South Staffordshire and
Shropshire Healthcare
NHS Foundation Trust
2009-10
Quality Accounts
Quality Report
1. Statement on Quality by
Chief Executive
I am pleased to present the first
S o u t h S t a f f o r ds h ir e a n d
Shropshire Healthcare NHS
Foundation Trust’s Annual
Quality Account Report. In our
Annual Report for 2008/09 I
stated our commitment, as an
organisation, to continue our
strong focus on delivering high
quality, safe and effective
s e r v ic e s , e v a l u a t e d a n d
monitored by external agencies,
as well as by our own audit and
performance monitoring teams.
This report summarises the
outcome of this work.
“We will continue our
strong focus on
delivering high quality,
safe and effective
services, evaluated and
monitored by external
agencies, as well as by
our own audit and
performance monitoring
teams”
Neil Carr, Chief Executive
In the 2008/09 annual report, we
made a commitment that in
2009/10 we would undertake a
range of initiatives to ensure that
we continue to deliver high
quality safe and effective
services whilst at the same time
targeting priority areas for
improvement.
This report
provides details of:
progress in our quality
improvement initiatives
how we have ensured we
continue to deliver the highest
quality services
how
we will embed
improvements
improved reporting processes
to provide robust assurance
to Trust Board
challenges for 2010/11
Some of our key achievements
in assuring the quality of our
services have been:
Service User Experience
Establish processes to
routinely gather and
learn from the views and
experiences of people
using our services
Service users of all teams in
the organisation now have
Page 2
access to a variety of paper
based, face to face and
electronic media to provide
real time feedback
Service user engagement in
the whole process from
choice of questions, format of
the survey tool, through to
collation and analysis of
responses
Range of media for feedback
Development of action plans
in response to the feedback
collected
Steering group established to
ensure continual improvements made to service user
experience feedback
Teams being able to access
feedback in “real time”
Safety
Improve the time taken to
respond to serious
untoward incidents
Achievement of all reviews of
serious untoward incidents,
where there are no unusual
complexities, now being
completed within 45 days.
Development
and
implementation of processes
for sharing of learning
throughout the Trust
Identification and training of
investigating officers
Monitoring of compliance with
response times for completed
investigations at each Quality
Effectiveness and Risk
Committee and then at each
subsequent Trust Board
meeting.
Re-des ign of reporting
providing assurance of the
effectiveness
of
organisational response to
adverse incidents.
Agreement of acceptable
circumstances and complexities for an extension to
45 days limit
2009-10 Quality Accounts
Effectiveness of Care
To implement meaningful
Patient Reported
Outcome Measures
All clinical services have a
meaningful Patient Reported
Outcome Measure in place
Service user engagement in
the c hoic e of Patient
Reported Outcome Measure
Service users are now able to
significantly influence the
outcome of the contact with
our services through
identifying within the PROM
what they see as their priority
needs
Where a service was not able
to identify a suitable Patient
Reported Outcome Measure
they have researched and
developed a tailored tool
wh i c h h as n o w b ee n
published.
In
addition
to
these
improvements we have been
able to achieve all the quality
indicators we set for ourselves
and are assured of the validity of
the data through our robust
performance monitoring
processes.
Our next year will be a challenge
where we aim to continue to
improve quality whilst managing
very tight financial resources.
Spurred on by our successes to
date I look forward to sharing
our progress in our Quality
Accounts for 2010/11.
The directors are required under
the Health Act 2009 and the
NHS (Quality Accounts)
Regulations 2010 to prepare
Quality Accounts for each
financial year.
In preparing these accounts,
directors are asked to take steps
to satisfy themselves that:
The Quality Accounts present
a balanced picture of the NHS
foundation
trust’s
performance over the period
covered;
The performance information
reported in the Quality
Accounts is reliable and
accurate
There are proper internal
controls over the collection
and reporting of the measures
of performance included in
the Quality Accounts, and
these controls are subject to
review to confirm that they are
working effectively in practice;
The data underpinning the
measures of performance
reported in the Quality
Accounts is robust and
reliable, conforms to specified
data quality standards and
prescribed definitions, and is
subject to appropriate scrutiny
and review; and;
The Quality Accounts have
been prepared in accordance
with the relevant requirements
and guidance issued by
Monitor.
The directors confirm to the best
of their knowledge and belief
that they have complied with the
above requirements in preparing
the Quality Accounts.
By order of the Board
Neil Carr, Chief Executive
3 June 2010
Steve Jones, Chairman
3 June 2010
2009-10 Quality Accounts
These quality accounts have been produced
in line with Monitor additional annual reporting
requirements and the Department of Health
Quality Accounts Toolkit. The structure and
order of the report is presented as per Monitor’s “finalised guidance for quality report
section of the annual reports”.
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Quality Report
2. Priorities for
Improvement
Safety – Improve the
time taken to respond
to serious untoward
incidents
Priorities for Improvement
2009/10
Target:
To improve the time taken
to respond to serious untoward incidents by completing reviews within 45
days in cases where
there is no unusual complexity preventing this that
justifies a delay beyond
this time
Within the 2008/09 Annual
Report the Trust outlined 3
quality improvement initiatives
for the forthcoming year that
had been agreed by the Trust
Board. The rationale and
prioritisation of these initiatives
was completed in line with the
framework for quality as laid
out in “High Quality Care for All
- Next Stage Review” (DH,
2008).
Rationale:
The national benchmark
for completion of serious
untoward incidents in
mental health is 90 days
(National Patient Safety
Agency). However, the
Trust wishes to ensure
that learning takes place
as early as possible and
local commissioners seek
this within 45 days. The
benefits to the patient
experience is that the
lessons learned can be
applied more rapidly thus
engendering more responsive services.
This section of the report
shows progress against the
achievement of these priorities.
The table below demonstrates
the improvements in the
timeliness of the completion of
serious untoward incidents and
achievement of the 45 day
target where no serious
complexities prevented this
throughout 2009/10.
Completion of SUI's over 45 days
Average number of
days over 45
100
80
60
40
20
0
-20 Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Month
Avg days over 45
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2009-10 Quality Accounts
Key Action
Current Position
1) Review senior clinical
roles to ensure sufficient
capacity is available to carry
out reviews
Appropriate senior clinical staff have been identified in each di
2) Strengthen mechanisms
to follow up review processes to ensure timeliness
and to offer specific support
where necessary
3) Develop a clear system
to identify where unusual
complexity will reasonably
delay completion of reviews
4) Monitor performance
through the Quality Effectiveness & Risk Committee
5) Liaise closely with commissioners to ensure good
communication
2009-10 Quality Accounts
rectorate to lead on investigations
Competences for lead investigators have been established and
job descriptions have been amended to reflect this
Expert training in line with National Patient Safety Agency Toolkit
has been delivered to 27 lead investigators from across the Trust
Directorates
All serious untoward incident investigations are closely monitored
by the Quality & Professional Practice Directorate
Regular monitoring meetings are held at both an organisational
and directorate level
The Risk Management team are available to offer specialist support to lead investigators and where appropriate will take on the
lead role for complex investigations
Each Directorate has strengthened its mechanisms for feeding
back and monitoring actions as well as learning lessons from serious untoward incidents
The Trust performance monitoring processes have been extended to incorporate action plans from investigations. This in
turn has enabled robust assurance to be provided to the Trust
Board
Timescales for completion of serious untoward incidents are
tracked closely by the Quality & Professional Practice Directorate
and authority for extensions are given if complexity justifies this
A mapping of the Trust’s serious untoward incident process has
taken place in line with the new National Patient Safety Agency
Framework for Serious Incident Reporting. As part of this mapping Trust wide consultation has taken place regarding acceptable circumstances and complexities for which an extension to 45
days would be authorised
Compliance against the response times for completed investigations are monitored at each Quality Effectiveness & Risk Committee and in addition at each subsequent Trust Board meeting
All reporting has been re-designed to provide assurance of the
effectiveness of organisational response to adverse incidents
Our Commissioners are notified the next working day of any serious untoward incidents that occur
In addition our three main PCT Commissioners are provided with
a detailed monthly progress report on all investigations set
against the 45 day timescale
Where requested our Commissioners are also provided with the
completed investigation reports
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Quality Report
Effectiveness of Care –
To implement meaningful Patient Reported
Outcome Measures
(PROMS)
Target:
All clinical services will
have a meaningful Patient
Reported Outcome Measure in place by the end of
the year that will be useful
to clinical staff, service
users and service commissioners
Rationale:
The need to develop suitable tools for evaluating
the effectiveness of individual care and services
is recognised nationally.
PROMS are cited in the
recent Darzi Review as a
priority for development,
their development would
be supportive of the
Trust’s commitment to
service user centred care
and local commissioners
require their development
in new contracts. Within
the Trust initial work has
already begun within clinical directorates to plan
how to implement
PROMS in a way appropriate to their own service
users
Patient Reported Outcome
Measures (PROMS) are integral
to ensuring that the services we
deliver are service user centred.
It was essential that the PROMS
chosen by services were aligned
to the needs of their service
users. This was a significant
challenge given the range of
services provided by the
organisation.
Sharing and
learning has been a key feature
of the development of PROMS in
the organisation. A range of
approaches have been used in
close co-operation with our
service users which have
included testing out of “off the
shelf” PROMS though to
development of specific tools
using robust research
governance.
The actions
described below demonstrate
evidence of the use of PROMS
in all service areas and during
2010/11 we plan to review and
increase the level of use.
The benefits to the service user experience is
that the service they receive will be more tailored
to the outcomes they wish
to achieve.
Page 6
2009-10 Quality Accounts
Key Action
Current Position
1) All directorates develop a project plan to
implement PROMS
All Directorate project plans were de-
2) Identify appropriate
PROMS and pilot with
service users
3) Identify which
PROM is most effective
4) Implement PROMS
5) Quality and Professional Practice
(QAPP) Directorate
support the implementation process
veloped and agreed through the
Trust’s Clinical Effectiveness Operational Group (CEOG)
All directorates identified PROMS and
have piloted them within their service
areas
Following a period of piloting all directorates have now identified a PROM
to be used
All directorates are now implementing
their identified PROMS at significant
points in individual service user’s
pathway of care
Progress of each Directorate is monitored through our Clinical Effectiveness Operational Group.
Learning from pilots has been shared
through the Clinical Effectiveness
Operational Group
Staff within Professional Practice Directorate provided support and advice
to clinical directorates throughout the
process
Governance sign off through Quality
Effectiveness and Risk Committee of
the Learning Disability PROM which
has been researched and implemented specifically for Learning Disability Services
% implemented
% of Services with PROMS
100
80
60
40
20
0
Ap
09
Ma
09
Ju Jul09 09
Au
09
Se
09
Oc
09
No
09
De
09
Ja
10
Fe
10
Ma
10
Month
2009-10 Quality Accounts
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Quality Report
Service User Experience –
Establish processes to
routinely gather and learn
from the views and experiences of people using our
services
Target:
Each service line will have
produced their own comprehensive Service User Experience reports that will
include commentary on how
this is being used to improve
services.
Rationale:
The Trust has already carried out two projects that
have developed approaches
to gathering service user
feedback in as “real-time” as
currently possible: the “Live
Feedback” pilot project and
the completion of a national
Monitor supported Patient
Experience Project. The Values Exchange is an award
winning electronic survey
tool that is used by the Trust
and offers great potential to
support the development of
service user experience
processes in the future. Using learning from these projects, the Trust has been
able to develop flexible approaches in line with the
service user centred values
of the Trust and the wishes
of commissioners.
There are a range of methods
currently in use to capture
feedback from service users and
carers about their experience of
our services. Nationally there is
the Mental Health Service User
Survey; locally we have service
user involvement groups in each
directorate, Service Relations,
PALS, and a number of
questionnaires have been
developed that are service
specific. The challenge we met
was to obtain and respond to
service user feedback in “real
time”. The feedback related to
what is both good and should be
shared, as well as what parts
need to be improved and all
directorates have developed
Key Action
Current Position
1) Implement the
processes agreed by
the Trust Board as a
result of the Patient
Experience Project
across the Trust
All processes agreed by Trust Board
have been implemented:
Phased implementation across whole
organisation
Service user representation at each
project steering group
Range of media for feedback made
available
Administrative support identified
2) Trial a number of
different electronic
tools to capture realtime feedback in as
user accessible way
as possible
Options appraisal of electronic tools
3) Develop an action
plan with each
directorate ensuring
comprehensive
service user and
carer involvement
using feedback from
these projects
Values Exchange further developed to
The benefits to the service
user will be that services will
deliver more timely responses to feedback they
receive..
Page 8
action plans in response to this.
We are aware that we do not
want to inundate our service
users and carers with requests
for feedback and also that
people respond better to
different media. Our Service
User Experience Project is now
embedded using a small number
of open questions which best
capture the experiences of our
service users using a variety of
media in order that they may
respond in a way that best
meets their needs.
carried out
Option to continue use of Values
Exchange agreed
Service User Volunteers recruited to
support service users in the
completion of the survey
Feedback incorporated into Productive
Ward processes
Collection boxes made available in
each area to post written responses
produce responses by directorate
Directorate responses collated and
used to develop action plans
Work commenced to align responses
to Service Line Reporting ensuring
reports will be generated by team
2009-10 Quality Accounts
The following graphs demonstrate the responses to our real time survey
throughout 2009/10 and provide some examples of comments made by our
service users in response to the care provided
Is there anything about the service that pleased you?
“Being able to contact someone
regularly and quickly”.
“Me & my carer were both treated
with courtesy and patience which in
turn made both of us confident in the
service”
“I felt secure, there was a good staff
to patient ratio and an open airy
environment”
Is there anything about our services that did not please you?
“Waiting times between appointments”
“Appointments running very late”
“Little opportunity to venture outside
the ward”
“Little opportunity for my children to
visit the ward”
How much of the time were you pleased with?
“All aspects of advice and help given
was very helpful”
“Happy with the service but appointments need to work around life”
“Not when the ward was unsettled,
even though the staff managed this
well”
2009-10 Quality Accounts
Page 9
Quality Report
Were you given information about your care?
“Was kept well informed about
my hospital care by the team”
“We completed new risk
assessment and care plans
together and we have
scheduled meetings every other
week”
“Yes but I need to have
information explained”
Were you helped to make decisions about your care?
“Yes I was given information to
aid decision making”
“Advised on medication options
including potential side effects”
“When you are sectioned it
feels like you have less control
over decisions”
Did your time with the service make a difference to the way you
feel?
“Feel more relaxed on the ward.
It's calming, it's made me feel I
can talk more about what's
bothering me”
“I knew that I had something to
fall back on and somewhere to
get in touch with if I ever felt
down”
“Don’t like being in hospital as I
feel isolated”
Page 10
2009-10 Quality Accounts
2.2 Priorities for Improvement
2010/11
The central aim of focusing
more on Quality, and developing
clearly defined measures, is to
improve the care provided and
hence the experiences and
outcomes for our service users.
In response to this the Trust has
a series of ongoing quality
initiatives whic h aim to
c on ti nu a l l y i nc r e as e o ur
effectiveness around quality and
ensure that this is embedded
into our internal processes. As
an organisation we have a range
of systems and processes for
monitoring and improving the
quality of our services. These
systems and processes include
real time feedback from our
service users, and engagement
of the public through our
Membership Council who also
are involved with unannounced
monitoring visits on our services.
The identification of our priority
areas for improvement have
come directly through feedback
from these processes. The Trust
Board has subsequently agreed
the three highest priorities for
quality improvement for the next
year. The action the
organisation plans to take and
the rationale for this prioritisation
is described further in this
section of the report. These
improvement initiatives are also
a priority for our commissioners
as expressed through the
Commissioning for Quality and
Innovation Framework (CQUIN).
Priority 1 - Safety
Falls have a major impact on the quality of life of our service
users. Research shows that the elderly population is at high
risk of falling as are those with a cognitive impairment. The
impact of falls in older people can lead to reduced
independence and a reduction in engagement with activities
as well as individual distress and pain. It is therefore
essential that we examine falls that occur within our older
peoples’ inpatient facilities, aiming to develop robust
processes which will reduce the impact of falls.
Target:
All older people admitted to inpatient services will have a
falls risk assessment conducted within 24 hours of
admission and where risk is identified an individualised
falls care plan will be implemented.
Key measure:
% of individuals admitted to older peoples’ inpatient wards
who have a falls risk assessment completed within 24 hours
of admission
% of individuals assessed as being at risk of falling who have
a individualised care plan in place
Key actions to be taken:
Agree a single falls risk assessment to be used across
all older peoples inpatient services
To develop and implement a plan to cascade use of
falls risk assessment for all older peoples’ inpatient
services
To ensure service users at risk of falls have a risk
management plan in place which will include
information for carers
To develop a clear system to monitor the effectiveness
of the implementation of the falls risk management
process.
Monitor performance through the Quality Effectiveness
and Risk Committee
Rationale:
Falls have a major impact on quality of life, health and
healthcare costs. Risk factors for falls should be minimised for
patients within hospitals. Reducing the impact of falls in
hospital will reduce unnecessary increased length of stay.
A thematic review of falls across the organisation in 2009/10
identified the need to improve processes for assessing and
managing risk of falls particularly in our services for older
people.
2009-10 Quality Accounts
Page 11
Quality Report
Priority 2 – Effectiveness of Care
Medicine doses are often omitted or delayed in hospital for a variety of reasons. Whilst
these events may not seem serious, for some medicines or conditions, such as patients
with sepsis or those with severe psychoses, delays or omissions can cause serious harm,
death or pose severe risks to others. Patients going into hospital with chronic conditions are
particularly at risk.
The Productive Ward initiative from the National Health Service Institute for Innovation and
Improvement (NHS III) provides information on minimising interruptions and streamlining
the medicines ward round and National Patient Safety Agency (NPSA)/National Institute for
Health and Clinical Excellence (NICE) guidance on medicines reconciliation supports the
reduction in omitted doses.
Target:
No unintentional omission of critical medicines should occur.
Unintentional omission of other medicines should be minimal and represent a decreasing trend.
Key measure:
% of omissions of medicines
Key actions to be taken:
Ensure medicine management procedures include guidance on the importance of pre-
scribing, supplying and administering critical medicines, timeliness issues and what to
do when a medicine has been omitted or delayed;
Review and, where necessary, make changes to systems for the supply of critical medi-
cines within and out-of-hours to minimise risks;
Review incident reports regularly and carry out a quarterly audit of medicines that have
been unintentionally omitted. Ensure that system improvements to reduce harm from
omitted and delayed medicines are made. This information should be included in the
organisation’s annual medication safety report;
Monitor performance through Medicines Management Committee
Rationale:
The omission of critical medicines has the potential to result in fatalities or severe harm to
patients. Inadvertent omission should easily be noticed at the next medicines round, since
the administration box will remain blank, and remedial action can be taken. Failing to record
intentional non-administration, using omission codes, can result in patients receiving double
doses, which has the potential to result in fatalities or severe harm.
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2009-10 Quality Accounts
Priority 3 – Service User Experience
In order to continue to improve care in the future, the Trust believes that it is essential
that we listen to service users and learn from their experiences within our services. To
achieve this, we will further develop and strengthen systems and processes that routinely
gather real time information from our service users and use this information to further
enhance and develop the quality of the services we provide.
Target:
Each service line will have processes for capturing and responding to, in real time,
the views and opinions of the service users.
Key measure:
% of service lines with a set of service users questions tailored to their needs
% of service lines with evidence of regular monitoring of service user feedback
% of service lines with action plans relating to service user feedback
% of service lines with evidence of improvements made in response to service user
feedback
Key actions to be taken:
To identify and establish a leadership role for driving forward user experience
methodologies
To align and improve existing processes for capturing service user feedback. Identify
and address any gaps in existing processes
To further develop, with each service line, survey questions incorporating both
generic and service specific themes
Service lines to develop and implement processes which respond to service user
feedback
To develop a clear system to monitor the effectiveness of the implementation of
service line action plans.
Monitor performance through the Quality Effectiveness and Risk Committee
Rationale:
The Trust has implemented over the past 12 months a process for capturing and
responding to real time service user feedback. The learning from the development of these
processes has shown that in order to effectively capture feedback from our diverse service
user population we need to develop and implement a range of methodologies. This will
ensure that service improvement is specific to local need as well as addressing
organisational wide priorities.
The areas for questioning directly relate to concerns raised in the national community and
inpatient mental health surveys.
2009-10 Quality Accounts
Page 13
Quality Report
3. Statements of
Assurance from the Board
3.1 Review of services
During 2009/10 South
Staffordshire and Shropshire
Healthcare NHS Foundation
Trust provided and subcontracted 58 NHS services as
listed in pages 8 and 9 of this
2009/10 Annual Report.
S o u t h S t a f f o r ds h ir e a n d
Shropshire Healthcare NHS
Foundation Trust has reviewed
all the data available to them on
the quality of care in all of these
NHS services. This data relates
to the areas for improvement
identified, our quality indicator
set and the minimum quality
standards set by external
regulatory bodies such as the
Care Quality Commission.
The income generated by the
NHS services reviewed in
2009/10 represents 100 % of the
total income generated from the
provision of NHS services by
S o u t h S t a f f o r ds h ir e a n d
Shropshire Healthcare NHS
Foundation Trust for 2009/10.
3.2 Participation in National
Clinical Audits and National
Confidential Inquiries
During 2009/10 six national
clinical audits and one national
confidential inquiry covered NHS
services that South Staffordshire
and Shropshire Healthcare NHS
Foundation Trust provides.
During 2009/10 South
Staffordshire and Shropshire
Healthcare NHS Foundation
Trust participated in 83% (the
other 17%
was a pilot) of
national clinical audits and 100%
of national confidential inquiries
in which it was eligible to
Page 14
participate.
The national clinical audits and
national confidential inquiries
that South Staffordshire and
Shropshire Healthcare NHS
Foundation Trust was eligible to
participate in during 2009/10 are
as follows:
National Clinical Audits
National Audit of Psychological Therapies for Anxiety and
Depression: Anxiety and Depression (pilot)
Prescribing Observatory For
Mental Health (POMH): Prescribing topics in mental
health services
Prescribing high dose and
combined antipsychotics
on adult acute and psychiatric intensive care wards
Medicines Reconciliation
Screening for metabolic
side effects antipsychotic
drugs in patients treated by
Assertive Outreach
Use of antipsychotic medicine in people with Learning Disabilities
Royal College of Physicians:
Continence Care Audit
National Confidential
Enquiries
National Confidential Inquiry
into Suicide and Homicide by
People with mental Illness.
The national clinical audits and
national confidential inquiries
that South Staffordshire and
Shropshire Healthcare NHS
Foundation Trust participated in
during 2009/10 are as follows:
2009-10 Quality Accounts
National Clinical Audits
Prescribing Observatory For
Mental Health (POMH): Prescribing topics in mental
health services
Prescribing high dose and
combined antipsychotics
on adult acute and psychiatric intensive care wards
Medicines Reconciliation
Screening for metabolic
side effects antipsychotic
drugs in patients treated by
Assertive Outreach
Use of antipsychotic medicine in people with Learning Disabilities
The national clinical audits and
national confidential enquiries
that South Staffordshire and
Shropshire Healthcare NHS
Foundation Trust participated in,
and for which data collection
was completed during 2009/10,
are listed below alongside the
number of cases submitted to
each audit or enquiry as a
percentage of the number of
registered cases required by the
terms of that audit or enquiry.
Royal College of Physicians:
Continence Care Audit
National Confidential
Enquiries
National Confidential Inquiry
into Suicide and Homicide by
People with mental Illness
National Clinical Audits
Audit Title
POMH:
Prescribing high dose and combined antipsychotics on adult acute and
psychiatric intensive care wards
Medicines Reconciliation
Screening for metabolic side effects antipsychotic drugs in patients treated by
Assertive Outreach
Use of antipsychotic medicine in people with Learning Disabilities
% cases
submitted
100%
77%
83%
89%
Royal College of Physicians: Continence Care Audit
(sample sizes required by site)
South Staffs
60%
Shropshire
48%
National Confidential Enquiries
Enquiry Title
National Confidential Inquiry into Suicide and Homicide by People with mental
Illness
2009-10 Quality Accounts
% cases
submitted
100%
Page 15
Quality Report
The reports of 4 national clinical
audits were reviewed by the
provider in 2009/10 and South
Staffordshire and Shropshire
Healthcare NHS Foundation
Trust intends to take the
following actions to improve the
quality of healthcare provided:
To nominate an antipsychotic
prescribing champion for
inpatient wards
Ensure ward staff have
ac c es s t o Pr es c r i bi n g
Observatory For Mental
Health resources
Work with PCT health
pr om otio n s er v ic es t o
implement a range of health
promotion leaflets
Improve
recording of
metabolic
syndrome
screening
Development of a standard
outpatient letter for clinicians
to send to GP’s
Strategic work in older
peoples’ services regarding
medicines adherence
Further training in medicines
reconciliation from ward staff
Agree and evaluate general
assessment of side effects of
m edication in learning
disability services
Investigate barriers to assess
weight change in learning
disability services
Investigate barriers to
monitor blood pressure in
learning disability services
The Trust undertakes a wide
ranging comprehensive
programme of “local” audit
activity. All projects are
prioritised based on their
rationale and drivers. Projects
are assessed according to four
levels of priority, these include:
National Priority
Trust Priority
National Good Practice
Clinical Interest
The reports of 88 local clinical
audits were reviewed by the
Page 16
provider in 2009/10 and South
Staffordshire and Shropshire
Healthcare NHS Foundation
Trust intends to take the
following actions to improve
quality of healthcare provided:
Improve processes that
support
effective
communication
Strengthen processes for
embedding and monitoring
policies and standards
Review the provision of
training to improve gaps in
knowledge
Further enhance the sharing
of good practice and
celebrating of success
Continual improvement of
standards of documentation
including appropriate
completion of care plans
Further
enhance the
appropriate use and
m onitor ing of ex is ting
pathways and assessment
tools.
3.3 Participation in Clinical
Research
S o u t h S t a f f o r ds h ir e a n d
Shropshire Healthcare NHS
Foundation Trust is committed
to research as a driver for
improving the quality of care and
patient experience. There is an
increasing level of participation
in clinical research which
demonstrates the Trust’s
commitment to improving the
quality of care we offer and to
making our contribution to wider
health improvement.
The number of patients
receiving NHS services provided
or sub-contracted by South
Staffordshire and Shropshire
Healthcare NHS Foundation
Trust in 2009/10 that were
recruited during that period to
participate in research approved
by a research ethics committee
was 500.
2009-10 Quality Accounts
South Staffordshire and
Shropshire Healthcare NHS
Foundation Trust was involved in
conducting 23 clinical research
studies all of which were
completed within the agreed
framework. South Staffordshire
and Shropshire Healthcare NHS
Foundation Trust used national
systems to manage the studies
in proportion to risk. Of the 12
studies given permission to start,
100% were given permission by
an authorised person. 100% of
the studies were established and
managed under national model
agreements and 100% of the 3
eligible r es earc h s tudies
involved used a Research
Passport.
In 2009/10 the
National Institute for Health
Research (NIHR) supported 15
of these studies through its
research networks.
As an organisation we have
developed a programme to
share the learning from
Research through delivery of
seminars which include both
local and national researchers.
In the last three years, 2
publications have resulted from
our involvement in NIHR
research, helping to improve
patient outcomes and
experience across the NHS.
3.4 Use of the CQUIN
framework
A proportion of South
Staffordshire and Shropshire
Healthcare NHS Foundation
Trust income in 2009/10 was
conditional upon achieving
qualit y im pr ovem ent and
innovation goals agreed
between South Staffordshire and
Shropshire Healthcare NHS
Foundation Trust and any
person or body they entered into
a contract, agreement or
arrangement with for the
2009-10 Quality Accounts
provision of NHS services,
through the Commissioning for
Quality and Innovation payment
framework.
The monetary total for the
amount of income in 2009/10
conditional upon achieving
qualit y im pr ovem ent and
innovation goals was £540k and
the Trust achieved this payment
in full.
Further details of the agreed
goals for 2009/10 and for the
following 12 month period are
available on request from:
Dr Neil Brimblecombe,
Director of Quality &
Professional Practice
South Staffordshire & Shropshire
Healthcare NHS Foundation
Trust Headquarters
Corporation Street, Stafford
01785 257888
3.5 Registration with the Care
Quality Commission
South Staffordshire & Shropshire
Healthcare NHS Foundation
Trust is required to register with
the Care Quality Commission
and its current registration status
is full compliance with no
conditions attached to its
registration.
We are pleased to confirm that
we have assessed all of our
services against the Care
Quality “Essential Standards of
Quality and Safety” and have
found them to be compliant with
all of these standards.
The Care Quality Commission
has not taken enforcement
action
against
South
Staffordshire and Shropshire
Healthcare NHS Foundation
Trust during 2009/10.
South Staffordshire and
Shropshire Healthcare NHS
Foundation Trust has not been
subject to periodic review by the
Page 17
Quality Report
Care Quality Commission during
2009/10.
S o u t h S t a f f o r ds h ir e a n d
Shropshire Healthcare NHS
Foundation Trust was not
subject to any visit as a result of
the periodic review by the Care
Quality Commission during
2009/10.
The CQC were
s a t i s f i e d wi t h a d d i t i o n a l
evidence requested for our core
standards declaration and our
quality and risk profile.
3.6 Quality of Data
S o u t h S t a f f o r ds h ir e a n d
Shropshire Healthcare NHS
Foundation Trust submitted
records during 2009/10 to the
Secondary Uses service for
inclusion in the Hospital Episode
Statistics which are included in
the latest published data. The
percentage of records in the
published data:
which included the patient’s
valid NHS number was 91.9%
for admitted patient care;
96.5% for outpatient care;
which included the patient’s
valid General Practitioner
Registration Code was;
97.4% for admitted care;
99.5% for outpatient care;
S o u t h S t a f f o r ds h ir e a n d
Shropshire Healthcare NHS
Foundation Trust score for
2009/10 for Information Quality
and Records Management,
assessed using the Information
Governance Toolkit was 74.6%
S o u t h S t a f f o r ds h ir e a n d
Shropshire Healthcare NHS
Foundation Trust was not
subject to the Payment by
Results clinical coding audit
during the reporting period by
the Audit Commission
4. Quality Overview
through the Foundation
Ma n ag em ent T eam an d,
formally on a six monthly basis
through performance review
sessions with the Executive
Team. A summary of these
reviews is presented to the
Finance and Performance
committee to provide assurance
to the Trust Board. Throughout
2009/10 each Directorate has
reported its performance against
a set of qualitative measures as
highlighted within the 2008/09
Annual Report. The indicators
are reflective of the services
provided by the organisation and
take into account what our
service users and carers say
matters to them.
This section of the report
provides an overview of the
quality of care provided by
S o u t h S t a f f o r ds h ir e a n d
Shropshire Healthcare NHS
Foundation Trust during 2009/10
against a range of indicators
agreed by the Board following
consultation
with
key
stakeholders.
The indicator set for 2009/10
spans the three domains of
safety, effectiveness and
experience and has been
expanded on from those
indicators laid out in the 2008/09
Annual Report to take into
ac c ount thr ee ind ic ator s
mandated by Monitor to
benchmark consistently across
all mental health foundation
trusts.
For 2010/11 the Trust will
continue to monitor the indictors
reported upon this year and will
also include our three
improvement priorities from
2009/10. This will allow us to
demonstrate continuity in
service improvement over time.
The organisation reviews its
performance on a monthly basis
Page 18
2009-10 Quality Accounts
Domain
Patient
Safety
Clinical
Effectiveness
2009/10 Indicator
2010/11 Indicator
Rationale
Percentage progress
against infection control
action plan
Percentage progress against
infection control action plan
Ensuring we continue to maintain the
highest standards to protect our patients
from the risks of Healthcare Acquired
Infections.
Compliance with Child
Protection Mandatory
Training
Compliance with Safeguarding
Mandatory Training
Changed to reflect the fact that we need to
address equally the needs of children and
vulnerable adults.
Robust processes for
reporting incidents
Robust processes for reporting
and learning from incidents
Changed to include the improvement
initiative from 2009/10 and ensure we
continue to learn from incidents in a timely,
effective manner.
100% Care Programme
Approach patients
receiving follow-up contact
within seven days of
discharge from hospital
100% Care Programme
Approach patients receiving
follow-up contact within seven
days of discharge from
hospital
National target – evidence is that patients
are most at risk immediately after they have
been discharged from a mental health
ward.
Percentage compliance
with NICE guidance
Percentage compliance with
NICE guidance
Ensure we continue to deliver services
which are based on the best up to date
evidence.
Staff regularly update
skills monitored through
percentage compliance
with appraisals
Staff regularly update skills
monitored through percentage
compliance with appraisals
Staff who deliver our services have the
skills and competencies to do their job to
the highest standards.
Compliance with Mental
Health Act
Compliance with Mental
Health Act
Ensure our services are fully compliant with
legislation and protect the interests of our
service users.
Minimising delayed
transfers of care
Minimising delayed transfers
of care
National target ensuring our service users
have access to the least restrictive, most
appropriate environment at the time they
are ready to move on.
Admissions to inpatient
services had access to
crisis resolution home
treatment teams
Admissions to inpatient
services had access to crisis
resolution home treatment
teams
National target to ensure service users
have been fully assessed to ensure
admission is the best option for them.
New indicator for 2010/11
Access to services for 16-18
year olds
Patients feel listened to
Patients feel listened to
Following the consultation process with our
key stakeholders, this specific indicator has
been included as this is an area of priority
that our South Staffordshire PCT
Commissioners would like us to focus.
Our service users feel that our staff have
heard what they (the service users) want to
say.
Environment responsive to
patients needs
Environment responsive to
patients needs
Our service users receive care in an
environment which enhances the quality of
the intervention given.
Percentage of complaints
resolved within the agreed
timeframe
Acknowledgement of
complaint within the agreed
timeframe
Changed to ensure that we acknowledge
the concerns of our service users and
carers and we are able to tailor the
timeframe for completion to the specific
issue.
New indicator for 2010/11
Views of carers contributes to
the review and development
of services
Following the consultation process with our
key stakeholders, this specific indicator has
been included as this is an area of priority
that our Shropshire and Telford & Wrekin
PCT Commissioners would like us to focus.
Patient
Experience
2009-10 Quality Accounts
Page 19
Quality Report
4.1. Patient Safety Indicators
2009/10
Infection Control – Progress
against infection control
action plan
The Infection Prevention and
Control team use audit on an
annual basis to monitor
compliance with policies and
clinical effectiveness in relation
to Infection Prevention and
Control for inpatient services.
This is effective in both
monitoring standards and
influencing change. The year on
year data assists in strategic
planning to meet long term
Infection Prevention and Control
objectives.
The audit tool is based on the
Infection Prevention Society
audit tool which was developed
Trust Overall Compliance
Infection Prevention & Control Audits 2008 & 2009
90
88
86
% Compliance
84
82
80
78
2008
2009
Year
Trust Compliance with Child Protection
Mandatory Training
100
90
80
70
60
% Compliance
50
40
30
20
10
0
94
69
2008
2009
Year
Page 20
using consistent evidence based
methodology.
The tool has
been adapted for the needs of
the Trust taking into account the
Code of Practice for the NHS on
the prevention and control of
healthcare associated infections
and related guidance (2008)
The tool incorporates nine
standards
including:
environment, waste disposal,
linen handling, and sharps
handling, care of equipment,
decontamination, hand hygiene
and clinical practice and staff
training. The audit demonstrates
a percentage progress against
the Infection Prevention and
Control action plan and shows a
year on year improvement with
the Trust’s overall percentage
compliance.
Results and audit action plans
are returned to managers in
order to ensure that staff
addr ess an y outstanding
problems identified. The audit
action plans are then returned
regularly to the Infection
Prevention and Control Team
until all objectives are achieved.
High priority audit findings are
included in the monthly Infection
Control Assurance Plan to the
Trust Board. The audit results
are also in the Infection Control
Annual Report that is presented
to the Trust Board.
Compliance with Child
Protection Mandatory Training
Employers have a responsibility
to ensure that all staff are given
the opportunity to attend local
courses in safeguarding and
promoting the welfare of
children. Staff who have regular
unsupervised contact with
parents, children and young
people need to be trained to
recognise and respond to the
indications of childhood abuse
and neglect.
2009-10 Quality Accounts
The chart on page 76 shows the
Trust’s significant improvement
towards achieving its 100%
compliance in line with Level 2
Safeguarding Children training.
The Trust will continue to
monitor attendance levels for
this training as well as the
competency of staff who may
need to use these skills.
to learn from these experiences
and taken appropriate action to
prevent harm.
Robust Processes for
Reporting Incidents
The first graph below details the
total number of incidents
reported within the Trust over
the past two financial years. The
graph shows that there is a
slight upward trend in the
number of incidents reported,
however this is not statistically
significant.
Patient safety is a key priority for
the Trust and therefore effective
reporting of patient safety
incidents is paramount to
ensuring that we learn lessons
and minimise future risk.
Despite the higher number of
inc idents r ep or ted i t is
encouraging to note that not all
incidents resulted in injury and
only very few resulted in serious
injury.
The National Patient Safety
Agency (NPSA) advocates an
open and robust reporting
culture within trusts and
recognises that organisations
that report more incidents
usually have a better and more
effective safety culture.
The
NPSA encourages NHS trusts to
report their patient safety
incidents via their local risk
management systems to the
National Reporting and Learning
System (NRLS). The national
data collected in the database
allows for trends to be identified
and for this information to inform
the development of patient
safety resources.
It also
enables our Trust to compare
itself with other trusts and
identify potential high risk areas.
The NPSA however also
recognise that reporting profiles
for similar organisations can
differ if there are differences in
reporting cultures, the types of
services provided or patients
cared for.
The graph below demonstrates
this against the national mental
health picture and is taken from
the last reported statistics for our
Trust by the NPSA.
2009-10 Quality Accounts
800
700
600
500
400
300
200
100
Ap
r0
M 8
ay
-0
Ju 8
n08
Ju
l-0
Au 8
g0
Se 8
p0
O 8
ct
-0
N 8
ov
-0
D 8
ec
-0
Ja 8
n0
Fe 9
b0
M 9
ar
-0
Ap 9
t -0
M 9
ay
-0
Ju 9
n09
Ju
l-0
Au 9
g0
Se 9
p0
O 9
ct
-0
N 9
ov
-0
D 9
ec
-0
Ja 9
n1
Fe 0
b1
M 0
ar
-1
0
0
Total
Linear (Total)
Incidents Reported to NPSA by Degree of Harm
80
Percentage of incidents occurring
S o u t h S t a f f o r ds h ir e a n d
Shropshire Healthcare NHS
Foundation Trust is fully
engaged with the NPSA national
reporting processes and is keen
Total Incidents Reported
70.4
70
60.5
60
50
40
34.2
30
22
20
7.3
10
4.5
0.1
0.3
0.2
0.4
0
None
Low
Moderate
Severe
Death
Degree of harm
Our Trust
All Mental Health trusts
Page 21
Quality Report
The graph below further breaks
down the Trust’s reported
incidents over the last two
financial years by cause group.
As previously noted there has
been an upward trend in the
total number of incidents
reported over the past two
financial years. The graph
demonstrates that this increase
is fairly distributed across the
cause groups other than for nonphysical aggression and other
clinical incidents for which there
has been a significant rise.
Disruptive and aggressive
behaviour is the second most
commonly reported incident type
for mental health and learning
disability trusts and accounts for
21% of all reported patient
safety incidents to the NPSA.
For our Trust disruptive and
aggressive behaviour accounted
for 39% of the total incidents
reported during 2009/10. This
figure includes aggression nonphysical which accounted for
48% of the disruptive and
aggressive behaviour, and 80%
of these incidents were directed
at staff by either patients or
visitors and are not reportable to
the NPSA. The Trust has
undertaken a review of its
Incidents Reported by Category
2008/09 - 2009/10 Comparison
2000
disruptive and aggressive
behaviour incidents and is
delivering a comprehensive
action plan to try and minimise
the number of incidents
occurring and the impact of
these incidents. The actions
include:
Training for staff around the
management of aggressive
behaviour
Early identification of risk
through specific risk
assessment tools
Multi-disciplinary
case
reviews to determ ine
individual management plans
for high risk individuals
Review of environmental
issues and staffing levels in
high risk service areas
Other clinical incidents is the
highest incident reporting cause
group for the Trust and
comprises of a wide range of
incident types from assessment
of need, care planning,
treatment through to discharge.
No significant clusters or themes
have been identified within the
data reported during 2009/10,
however the Risk Management
Department are reviewing the
Trust’s incident categories so
that clinical incidents are further
categorised and can be reported
in more detail.
1800
Total Number of Incidents
1600
1400
1200
1000
800
600
400
200
s/
Fa
lls
/T
rip
ip
s
m
em
es
ti c
k
dl
s/
N
ee
rp
Sh
a
Sl
Se
lf
H
ar
s
ic
al
-C
lin
Pr
ob
l
ity
-N
on
cu
r
Se
r
ic
al
-C
lin
er
er
O
th
g
Er
ro
ed
M
O
th
ic
at
io
n
H
an
al
an
u
Category
2008/09
Page 22
dl
in
io
n
s
Fi
re
ol
lis
ct
/C
pa
Im
M
le
m
bl
em
ob
tP
ro
Pr
m
en
os
is
gn
ui
p
D
ia
Eq
m
SH
H
C
O
er
le
O
th
n
ti o
n
ic
a
un
m
Pr
ob
ys
ic
al
Ph
si
o
N
on
gr
es
Ag
C
om
gr
e
ss
io
n
lN
o
ys
ic
a
Ag
si
o
Ag
gr
e
gr
es
Ag
ss
io
n
n
Ph
Ph
y
si
ca
l
In
In
j
ju
r
ur
y
y
0
2009/2010
2009-10 Quality Accounts
100.5
100
99.5
99
98.5
98
0
Fe
b1
9
-0
ec
-0
9
D
O
ct
9
ug
-0
9
A
09
Ju
n0
9
pr
A
Fe
b0
8
-0
ec
-0
8
D
O
ct
8
ug
-0
8
A
Ju
n0
pr
-
08
97.5
A
Reduction in the overall rate of
death by suicide needs to be
supported by arrangements for
securing appropriate care for all
those with mental ill health. This
should include actions to follow
up quickly those service users
on the Care Programme
Approach who are discharged
from a spell of inpatient care,
aiming to reduce risk and social
exclusion whilst improving care
pathways.
% compliance with 7 day follow up
% service users followed
up within 7 days
Care Programme Approach Patients Receiving Follow-Up
Contact Within Seven Days of
Discharge From Hospital
Month
% compliance with 7 day follow up
The following data demonstrates
that all of South Staffordshire &
Shropshire Healthcare NHS
Foundation Trust’s patients
discharged from a spell of
inpatient care who are subject to
CPA were followed up within
seven days of discharge.
2009-10 Quality Accounts
Page 23
Quality Report
4.2. Clinical Effectiveness
Indicators 2009/10
Compliance with NICE
Guidance
S o u t h S t a f f o r ds h ir e a n d
Shropshire Healthcare NHS
Foundation Trust has an
established process for the
identification, assessment,
implementation and review of
NICE guidance in line with the
Care Quality Commission
requirements. The Quality and
Professional
Practice
Directorate is responsible for
ensuring that all newly published
NICE guidance is received and
disseminated so that the
Published NICE Guidelines
relevance of impact on the
clinical services is assessed and
where relevant addressed.
For all guidance assessed as
relevant a systematic facilitated
approach to implementation is
adopted and D ir ec tor ate
progress with implementation is
monitored through the Trust’s
governance processes. The
Trust recognises the importance
of compliance against NICE
guidance and therefore all
implemented guidelines are
incorporated within the Trust’s
clinical audit programme. The
Trust Board receives regular
update on progress with
im plem entation of newl y
published NICE guidance and
compliance
against
implemented guidance.
39
40
Currently there are 64 pieces of
published NICE guidance that
have been assessed as relevant
by the Trust. These include
Technology Appraisals, Public
Health Guidelines and Clinical
Guidelines as summarised in the
two graphs to the left. To date
there
have
been
no
i nt er v e n t io n a l pr oc e d ur es
published that the Trust have
assessed as relevant.
35
30
25
20
13
12
15
10
5
0
Technology Appraisals
Pulic Health Guidelines
Clinical Guidelines
Compliance with Staff
Appraisals
NICE Guidance Current Status
30
30
25
20
Number 15
11
9
10
6
3
5
0
4
1
0
0
Technology Appraisals Public Health Guidelines
Clinical Guidelines
Guidance Type
Information Only
Page 24
Currently Being Implemented
Implemented & Audit in Place
S o u t h S t a f f o r ds h ir e a n d
Shropshire Healthcare NHS
Foundation Trust has worked
closel y with all of the
directorates to ensure that staff
are not only appraised on an
annual basis but also, as a
result of the appraisal, have a
personal development plan
which reflects the changing
needs of the services they
deliver. The appraisal process
ensures that the member of staff
fully understands what skills and
2009-10 Quality Accounts
competencies they need to
deliver a quality service. The
personal development plan
ensures that current skills are
kept up to date and, where new
skills are required, that these are
planned for in a timely, effective
manner.
The use of the
Knowledge
and
Skills
Framework within the appraisal
process
ensures
that
competencies are not assumed
but must be evidenced. The
graph to the right shows the data
from the National Staff Opinion
Survey. It can be seen that this
organisation is significantly
higher than the national average
for staff having received an
appraisal. It must be recognised
that for a number of staff, such
as those returning from long term
leave or who have only been in
post for a short time, it would not
have been appropriate to have
carried out an appraisal in the
last 12 months.
Percentage of staff appraised in the last 12 months
78%
76%
74%
72%
70%
68%
66%
2009 National average 2008 Trust Score
for Mental Health and
Learning Disability
Trusts
from the Commission visits. The
Commission
made
8
r e c om m e n d a t i o n s wi t h 9
associated actions as detailed
below:
Ensure that all clients who are
Compliance with Mental Health
Act
On 1 April 2009, the duties of the
Mental Health Act Commission,
including visiting sites where
patients are detained under the
Mental Health Act, were
amalgamated into the Care
Quality Commission. Since this
time frequency of visits from our
designated local commissioner
has incr eas ed. Relations
between the Mental Health Act
Commissioner and senior
members of the Trust have
continued to be constructive
throughout the reporting period
and the diligence of the Mental
Health Act managers in ensuring
all detentions are lawful has
been observed.
An Annual Statement was
presented to the Trust in
November 2009 on the findings
2009-10 Quality Accounts
2009 Trust Score
subject to the Mental Health
Act are informed of their rights
as per the Code of Practice.
Ensure that ‘Qualifying’
patients understand that help
is available to them from the
Independent Mental Health
Advocates.
Ensure that Statutory
Consultees should make a
record to be placed in the
patient’s notes of their
consultation with the Second
Opinion Appointed Doctor
Continue to actively monitor
the effectiveness of the ‘trigger
system’ to identify and refer
eligible clients who qualify for
an automatic referral to the
Mental Health Tribunal.
Ensure
that
legal
documentation is moved into
the current patient file so as to
enable easy access to key
documents.
Continue to review its staffing
levels and ensure that its
r e l ia nc e o n t he ‘N HS
Professionals’ is kept to an
absolute minimum
Keep the Care Quality
Page 25
Quality Report
Commission informed as to
the progress in the
management of clients who
are absent without leave.
Ensure that a multi-agency
approach to the offering of
leave is based upon effective
communication of the Care
Programme Approach (CPA).
To provide assurance to the
Care Quality commission that
any reduction in bed numbers
is supported by a robust risk
management plan.
Minimising Delayed Transfers
of Care
As an organisation we recognise
the importance for our service
users of moving smoothly along
the pathways of care. For those
of our service users who require
a stay in hospital this can be a
challenge, particularly when they
are unable to return to the
accommodation from which they
were admitted.
Delayed
transfers back to the community
can sometimes negate the
improvements brought about by
the admission in to hospital. We
have worked closely with our
partners in the community to
Percentage
Delayed
Discharges
% Delayed discharges
10
8
6
4
2
Se
pO 08
c
N t-08
ov
D -0
ec 8
Ja 08
n
Fe -09
bM 09
ar
Ap -09
M r-0 9
ay
Ju 09
n0
Ju 9
l-0
Au 9
g
Se -09
O p-0
ct 9
N 09
ov
D -0 9
ec
J a -0 9
nFe 10
b
M -1 0
ar
-1
0
0
Month
% Delayed discharges
Page 26
significantly reduce the time
taken to transfer out of hospital
to a community placement thus
maximising the benefits brought
about by the admission. These
improvements in reducing the
delays can be seen in the chart
below.
Admissions to Inpatient
Services had Access to Crisis
Resolution Home Treatment
Teams
The
National
Service
Framework for Mental Health in
1999 highlighted the need for
crises and emergencies to
access early intervention for the
safety of both the public and the
patient
Timely access to
services reducing delays in
assessment, treatment and care
can also reduce the risk of
relapse and potential harm to
the service user and others.
Service users and carers
themselves indicate that in a
crisis they require a rapid
response; continuity of care; and
alternatives to hospital-based
assessment and admission.
Community-based assessment
and treatment can offer effective
alternatives to hospital
admission, with crisis resolution
and sustained home care for
people with serious mental
illnesses.
The service users
benefit from receiving treatment
in an environment they know as
well as being able to keep close
contact their families/carers who
are integral to the treatment
process. As an organisation, for
the first time this year we have
ensured that all access to
inpatient beds is “gatekept” by
Crisis Resolution/Home
Treatment Teams who ensure
that when a patient is admitted
to hospital it is truly the only
option.
2009-10 Quality Accounts
In 2009/10 100% of admissions
to our acute mental health wards
were through the Crisis
Resolution/Home Treatment
Teams.
Percentage of service users who felt that the psychiatrist
"listened carefully" to them
14.5%
1.7%
Yes, always
4.3. Patient Experience
Indicators 2009/10
Yes, sometimes
No
21.5%
62.2%
Patients feel listened to
In 2009 we launched our
organisational Trust strategy
“Positively Different through
positive practice and positive
partnerships” in it the first of our
three core values states that
“People who use our services
are at the centre of everything
we do – they are our reason for
being”. We know that key to
ensuring contact with our
services is a positive experience
for our service users, is that our
staff listen carefully to them.
In 2009 the Care Quality
Commission undertook the first
survey of mental health
inpatients. It is recognised that
some inpatients may not have
been in hospital voluntarily and
therefore feel disempowered
which reflects in the survey
results.
We are therefore
pleased that the significant
majority of our service users felt
that they were listened to as the
charts to the right demonstrate.
Environment responsive to
patients needs
The tables overleaf outline the
2009 Patient Environment
Action Team assessment areas,
along with key scores against
the Trust’s main sites providing
inpatient accommodation of 10
beds or more. Our full report
also identifies recommendations
for improvements and actions
that are currently taking place, to
ensure we maintain high
2009-10 Quality Accounts
Did not see a psychiatrist
Percentage of service users who felt that the nurses "listened
carefully" to them
9.7%
Yes, always
Yes, sometimes
38.6%
51.7%
No
standards for the environment
and food. These are made
within the context of informed
decisions based upon the
Trust’s current and future
operational requirements for
each site.
Further details of the full report
and its associated recommendations for improvements,
plus the actions taking place are
available on request from:
Jon Meigh, Director of Facilities
& Estates
South Staffordshire &
Shropshire Healthcare NHS
Foundation Trust
Trust Headquarters
Corporation Street
Stafford
01785 257888
Page 27
Quality Report
Patient’s Environment Scores
In-Patient Facility
2007
2008
2009 projected
2009 actual
White Lodge
Good
Good
Good
Good
Burton House
Good
Acceptable
Acceptable
Acceptable
George Bryan Centre
Excellent
Good
Good
Good
Margaret Stanhope
Centre
Excellent
Good
Good
Good
St George’s Hospital
Excellent
Good
Good
Good
Shelton Hospital
Excellent
Excellent
Good
Acceptable
Castle Lodge
Excellent
Excellent
Good
Good
Oak House
Excellent
Excellent
Good
Good
The Elms House
Good
Excellent
Good
Good
West Bank
Good
Good
Good
Good
2007
2008
2009 projected
2009 actual
White Lodge
Good
Excellent
Excellent
Good
Burton House
Good
Excellent
Excellent
Excellent
George Bryan Centre
Excellent
Excellent
Good
Good
Margaret Stanhope
Centre
Excellent
Excellent
Good
Good
St George’s Hospital
Excellent
Good
Good
Good
Shelton Hospital
Excellent
Good
Good
Excellent
Castle Lodge
Excellent
Excellent
Excellent
Excellent
Oak House
Excellent
Excellent
Excellent
Excellent
The Elms House
Good
Good
Good
Excellent
West Bank
Excellent
Excellent
Excellent
Excellent
South
StaffordshireDivision
Shropshire Division
Better Hospital Food Scores
In-Patient Facility
South Staffordshire
Division
Shropshire Division
Page 28
2009-10 Quality Accounts
Percentage of complaints
resolved within the agreed
timeframe
Trust had investigated at the
time of writing, 19 were
considered upheld and 54
partially upheld.
In April 2009, the Local Authority
Social Services and National
Health Service Complaints
(England) Regulations came into
force. These new arrangements
have resulted in a more
personalised and accessible
experience for the complainant.
The Trust, by Regulation,
acknowledges receipt of all
complaints, either verbally or in
writing, within three working
days, and every effort is made to
ensure that the matter is
resolved as quickly as possible,
allowing for robust investigation
and response.
It is essential that the
Investigating Officers work with
the complainant to ensure that
the nature of the complaint is
fully understood and, as part of
that contact, agreement is
reached on the likely timescale
for resolution. However, should
the timeframe be likely to be
exceeded, the Investigating
Officer, in line with Regulation,
should notify the complainant
accordingly.
Taking into consideration agreed
and actual timescales, the Trust
is aware of 9 minor breaches to
timescale and is actively working
towards 100% compliance.
However, for future years, it is
suggested that a more tangible
m e a s u r e wo u l d b e t h e
acknowledgement timeframe of
3 days; this being the only
statutory measurement.
During 2009/10, the Trust
received 178 formal complaints,
which represented an increase
of 56% on last year. From the
number of complaints, which the
2009-10 Quality Accounts
Page 29
Quality Report
4.4. Performance against key national priorities and National Core Standards
Page 30
National Targets and Regulatory Requirements
Target
CPA 7 day follow-up
100%
Delayed transfers of care
<7.5%
Experience of patients – benchmark with other trusts
“Overall how would you rate the care you received in
hospital” (CQC survey)
Top 20%
Drug users in effective treatment - % retained in
treatment for 12 weeks
100%
Achieved
Data quality on ethnic group
95%
Achieved
Access to crisis resolution
100%
Patterns of care from MHMDS
100%
Completeness of the MHMDS
100%
Child and adolescent MH services – CQC performance against key indicators
80%
Achieved
100%
On target to achieve
99% for 2009/10 year
end figures, due for validation June 2010
On target to achieve
99% for 2009/10 year
end figures, due for validation June 2010
100% Achieved
Green light toolkit – completion of action plan for key
indicators
100%
100% Achieved
NHS staff satisfaction – risk areas addressed in CQC
Quality Risk Framework
100%
100% Achieved
Number of people on CPA with a care plan
95%
Campus provision percentage of persons receiving
care in an NHS campus provision who have a discharge plan
Care Quality Commission “Essential Standards of
Quality and Safety” (16 standards)
100%
Achieved
100%
Achieved 100% have a
PCP and Discharge plan
for December 2010.
100% - All services
meet all 16 standards
100%
Trust Achievement
09/10
Achieved
100%
Achieved
Shropshire 0%
Staffordshire 2%
Achieved –positive response in top 20% nationally
2009-10 Quality Accounts
4.5 Statements from our Key
Stakeholders
Copies of our draft Quality
Accounts were sent to our Local
Involvement Networks (LINK),
Overview and Scrutiny
Committees (OSC) and
Commissioning Primary Care
Trust for consultation and
comment prior to publication.
This consultation forms part of
an ongoing cycle of engagement
and discussion with our
stakeholders regarding quality
improvement.
We welcome and thank our key
stakeholders for the comments
received and for their continued
involvement within the Trust’s
quality assurance processes.
This is the first set of Quality
Accounts produced by the Trust
and the feedback we have
received is invaluable as it will
help to shape the content and
format of our future reports.
Comments received in response
to this consultation are included
overleaf and we note that no
significant changes were made
to this document subsequent to
these statements being
provided.
stakeholder engagement and
feedback
A
focus
on
the
responsiveness of services
A
focus on learning and
changes made in response to
service reviews
A closer focus and recognition
of the importance of carers in
reviewing and developing
services
Links between developing the
workforce
quality
and
improving
The particular themes that have
been drawn from the written
comments received and those
that we intend to focus on in
partnership with stakeholders
during 2010/11 include:
In addition to the Trust Wide
Quality Accounts that forms part
of a suite of documents within
our Annual Report, the Trust
also intends to produce a more
public friendly version of the
accounts that will reflect more
closely local quality priorities
and local services
Clearer
evidence
of
2009-10 Quality Accounts
Page 31
Quality Report
Written statements by other bodies
On a general note, we recognise that this is report reflecting the whole Trust. This does not, therefore,
necessarily reflect the local priorities, information associated with, or experiences from the T&W perspective. It would be helpful to see something that specifically highlights progress and areas for further development in each area. We, as commissioners, would gain a sense of the overall work and
specific local issues (and be able to see the local issues which may be better or worse than elsewhere). This may be towards the end of the report, rather than expecting that analysis throughout
each subject area.
P2 Safety.
There was some concern that we are not receiving SUIs completed within 45 days.
P4 Safety – to improve the time taken to respond to serious untoward incidents
Helpfully set out the clinical responsiveness. It would be helpful to have some comparison of SUIs
across areas eg to see T&W responsiveness against other areas.
Service user experience
When considering your comments in this section we reflected on potential gaps in experience of your
service. We wanted you to consider feedback from other stakeholders including from primary care,
PRH/RSH regarding Liaison services. One issue of concern or to reflect on is the, at least anecdotal
feedback of services being hard to access at the point of referral. It would be helpful for you to receive
that as part of your review in order to respond to that or other feedback.
It has been noted that there is no comment about the involvement of carers in reviewing or feedback
are the quality of care. There would be significant value in this being included.
P13 Participation in national clinical audits
We currently receive a schedule of audits planned. It would be helpful to receive, as a matter of routine, all clinical audits completed related to T&W, as completed. The content and findings can then be
discussed, as well as monitor the level of embedding good practice.
Further comments
I would offer a number of thoughts for consideration for next and future years:
It would be helpful to summarise the areas that have undertaken, learning or changes made from
service reviews mentioned with the report.
Clarification of how services have been developed to meet local needs, taking account of, for example the JSNA, stakeholder feedback, internal analysis of data.
Clear evidence of stakeholder engagement and feedback of performance including Council colleagues, police, Probation, acute and community providers
Michael Bennett
Lead Joint Commissioning & Contracting Manager
NHS Telford & Wrekin/Telford & Wrekin Council
Page 32
2009-10 Quality Accounts
The PCT has received the quality account from South Staffordshire and Shropshire Healthcare NHS
Foundation Trust and makes the following comments:
Falls Risk Assessment
The PCT notes the quality improvements the trust is proposing to introduce to both identify those at
risk of falling and to implement appropriate care. This is an appropriate response as there has been
an increase in the number of falls reported. The PCT expects to see a reduction in the number of falls
during the year and have agreed a CQUIN scheme with the Trust to facilitate this improvement.
Service User Experience
The PCT is aware of the significant work already undertaken by the trust in this area and looks forward to seeing the further developments in the coming year.
Clinical Audits
The PCT has received a copy of the trust’s forward plan for clinical audit and will be receiving and reviewing a selection of completed audits during the year.
Incident Reporting
The PCT is aware that the trust has a robust system for reporting incidents and it is useful to see the
breakdown in terms of incident types. The increase in falls this year explains why this was chosen as
a priority for the CQUIN scheme in the year ahead.
It would be useful to see the number of serious untoward incidents (SUIS) reported by the trust and a
breakdown of the type. The PCT has noted that the trust has improved its ability to complete the investigation and reporting process for SUIs and will continue to work with the trust on this in the coming
year, as there is still further progress required.
Complaints
Although the number of formal complaints are low (178 during 2009/10) there has been a 56% increase from the previous year. It would have been useful to see a breakdown as to the subject matter
of these complaints in comparison to previous years, as well as a summary of what the trust is doing
to ensure changes are made to prevent a recurrence.
In summary, the Trust’s statement about its priorities and the quality of services it delivers is welcomed. The PCT also acknowledge that to the best of our knowledge, the data provided is accurate.
However, the PCT continues to hear concerns raised by local GPs on behalf of their patients about
the responsiveness of services on occasion, and would like to see some of these issues noted and
responded to in future quality accounts.
S Poynor
CHIEF EXECUTIVE
South Staffordshire Primary Care Trust
2009-10 Quality Accounts
Page 33
Quality Report
The PCT recognises the aspirations of the Foundation Trust, and welcomes the focus on safeguarding, quicker responses to incidents and improving the experience of users. The PCT looks forward
to this information being shared not only for contract monitoring but also in partnership forums, so
that the learning can be used to improve safety and care pathways.
We suggest that the approach would be further strengthened with a recognition of the importance of
carers in reviewing and developing high quality, responsive services in Shropshire and in developing
outcome reporting.
In addition, we suggest that the Quality Account would be improved by showing an understanding of
our local communities’ needs, taking into account the findings in the Joint Strategic Needs Assessment for Shropshire. This would help to describe the opportunities and challenges in delivering quality services to people in this county, for example, in relation to its population, demographics and geography.
Accuracy of information:
It is not possible to state whether we consider that the information provided in relation to quality indicators is accurate, in relation to our contract with the provider, as the data relates to the whole of the
Foundation Trust’s provision. Therefore it is not possible to check against data we have been supplied with. The Account does not therefore enable the public in Shropshire to judge quality in their
local services against the data provided.
Other comments
The PCT notes that service reviews are referred to as having been completed. It would be helpful to
provide further detail about how the learning from these reviews has been used and what changes,
if any, have been made as a result.
Similarly, the PCT would welcome further information on a service or specialist basis, for example
service level indicators or themes including privacy and dignity.
It would also be useful to demonstrate how the provider responds to any matters raised by commissioners and other stakeholders, GPs and clinicians working locally with the provider, as well as patient derived feedback such as PALS and complaints. This would provide a useful account of how
learning is used and shared which can be embedded into commissioning and partnership working.
It would also be helpful to note the role that the Foundation Trust plays in delivering plans across the
health and care economy in relation to quality – for example working with partners in urgent care, to
ensure people get the right care at the right time, expediting discharges, avoiding delayed transfers
and inappropriate emergency admissions in acute or community hospital settings.
We would welcome the opportunity to participate in the development of the Quality Account in future
so that it can reflect local priorities. This will help build an understanding of quality in terms of what it
means to users and carers in Shropshire - so that people can recognise and compare services with
other providers if appropriate. This will ensure that the document is meaningful and support the
strong partnership working on the modernisation of mental health in Shropshire.
Simon Kenton, Director of Joint Commissioning
Shropshire County PCT / Shropshire Council
Page 34
2009-10 Quality Accounts
As this is the first year of Quality Accounts, our approach has been to review the Trust’s draft Account
and make comments for them to consider in finalising the publication. We have been encouraged, by
the Department of Health’s NHS Medical Director, to consider whether such Accounts are representative and give comprehensive coverage of a provider’s services and if we believe that there are significant omissions of issues of concern.
There are some sections of information that the Trust must include and some sections where they can
choose what to include. We focused on what we might expect to see in the Quality Account, based
on what we have learned about the Trust’s services through health scrutiny activity in the last year.
We also looked at how clearly the Trust’s draft Account explained for a public audience what they are
doing well, where improvement is needed and what will be the priorities for the coming year.
We are pleased that, as a result of our comments, the Trust has developed the explanations of the
2009/10 and 2010/11 priorities for improvement - to make a clearer link to the quality of patient experience. We like the presentation of the information from the real time patient survey and the mix of diagrams and text. However, there remains scope to develop, for the reader, the explanations of the
mandatory content and performance information to say why this is important / relevant to quality.
Whilst the importance of the workforce in regard to quality is recognised in the document, we would
have liked to see a paragraph to explain the link between developing the workforce and improving
quality.
We would have preferred the statement at the beginning of the document to have focused more on
giving an overview of the quality of services (rather than of quality assurance) and to have referred to
who has been involved in developing the quality account.
We encourage people to provide feedback to the Trust on the Quality Account as this will help with
next year’s publication.
We expect to see, and contribute to, increasing patient and public involvement in the assessment and
improvement of the quality of services that health trusts provide.
County Councillor Janet Eagland
Staffordshire Health Scrutiny Committee Chairman
2009-10 Quality Accounts
Page 35
Quality Report
Telford & Wrekin LINk welcomes the opportunity to comment on the first Quality Account Report to
be produced by the South Staffordshire & Shropshire Healthcare NHS Foundation Trust.
We are pleased that the Trust identified use of patient experience as a priority in 2009 and that it
acknowledges that further work needs to be done in this area in 2010/11. Although some progress is
being made, our concern is that the improvements that the Trust says it wants - and which the LINk
believes is needed - will not be achieved unless far greater commitment is given to identifying and
implementing change that is led by service users.
Our overall assessment is that whilst the report provides a clear overview of achievements in the
three areas identified for improvement in 2009/10 and identifies how it intends to build on them in
2010/11, by focusing on process it fails to capture what the service is really all about: making a difference to the lives of vulnerable people who rely on the support it provides to enable them to lead a
more independent and better quality of life.
To this end, we would like to work with service users and the Trust to develop the indicators for patient experience and the performance targets as these seem to be unimaginative and less than demanding which suggests an underlying ‘tick box’ approach to service delivery and a disconnection
to the good work being done on developing Patients Recorded Outcome Measures.
A few examples of the outcome measures to illustrate what a PROM looks like and how it expresses
the needs and wants being identified by service users would strengthen the report. The staff appear
to have evaluated the piloting of the PROMs is of some concern as this appears to devalue service
user involvement in testing effectiveness.
And whilst the ‘real time’ feedback being collected from individual service users is very useful, our
research indicates that service users also need time to reflect on their experience before being
pressed for feedback; they also often admit to being apprehensive about complaining even when
assurances are given that individual comments cannot be traced.
Telford and Wrekin LINk would have liked the report to contain less quantitative data and more narrative, with a focus on
the challenges of involving service users whose needs and expectations are as complex as they are
diverse
the role played by governor members, advocacy organisations and other partners
lessons that have been learned from getting it wrong, as well as getting it right
case histories with specific examples of the difference being made to people lives and how such
experiences influence wider practice
We would be pleased to discuss ways that the LINk can support the person to be assigned responsibility for driving forward user experience methodologies, which is a recommendation that we
strongly support.
We would also welcome the opportunity to work with the Trust particularly in relation to the way staff
communicate with patients with cognitive, sensory and learning impairments and with individuals for
whom English is a second language. We also believe that we can also assist the Trust with the way
that care pathways are implemented.
Jean Gulliver
Chair, Telford & Wrekin LINk
Page 36
2009-10 Quality Accounts
Staffordshire LINk was provided with the draft Quality Account by the Trust with the request for
comments and feedback. The draft Account was distributed to relevant LINk network organisations
and also published on the Staffordshire LINk website for comment by LINk members. One LINk
network organisation provided feedback and comments.
Staffordshire LINk comments:
Who is the intended audience for this document?
It is 28 pages of lots of words and if the team responsible for this work want feedback and
confirmation of the findings noted, then perhaps it can be available in a more accessible format.
Was impressed with the diagrams and would like more of this.
Easy read format would perhaps encourage more feedback.
Page 7 – “locally we have service user involvement groups in each directorate” – unless this is
in reference to the SURF meeting, we are not aware of these groups currently – could more
information be provided please?
Would this document not be a good opportunity to promote these groups and the other
involvement methods listed.
How does this document, certainly the Priorities for Improvement section, tie in with other plans
and projects, such as No Delays?
Would ‘No Delay’ have to be reviewed with these priorities in mind?
Perhaps a paragraph outlining how this document fits into the bigger picture, such as the Mental
Health Directorate Business Plan, No Delays (in South Staffordshire), etc? Perhaps it does but
this is not clear.
To be kept informed more regularly would be helpful.
It may be that the length and complexity of the information provided could account for the lack of
responses and the LINk would ask that the Trust consider a more user friendly way of presenting the
information next year and, perhaps through a presentation of the report to a meeting of LINk
participants which would be more effective and engaging.
Staffordshire LINk appreciated being sent the draft proposals for comment and feedback, and
acknowledges that this is the first year of a new process for the Quality Accounts and will seek to
develop a more robust process for involving the LINk in the production of future Quality Accounts with
the Trust.
Sue Baknak
LINk Co-ordinator, Staffordshire LINk
As CinCH the Shropshire Link we thank you for the level of our involvement in your Quality Accounts
Process, We are aware that this process has had a very short time scale, and would hope to have a
greater time period in future years.
From Our perspective we are pleased to note and agree the comprehensive range of detail included
within the accounts, and would single out some areas for comment. We are reassured with references
to single sex accommodation, and note the wide range of CQUIN's identified.
CQUIN's and Quality Priorities we can confirm have been discussed openly with the Link, under the
umbrella of regulation 8 NHS (QA) regulations 2010, in that Community Involvement in Care and
Health is considered an appropriate Link,
From discussions at with senior PCT personal we wish to confirm we are pleased with the level of public involvement shown. CinCH concur with those elements of the Quality Accounts where CinCH has
been involved.
Hannah Thompson BA(Hon,s) MA
Chair & CEO CinCH, The Shropshire Link
2009-10 Quality Accounts
Page 37
Contact Details
For more information about anything contained in this report please
contact;
Liz Lockett
Associate Director of Quality & Risk
South Staffordshire & Shropshire Healthcare NHS Foundation Trust
Trust Headquarters
St George's Hospital
Corporation Street
Stafford
Staffordshire
ST16 3AG
Tel: 01785 257888 ext. 5575
Mob: 07805017312
Email: liz.lockett@sssft.nhs.uk
Page 38
2009-10 Quality Accounts
A large print version of this document
is available on request. If you would
like a copy of this document in another
language or format, please let us
know.
South Staffordshire and Shropshire Healthcare
NHS Foundation Trust
St George’s Hospital
Corporation Street
Stafford
ST16 3SR
tel 01785 257888
email enquiries@sssft.nhs.uk
www.southstaffsandshropshealthcareft.nhs.uk