.
Consulted widely on a revised Single Equalities Scheme and Action
Plans.
Quality Account 2010-11
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There are no outstanding actions from the Care Quality Commission’s
Review.
NHS Somerset (our main commissioning Primary Care Trust) has supported
the Trust’s priority areas saying:
“We welcome the five quality improvement areas, which relate to the quality
and patient safety discussions we have had with the Trust through the quality
monitoring and patient experience meetings”. The full response from NHS
Somerset is reproduced at Appendix 1 of this report.
The Trust’s Director of Nursing Development and Governance met with the
LINKs Stewardship Group, and LINKs have had, discussions regarding the
Trust’s draft priority areas. The Trust’s Members’ Council has extended a
standing invitation to LINKs for a representative to attend Members’ Council
meetings and a representative of LINKs is a member of the Trust’s Patients
and Carers Experience Group. Members of Trust staff attended the LINKs
Mental Health Group on 20 April 2010 and the LINKs event “A Voice for your
Mental Wellbeing” on 17 May 2010 to talk about the contents of the Quality
Account. We welcome further discussion and dialogue with LINks over the
next 12 months.
A copy of this Quality Account was sent to the Health Oversight and Scrutiny
Committee of Somerset County Council before 30 April 2010. This was in line
with Department of Health Guidance and invited comments on the draft
Quality Account.
Although it was not required of the Trust, we worked with the Learning
Disabilities Partnership Board on the suggested content of the Quality
Accounts. Their feedback was that:
i.
Work has already commended on developing a care planning
approach that is accessible to service users with LD. Work is being
done jointly with the Local Authority and the Trust.
ii.
The Trust’s plan around Healthcare for All will address some of the
past concerns of LD service users. It was recognised the
employment of Strategic Liaison LD Nurses, Annual Health Checks
and Health Action Plans had assisted and would continue to assist
in Somerset.
Section 5 – Quality of Data
In records submitted to the Secondary Uses System (SUS) for inclusion in
Hospital Episode Statistics (HES), the percentage of records including the
valid patient's NHS Number at year end was 100% and the percentage of
records including the valid patient’s General Practitioner Registration Code
was 99.94%.
Quality Account 2010-11
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The Trust’s score for Information Quality and Records Management,
assessed using the Information Governance Toolkit as of March 2010 was
82%
Quality Account 2010-11
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Section 6 – Performance against National Priorities
Monitor Compliance Framework
The Trust has achieved the Monitor Compliance Framework targets during the
year. The Trust performance over the year 2009/10 was as follows:
Quarter
Clients on Enhanced CPA
followed up within 7 days of
discharge
(Target >95%)
Minimising delayed transfers
of care
(Target <7.5%)
Admissions to inpatient
services had access to crisis
resolution home treatment
teams
(Target >90%)
Maintain level of crisis
resolution teams set in
March 2006 planning round
(or subsequently contracted
with PCT)
(Target 4 agreed)
Q1
Q2
Q3
Q4
96%
98%
96%
98%
2.8%
3.6%
3.9%
2.5%
96%
96%
93%
95%
4
4
4
4
Somerset Partnership NHS Foundation Trust declared to the Care Quality
Commission that it is compliant with all 44 of the Core Standards part of the
Annual Health Check process for 2009-2010.
Quality Account 2010-11
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APPENDIX 1
Our Ref: LW/jy/lucywatson/letters
25 March 2010
Philip King
Director of Nursing Development and Governance
Somerset Partnership NHS Foundation Trust
Mallard Court
Express Park
Bridgwater
TA6 4RN
Somerset Primary Care Trust
Wynford House
Lufton Way
Lufton
Yeovil
Somerset
BA22 8HR
Tel: 01935 384000
Fax: 01935 384079
headquarters@somerset.nhs.uk
Dear Philip
Quality Accounts, Somerset Partnership
I am writing in reply to your letter of 3 March 2010 concerning the five quality
improvement areas that Somerset Partnership NHS Foundation Trust have decided to
focus on in the Quality Accounts for 2010 -11.
We welcome these five quality improvement areas, which relate to the quality and
patient safety discussions we have had with the Trust through the quality monitoring
and patient experience meetings. We welcome the focus on preventable suicides, and
on the physical health of mental health patients, which are both areas of work that
have arisen from the lessons learned from serious untoward incidents. NHS Somerset
wishes to see clear evidence of implementation of the lessons learned and action
taken as a result of serious untoward incidents, and this approach will provide this. We
also welcome the focus on accessibility of Trust services for people with a learning
disability, following the Ombudsman’s Six Lives Report into the care provided by health
services to people with a learning disability, and the significant patient safety issues
that can arise for this group of people.
The focus on patient and carer experience underpinning these will contribute to
improved user and carer experience and the continuing improvement in the quality of
the services that the Trust provides.
We will be writing to the Trust in the next few weeks to propose the arrangements for
confirmation and corroboration of NHS provider Quality Accounts by NHS Somerset
prior to publication.
Thank you for informing us of your progress with this work.
Yours sincerely
Lucy Watson
Deputy Director of Nursing and Patient Safety
Quality Account 2010-11
- 19 -
APPENDIX 2
Monitored by
Assurance format
May
10
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Area 1 - Care Planning
Service users feel involved in the development, delivery and review of their care.
D D D D D D D D D D D
5.
Level two clients (clients
supported within the Care Programme
Approach) have a care plan and the plan
is reviewed in line with the Trust’s
Recovery Care Programme Approach
(RCPA) guidelines.
Monthly Performance
report
6.
Audit of the quality of assessment
against RCPA policy and standards
Clinical audit plan
D
7.
Audit of the quality of care plans
against RCPA policy and standards.
Clinical Audit plan
D
8.
Face to face structured interviews
of patient involvement in care plan
(audit), to include thematic review and
service involvement.
Trust Survey
D
9.
Information given about
condition/treatment (national patient
survey/tracker survey).
Annual external
assurance
D
10.
Involvement in decision making
(national patient survey/tracker survey).
Annual external
assurance
D
D
Monitored by
Assurance format
11.
Information on medication and
side effects (national patient
survey/tracker survey).
Annual external
assurance
May
10
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
D
Area 2 - Preventable Suicides
Service users at risk of suicide are provided with care in line with best practice
12.
The NPSA have provided two
valuable audit tools, one of which can be
used by Ward Managers.
Clinical Audit plan
13.
Clinical audit of risk assessment
procedures, care planning and review,
particularly focussing on the use of the
risk screen and ensuing plans.
Clinical Audit plan
14.
Monitoring of seven day follow up. Monthly Performance
report
Trustwide audit using NPSA Preventing
NPSA Preventing
Suicide Toolkit
Suicide Toolkit
15.
A sample of post discharge semistructured interviews with service users
who had been identified as being at risk
of suicide.
Quality Account 2010-11
- 21 -
Trust Survey
D
D
D D D D D D D D D D D
D
D
D
Monitored by
Assurance format
May
10
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Area 3 – “Healthcare for all”
Improving the care and treatment of people with a Learning Disability (LD) in mental health settings.
16.
Progress report of all areas of the
action plan in conjunction with LD
service users from Somerset Advocacy.
D
Action Plan report
D
Area 4 - Physical Health Monitoring
1a
Clinical audits on Nurse-led
assessment of physical health within 48
hours of admission
Clinical Audit plan
1b
Clinical audits on Nutritional
screening within RiO
Clinical Audit plan
17.
Monitoring and reporting of Local
Quality Improvement Plans.
Annual report
18.
Monthly Performance
report
Monthly Performance
report
Monthly Performance
report
D D D D D D D D D D D
D D D D D D D D D D D
D
D
19.
Commissioning for Quality and
Innovation (CQUIN) target with Primary
Care.
Monthly Performance
report
D D D D D D D D D D D
D D D D D D D D D D D
20.
Project with Somerset PCT
reporting monthly on baseline access to
health screening within primary care for
people with severe and enduring mental
Monthly Performance
report
D D D D D D D D D D D
Health Action Plans for LD.
Quality Account 2010-11
- 22 -
Monitored by
Assurance format
May
10
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
health problems.
Area 5 - Cancelled Appointments
Clinical Audit plan
21.
Clinical Audit and Patient
Feedback Surveys on:
Trust Survey
D
D
D
D
D
D
a)
How and when patients are given
a further appointment. This should be
within an agreed timescale that is
shorter than the time that is taken for
other routine patient appointments.
d)
e)
Was there a clear explanation
given regarding the cancelled
appointment?
Clinical Audit plan
Was a choice offered of when a
further appointment should take
place?
Clinical Audit plan
Quality Account 2010-11
Trust Survey
- 23 -
Trust Survey
Mar
APPENDIX 3
Chairman: Jane Barrie OBE
Chief Executive: Ian Tipney
www.somerset.nhs.uk
APPENDIX 4
Our Ref:
LW/jy/lwletters
2 June 2010
Philip King
Director of Nursing Development and Governance
Somerset Partnership NHS Foundation Trust
Mallard Court
Express Park
Bristol Rd
Bridgwater
Somerset
TA6 4RN
Somerset Primary Care Trust
Wynford House
Lufton Way
Lufton
Yeovil
Somerset
BA22 8HR
Tel: 01935 384000
Fax: 01935 384079
headquarters@somerset.nhs.uk
Dear Philip
I am writing in response to your letter to Mary Monnington Director of Nursing and
Patient Safety dated, 29 April 2010. Thank you for giving us the opportunity to
comment on the Quality Account 2009/10 for Somerset Partnership NHS
Foundation Trust.
During 2009 -10 NHS Somerset has strengthened the arrangements for
monitoring the quality and patient experience for mental health services that we
commission from Somerset Partnership NHS Foundation Trust. We have
welcomed the Trust engagement in this process as part of quality contract
monitoring. This has placed NHS Somerset in a strong position from which to
comment on the Somerset Partnership NHS Foundation Trust for 2009 -10.
We have reviewed the report submitted for the four priority areas for improving
quality the Trust for inclusion in the Quality Accounts for 2009 / 10. These are:
•
•
•
•
Care planning
Privacy, Dignity and Gender Sensitivity
Waiting times
Support for carers
We can confirm that the key performance indicators included for each of these
areas are congruent with the data submitted to us as part of the contract
monitoring process.
We would like to commend the Trust for the achievements in each of these areas
and in particular the progress made in achieving the Department of Health
standards for Delivering Single Sex Accommodation. Compliance with these
standards makes an important contribution to the experience of patients using
Quality Account 2010-11
- 25 -
your services, in protecting their privacy, and maintaining their dignity when they
are most vulnerable. We note that the Trust is undertaking further capital
development to achieve the more stringent measures for single sex
accommodation set by the Care Quality Commission ( former Mental Health Act
Commissioners).
In future quality accounts it would be helpful to consider the user and carer
feedback on the achievement in these four priority areas and in particular in
respect of the reduced waiting time to receive service and the impact this may
have had on their mental illness and recovery, and or stabilisation of their
condition.
We also commend the Trust for the level of positive response from the recent
inpatient survey that placed you in the top 20 % of for mental health and learning
disability trusts, and for the results of the NHS staff survey for 2009 that placed
Somerset Partnership NHS Foundation Trust as the top NHS organisation in
which to work in the South West. This is an indicator of both the good
management and support provided to your staff and an indicator of patient safety
and experience in your services.
Section 2 – Quality Overview
We have reviewed the key performance indicators reported in this section and
confirm that these are congruent with the information that we have reviewed with
you through the contract monitoring process.
We would encourage the Trust to make reference to the compliance of the Trust
with the quality standards within the Trust contract for Safeguarding Adults and
for Safeguarding Children, and the statement of compliance made with the Care
Quality Commission recommendations for safeguarding children published during
2009 -10. The Trust annual report submission for Safeguarding Children
demonstrates the significant progress that the Trust has made during 2009 -10 to
ensure that all staff have access to safeguarding children training, the provision
of supervision particularly for staff who work directly with children within the Child
and Adolescent Mental Health Service and the audit programme in place for 2010
– 11 following the safeguarding children policy development in 2009 -10.
We would also encourage the Trust to include an outline of the arrangements in
place for management of serious untoward incidents and to highlight three or four
key actions taken to improve quality of services provided during 2009 -10 as a
result of the lessons learned from these.
Priorities for Quality Improvement for 2010 -11
NHS Somerset has responded to the Trust on the five priorities identified for
quality improvement in 2010 -11. We particularly welcome the focus on
preventable suicides and clinical audit of risk assessment procedures, care
planning and review. Risk assessment of risk and care planning are the
cornerstone of the safe management for patients with mental illness, and we
welcome the opportunity to review the outcome of these audits with you during
2010 - 11.
Quality Account 2010-11
- 26 -
We look forward to continuing to work with Somerset Partnership NHS
Foundation Trust to improve the safety, clinical effectiveness and patient
experience of the services provided by the Trust, and in development of the
Quality Account for 2010/11. Our work with the Trust in monitoring reviewing the
quality, patient safety and patient experience of services throughout the year will
support this. We will also consider the Chief Nursing Officer nurse sensitive
metrics that have recently been published so that these can be reported within
the Trust Quality Account for 2010 -11.
I hope you find these comments helpful. Please contact me at the above address
if you wish to discuss these further.
Yours Sincerely
Lucy Watson
Deputy Director of Nursing and Patient Safety
Cc:
Deborah Gray, Associate Director of Nursing and Patient Safety
Debby Blease, Associate Director of Nursing and Patient Safety
Wayne Lewis Associate Director for Joint Commissioning
Quality Account 2010-11
- 27 -
APPENDIX 5
Quality Account 2010-11
- 28 -