QUALITY ACCOUNT – 2009/10
SOUTH WEST LONDON & ST
GEORGE’S MENTAL HEALTH NHS
TRUST
Chair:
John Rafferty
Chief Executive: Judy Wilson
Contents:
Executive Summary
3
Part 1 Statement from Chief Executive
4
Part 2 Priorities for Improvement
5
2.1 Review of services
5
2.2 Participation in Clinical Audits
5
2.3 Research and Development
7
2.4 Goals agreed with commissioners
7
2.5 What others say about the Trust
7
2.6 Data Quality
8
2.6 (i) Information Governance Toolkit attainment levels
2.7 Priorities for 2010-11
10
2.7 (i) Priority One: Safety
Hospital acquired infections
10
2.7 (ii) Priority Two: Safety
Community follow-up following discharge
11
2.7 (iii) Priority Three: Clinical Effectiveness
Care reviews within 12 months
12
2.7 (iv) Priority Four: Clinical Effectiveness
Improving the use of the Health of the Nation Outcome Score
13
2.7 (v) Priority Five: Patient Experience
Reducing reliance on bank and agency staff
14
2.7 (vi) Priority Six: Patient Experience
Reducing the number of transfers during admission
15
Part 3 Review of Quality Performance
16
3.1 Quality Management Systems
16
3.2 An explanation of which stakeholders have been involved
17
3.3 Statement from lead commissioning PCT
17
3.4 Statement from LINks
17
3.5 Statement from OSCs
18
3.6 An explanation of any changes made to Quality Accounts report
18
3.7 Feedback
18
Chair: John Rafferty
2
Chief Executive: Judy Wilson
Executive Summary
High-quality care for all (The ‘Darzi Review’) introduces Quality Accounts as a mechanism for
public reporting on quality. These reports will be available to the public from April 2010 and
provide information across all service provision; looking at safety, experience and outcomes.
The Trust has identified key areas for improvement and has in place plans to monitor and
report on progress. The suggested priorities for the 2010/11 Quality Accounts Report focus
attention and resources on achieving a maximum of quality improvement within a one year
period. All of these priorities are intended to improve clinical effectiveness, patient experience
and patient safety.
The Trust Executive Committee has consulted upon a long list of proposed measures to include
in this Quality Account. Several additional measures were suggested to the original list during
the consultation, of which two have been included in the final list of agreed priorities that will be
reported through the Quality Account:
Safety
 Hospital acquired infections
 Community follow-up within 7 days following discharge from inpatients
Clinical Effectiveness
 Care Programme Approach (CPA) review within 12 months
 Improving use of the Health of the Nation Outcome Scale (HoNOS)
Patient Experience
 Reducing reliance on bank and agency staff
 Reducing the number of transfers between wards during an admission
For each priority, indicators have been suggested which will simplify the assessment of whether
sufficient improvements have been achieved or not.
In future years our Quality Account will enable us to reflect on the quality of service provision for
the identified areas of priority for the previous year.
The rationale and details for each priority were developed in co-ordination with senior clinical
and management staff across each of the service delivery areas. The proposed priority areas
were also reviewed by the Service User and Carer reference groups, LINks and OSCs. These
discussions form part of an ongoing dialogue about the quality of our services and are intended
to make the Quality Accounts process as practicable as possible, whilst allowing for the
realities of good practice.
Chair: John Rafferty
3
Chief Executive: Judy Wilson
Part 1: Statement from Chief Executive
On behalf of our Trust Board, I would like to commend to you, our first Quality Account. We are
confident that these represent an open and honest account of the quality of the services for
which the Board is accountable.
The Board is committed to ensuring the Trust delivers the highest standard of services, which
support people with mental health problems to do the things they want to do, live the lives they
want to live and access those opportunities that all citizens should take for granted. The
information in these Quality Accounts will demonstrate how we are working to deliver this aim.
To ensure transparency and the involvement of our partners South West London & St George’s
Mental Health NHS Trust asked key stakeholders to be involved in the development of the quality
account. The Trust has consulted on its priorities for 2010-11 with its PCTs, Overview and
Scrutiny Committees, LINks, and NHS London. The Trust has also liaised with Heads of
Profession, Consultants, Senior Nurses, Senior Managers and Staff Side Representatives to
ensure the content of this Quality Account reflects their views and comments.
The Quality Account will enable readers to find easily accessible information regarding what the
trust has done well, how we plan to improve and what our priorities are for the coming year.
The NHS Next Stage Review; High Quality of Care for All (2008) states that if quality is to be at
the heart of everything we do, it must be understood from the perspective of service users. The
review identified that for the NHS, quality should include the following aspects
 Patient Safety – Ensuring the environment is safe and clean and reducing avoidable
harm such as rates of healthcare associated infection
 Clinical Effectiveness – Understanding success rates from different treatments for
different conditions. This may also extend to people’s well-being and ability to live
independent lives
 Patient Experience – How personal the care is; the compassion, dignity and respect with
which service users are treated
The Trust Executive Committee consulted upon a long list of proposed measures to include in
this Quality Account. Six measures have been agreed and included in this Quality Account.
This work will all be carried forward in the context of a wide ranging programme of
transformational change we are undertaking to embed the culture of coaching and enabling
required to support service users in their recovery. This work will help us provide the best
possible services and also save costs.
The Trust Board signed off this Quality Account following the submission of commentaries from
our Commissioners, Overview and Scrutiny Committees and LINks. I hope that you find the
report both interesting and informative.
I would like to thank all those involved in helping us move towards our vision of ‘a future in which
people with mental health problems have the same opportunity as other citizens to participate in
and contribute to our communities. It is through this vital partnership working and engagement
with many stakeholders, particularly staff, commissioners, service users and their friends, family
and carers, that we are able to continue developing and improving services for the future.
Chair: John Rafferty
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Chief Executive: Judy Wilson
Part 2: Priorities for Improvement
2.1 Review of services:
During 2009-10 South West London & St George’s Mental Health Trust provided NHS inpatient
and community mental health services in under four strategic management teams; Kingston and
Richmond, Sutton and Merton; Wandsworth and Specialist Services. Our services areas in
2009-10 included:





Adults of working age mental health
Older people’s mental health
Child and adolescent mental health
Learning disability services for people with mental health needs
Specialist drug and alcohol services
The Trust has provided some specialist national services in 2009-10 including forensics services
and eating disorder and deaf services for children, adolescents and adults.
The Trust has reviewed all the data available on the quality of care in all of these NHS services.
The income generated by the NHS services reviewed in 2009-10 represents 100% of the total
income generated from the provision of NHS services by the Trust for this period
2.2 Participation in clinical audits
During 2009/10, nine national clinical audits and one national confidential inquiry covered NHS
services that South West London & St George’s Mental Health NHS Trust provides.
During that period South West London & St George’s Mental Health NHS Trust participated in
67% national clinical audits and 100% national confidential inquiries of the national clinical audits
and national confidential inquiries which it was eligible to participate in.
The table below outlines the national clinical audits and national confidential enquiries that South
West London & St George’s Mental Health NHS Trust participated in or reviewed during 2009/10:
Audits and National
Confidential Enquiries
Prescribing Observatory for
Mental Health (POMH-UK) Topic
2d Screening for metabolic
syndrome in community patients
on antipsychotics
POMH-UK Topic 6 Assessment
of side effects of depot
antipsychotics
POMH-UK Topic 8a Medicines
Reconciliation
POMH-UK Topic 9 Use of
antipsychotics in people with
learning disability
National Audit of the Organisation
of Services for Falls and Bone
Health of Older People
Chair: John Rafferty
Co-coordinating
Body
Number of
Cases
Submitted
143
Number of
Registered
Cases Required
No set number
required
Royal College of
Psychiatrists
338
No set number
required
Royal College of
Psychiatrists
Royal College of
Psychiatrists
67
No set number
required
No set number
required
Royal College of
Physicians
Organisational
data only – No
individual cases
Royal College of
Psychiatrists
5
44
N/A
Chief Executive: Judy Wilson
Audits and National
Confidential Enquiries
National Confidential Inquiry into
Suicide and Homicide by People
with Mental Illness
Co-coordinating
Body
University of
Manchester –
The Centre for
Suicide
Prevention
Number of Cases Submitted
Response data not available for 200910. Last available response rate
99.39% (national rate 98.19%)
Other national clinical audits and national confidential inquiries that South West London & St
George’s Mental Health NHS Trust was eligible to participate in during 2009-10 are as follows:



Royal College of Psychiatrists POMH-UK Topic 1e High Dose and Combined
antipsychotics on acute wards
Royal College of Psychiatrists POMH-UK Topic 5c Benchmarking of high dose and
combined antipsychotics on acute wards
Royal College of Physicians Continence Care Audit
The reports of five national clinical audits were reviewed by the provider in 2009/10 and below
are some of the actions the Trust has taken or intends to take to improve the quality of
healthcare provided.
POMH-UK audit reports have been circulated to all teams to enable improvement before re-audit
after 18 months. Additionally, they have been presented to the Drug’s and Therapeutics
Committee and post-graduate meetings. Key actions include piloting a draft medicines
reconciliation policy and purchasing and making available the POMH-UK change intervention
folders to all community teams and wards. The POMH-UK change intervention folders contain
information to enable clinicians to discuss side effects more effectively with service users and
carers and also include service user and carer information.
The National Audit of the Organisation of Services for Falls and Bone Health of Older People
report was discussed at the Trusts Clinical Reference Group. The Trust has appointed a Falls
Clinical Champion and established a Falls Group. One of the functions of this group is to review
and follow-up slips, trips and falls incidents. The Trust Slips, Trips and Falls Policy has been
revised to include an improved falls assessment tool and provide clarity on risk assessment.
South West London & St George’s Mental Health NHS Trust has recently registered to take part
in the next stage of the National Audit for Falls and Bone Health and the National Audit of
Psychological Therapies for Anxiety and Depression. Participation in the POMH-UK audit
programme will continue in 2010-11.
The reports of a number of local clinical audits were reviewed by the provider in 2009/10. Below
are examples of some of the actions South West London & St George’s Mental Health NHS
Trust has taken or intends to take to improve the quality of healthcare provided.
South West London & St George’s Mental Health NHS Trust undertook a comprehensive
programme of infection control audits. Corrective action was taken to address areas of non
compliance and action plans were monitored by Senior Nurses. Wards scoring less than 80%
were re-audited after six months. Audits of mattresses and sinks were also undertaken and
concerns were escalated onto the Trust risk register. Executive Directors accompanied the
Director of Facilities on an inpatient visits programme, measuring environment and privacy and
dignity standards. Actions to address concerns were undertaken by Estates and Facilities and
the local wards.
The programme was commended by the Department of Health as
demonstrating “a strong Board to ward connection”. The Trust undertook a safeguarding
children audit in 2009-10. Actions included reinforcing the use of the Laming Form and
developing guidance about where to record information about dependents on ‘RiO’.
Chair: John Rafferty
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Chief Executive: Judy Wilson
2.3 Research & Innovation
The number of patients receiving NHS services provided or subcontracted by South West
London & St George’s Mental Health NHS Trust in 2009-10 that were recruited during that
period to participate in research included on the NIHR Portfolio, was 37. The Trust has
successfully bid for extra research funding to improve recruitment in 2010-11 and give more
service users the opportunity to contribute to research.
The Trust continues to support academic posts in the Division of Mental Health at St George’s,
University of London. Recent projects with the University have included an evaluation of different
models of self-care, assessment of the quality of care in residential mental health units in Europe
with particular reference to human rights and the recovery approach, and a review of the needs
of young carers. Projects in development include an evaluation of the role of service users as
researchers, the implementation of a new model of peer support workers where service users
work as part of the clinical team, the effectiveness of peer interventions to reduce teenage
pregnancy, and the meaning of the recovery approach in specialist forensic settings.
In the financial year ending 2008, 96 peer reviewed scientific papers were published as a
result of our involvement in research together with several books and book chapters. In the
financial year ending 2009, 50 peer reviewed scientific papers were published as a result of
our involvement in research, together with several books and book chapters. These
publications are helping to improve patient outcomes and experience across the NHS.
2.4 Goals agreed with commissioners
A proportion of the South West London & St George’s Mental Health NHS Trust income in 200910 was conditional on achieving quality improvement and innovation goals agreed between the
Trust and the four local PCTs for the provision of NHS services, through the Commissioning
for Quality and Innovation payment framework.
Three measures for 2010-11 have been agreed regionally (across London) and four locally. The
measures are:
Regional Goals
1. Improving physical health care for mental health service users
2. Establishing baseline information and the prescription of antipsychotic drugs for people
with dementia
3. Collection and reporting of HoNOS-PbR (Health of the Nation Outcome Scale – Payment
by Results)
Local Goals
4. Improving patient satisfaction on inpatient wards
5. Smoking cessation
6. Improve data quality in National Drug Treatment Monitoring Service (NDTMS) fields
7. Collection and reflective reporting of HoNOS (Health of the Nation Outcome Scale) data
Further details of the agreed goals for 2010-11 and for the following 12 month period are
available on request from glynn.dodd@swlstg-tr.nhs.uk
2.5 What others say about the Trust
South West London & St George’s Mental Health NHS Trust is required to register with the
Care Quality Commission. The Trust has been registered with the Care Quality Commission
(CQC) without conditions on registration. South West London & St George’s Mental Health
NHS Trust has been registered to carry out the following regulated activities:
Chair: John Rafferty
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Chief Executive: Judy Wilson

Treatment of disease disorder or injury

Assessment and medical treatment of persons detained under the Mental Health Act

Diagnostic and screening procedures
South West London & St George’s Mental Health NHS Trust submitted a declaration of full
compliance against the core standards for the reporting period 1 st April 2009-31st October
2009. In March 2010 the Trust submitted a core standards update declaring non compliance
with C13b Consent to Care and Treatment. The Trust developed an action plan to strengthen
compliance which was accepted by the CQC. The Trust continues to closely monitor its
compliance with consent to treatment and other areas of the Mental Health Act.
South West London & St George’s Mental Health NHS Trust has recently submitted a
completed return against the mental health national priorities for 2009-10 which demonstrated
improvements in performance since 2008-9. The Trust is awaiting confirmation of ratification
from the CQC.
The Care Quality Commission has taken enforcement action against South West London & St
George’s Mental Health NHS Trust during 2009/10. In April 2009 the Trust was registered
against the Health and Social Care Act 2008 for the Prevention and Control of Healthcare
Associated Infections with an imposed condition to implement an action plan following an
unannounced inspection by the Healthcare Commission. This condition was removed following a
CQC visit in September 2009. The CQC concluded that “when we followed up, we found no
evidence that the Trust has breached the regulation to protect patients, workers and others from
the risks of acquiring a healthcare-associated infection”. Following a CQC recommendation, the
Trust has strengthened the implementation of a programme of audit that stipulates which policies
are to be audited and includes regular hand-washing audits.
South West London and St George’s Mental Health Trust has participated in a follow up review
by the CQC in 2009-10 to assess progress against recommendations of an intervention report
published by the Healthcare Commission in January 2009. The CQC concluded that “The
Commission are satisfied with the action taken by the Trust and the case will be closed”.
Following CQC recommendations, the Trust has continued to make progress with care planning,
the use of ‘RiO’ and engagement with service users on the wards.
The Trust has not participated in any special reviews by the CQC during the reporting period.
2.6 Data quality
The Trust has moved from using multiple systems to provide clinical and activity information to
just one; RIO. This unification of information means that the Trust can be sure that everything
included in the clinical record can be reported if necessary and direct comparisons can be made
between services and functions. The information that is reported to the Board and externally
comes directly from this one source and so provides accurate analysis from data contained
within the notes.
Key performance indicators are reported to the Board quarterly, but there is also a monthly
meeting between the Executive and each directorate to review performance at a local level
against a performance scorecard. The Directorates have local performance meetings where the
activity of each local team can be reviewed and assessed. The Trust has developed a data
warehouse containing information from RIO, which is updated almost daily, that can be
interrogated by key staff to quickly understand issues as they emerge from the clinical services.
These structures allow a dialogue between the Trust Board and front line services, using the
same data as the basis for enquiry.
The Trust has developed a strong team of analysts, who are able to programme changes in
order to meet any new information needs. This strong information base has allowed the Trust to
improve on existing national targets and develop practice as new priorities emerge.
Chair: John Rafferty
8
Chief Executive: Judy Wilson
The systems therefore can robustly report upon the information contained within RIO. It is
therefore important to ensure that necessary details are entered into the system at the right time.
The Trust has had data quality improvement exercises in December 2008 and again February
2010, to ensure that the recording of key information is complete and accurate. These have
significantly improved the Trust’s data quality as reported by the NHS Information Centre, but
there is ongoing work needed to improve the recording of the Health of the Nation Outcome
Scale (HoNOS).
South West London & St George’s Mental Health NHS Trust submitted records during 200910 to the Secondary Uses service for inclusion in the Hospital Episode Statistics which are
included in the latest published data. The percentage of records in the published data:

which included the patient’s valid NHS number was: 97.4% for admitted patient care

which included the patient’s valid General Medical Practice Code was: 99.9% for admitted
patient care
2.6 (i) Information Governance Toolkit attainment levels
South West London & St George’s Mental Health NHS Trust score for 2009-10 for
Information Quality and Records Management assessed using the Information Governance
Toolkit was 84%.
South West London & St George’s Mental Health NHS Trust was not subject to the Payment by
Results clinical coding audit during 2009-10 by the Audit Commission.
Chair: John Rafferty
9
Chief Executive: Judy Wilson
2.7 Priorities 2010/11
2.7 (i) Priority 1 - Safety
Hospital acquired infections
Description
Number of hospital acquired infections, including the number of deaths that
result from these infections.
Target: No cases of MRSA Bacteremia or Clostridium Difficile
Rationale for
this priority
Richmond LINk has requested that this priority be included to ensure that
basic standards of cleanliness and safety are maintained in the inpatient
settings.
This measure will help ensure that people who require hospital admission will
be treated in environments that are safe and by staff who are able to maintain
good standards of hygiene.
How will the
To meet the requirements of this standard the Trust will ensure that the
improvement be following are in place:
achieved
 Specifically trained infection control staff
 Robust infection reporting mechanisms
 General training to inpatient staff
 Cleaning standards for the wards
 A programme to monitor and clean the water systems
Suggested
process
measures
Any cases of the following infectious diseases in the inpatient units will be
reported to the board monthly:
 C Difficille
 MRSA
 Tuberculosis
 Legionnella
This will include information of where the source of infection arose.
Reporting
Chair: John Rafferty
The figures for 2010-11 for the Trust will be reported as part of the Quality
Account in 2011. They will also be made available through Board papers.
10
Chief Executive: Judy Wilson
2.7 (ii) Priority 2 - Safety
Community follow-up following discharge from inpatients
Description
Evidence suggests that people are most vulnerable to suicide during the
period immediately following discharge from an inpatient unit.
Making sure that people are seen during the first seven days will reduce the
risk of suicide and ensure there is continuity of care into the community.
Target: 100% of discharged patients are followed up within seven days
Rationale for
this priority
This will aim to ensure that everyone who is discharged from an acute ward
has a follow-up in the community within seven days of discharge.
Richmond LINk has requested that a measure be included to ensure that
there is proper care following discharge.
This is a national indicator on which the Trust currently performs poorly and
is determined to improve.
How will the
improvement be
achieved
Systems will be set up to ensure that community support arrangements are
identified prior to discharge from the ward. The responsible community staff
will be informed when discharge is expected and of the requirement to
contact the service user.
Email reminders will be sent to ensure that community staff know of the
requirement to contact the client within the expected timescale.
Suggested
process
measures
A further refinement of this measure is to ensure that those at highest risk of
suicide are seen more rapidly. A robust system to ensure that this most
vulnerable group are seen more assertively will be set up
Reporting
Performance against this requirement will be reported quarterly to the Trust
Board and monitored at monthly performance meetings
Chair: John Rafferty
11
Chief Executive: Judy Wilson
2.7 (iii) Priority 3 – Clinical Effectiveness
Care reviews within 12 months
Description
People experiencing the most complex mental health problems are catered
for under the Care Programme Approach (CPA). This system ensures that
each service user has an identified care coordinator and that their care is
thoroughly reviewed, at least annually, with the wider clinical team. From
this review, a care plan is agreed with the service user which outlines the
expected steps to support their recovery.
Target: 100% of patients will have their care reviewed at least annually.
Rationale for
this priority
Ensuring that every person on the care programme approach has had a
review, at least each year is good practice and ensures that there is an
agreed basis for care. It can involve GPs, family or carers as well as the
service user and professionals involved in providing care.
It therefore ensures involvement from all parties in the care planning
process, monitors progress and maintains the effectiveness of the
interventions.
The review also provides the opportunity to ensure that required information
is accurate and a check-point to record outcome measures.
How will the
improvement be
achieved
A new system has been set up so that care coordinators can review their full
caseload and see if any reviews are due. This will be enhanced with
automatic email reminders being sent before the review date to provide
warning that a CPA review is expected.
Suggested
process
measures
Set up of email alert system and monthly reporting on Directorate, team and
individual basis.
Reporting
Performance against this requirement will be reported quarterly to the Trust
Board and monitored at monthly performance meetings
Chair: John Rafferty
12
Chief Executive: Judy Wilson
2.7 (iv) Priority 4 – Clinical Effectiveness
Improving the use of the Health of the Nation Outcome Scale (HoNOS)
Description
The outcomes of clinical interventions in mental health are often more
difficult to measure than those for physical health conditions. The Health of
the Nation Outcome Scale (HoNOS) is a simple rating scale that can be
used to assess several aspects of a person’s well being at different stages
of their pathway through care.
Target: 80% of patients have HoNOS completed at assessment
Rationale for
this priority
The use of HoNOS is a national priority as it provides a clear view of the
outcomes of an intervention. This will help to ensure that the most effective
services are provided for each client and demonstrate any changes that
result from care.
HoNOS can also be used to identify an individual’s range of needs at
assessment and is likely to become the basis upon which service provision
is planned, commissioned and provided in the future.
The Trust wants to improve on the current recording of this information in
order to develop and modernise mental health services. Richmond LINk has
requested that the outcomes of care be reported through the Quality
Account and improving recording of this measure will enable will help deliver
this goal.
How will the
improvement be
achieved
Staff will be trained during the first six months of the year in the use of the
new HoNOS measure, designed to provide information for payment by
results. In the second half of the year, the Trust will implement the new tool
in adult and older people’s services.
Meanwhile, the more basic HoNOS tool will continue to be recorded.
Improving the number of reviews carried out (see priority 3) will support this
as HoNOS can be recorded at this time.
Suggested
process
measures
Reporting
Chair: John Rafferty



Number of staff trained in the new HoNOS measure
Recording of HoNOS at assessment
Recording of matched pairs of HoNOS assessment – before and
after interventions
Performance against this requirement will be reported quarterly to the Trust
Board and monitored at monthly performance meetings
13
Chief Executive: Judy Wilson
2.7 (v) Priority 5 – Patient Experience
Reducing reliance on bank and agency staff
Description
Feedback from service users suggests that the use of bank and agency staff
is detrimental to the quality of their experience. They report that these staff
do not share the levels of responsibility of the permanent staff and do not
understand the systems sufficiently.
Target: To be agreed once ‘NHS Professionals’ is in place.
Rationale for
this priority
The Trust believes that better quality care is provided by permanent staff.
They provide continuity, stability and an appropriate range of expertise.
There will always be a need for some temporary staff, to cover unexpected
absence or short term skills gaps, but this should be kept to a minimum.
Bank and agency staff often cost more; require greater management support
and it is more difficult to assure the level of training or ability. They therefore
constitute an inefficient use of resources.
How will the
improvement be
achieved
The Trust has identified three improvement areas:
 The use of electronic nurse rostering, to help ward managers to plan
and monitor the shift usage of the permanent staff
 A move to “NHS Professionals” to manage the Trust bank and
ensure the quality of the staff that are used
 Putting in place mechanisms for inpatient services to ensure that
basic staffing levels are appropriate
Suggested
process
measures
The fill-rate of shifts by NHS professionals and the use of agency staff in
each directorate
Reporting
Performance against this requirement will be reported quarterly to the Trust
Board and monitored at monthly performance meetings
Chair: John Rafferty
14
Chief Executive: Judy Wilson
2.7 (vi) Priority 6 – Patient Experience
Reducing the number of transfers during admission
Description
Service users are sometimes transferred between wards during their
admission, due to clinical need, bed pressures or to transfer them to their
“home” ward, where they are normally admitted.
Service users report that process of transferring between wards during an
admission is unsettling, unpleasant and detrimental to their experience.
Target: 0% of patients are transferred between wards within the first seven
days of admission when there is no clinical need.
Rationale for
this priority
The Trust takes these concerns very seriously and believes that transfers
should only take place when there is absolute clinical need. Minimising
transfers will improve the inpatient experience and promote patient dignity.
How will the
improvement be
achieved
There are two planned changes that will help to reduce the number of
transfers, especially those taking place within the first week of admission:
 Move to inpatient wards not being solely based on geography. At the
moment, people are admitted to general wards, often with men and
women in the same unit - based on the borough in which they live.
The Trust will move to providing wards based more on gender and
clinical need.
 Move to specialised inpatient clinical teams. At the moment the
community Consultant retains responsibility for the service user
during inpatient admission, which means that people are often
transferred to return to the ward of their consultant. The Trust will
move to having a consultant team responsible for each ward, so that
anyone admitted to a unit has no need to be transferred (unless
there is a particular clinical need that cannot be met in that
environment)
Suggested
process
measures
Number of wards with single clinical teams
Reporting
A measure will be developed to report the number of transfers between
wards, and when during an admission they occur.
Chair: John Rafferty
15
Chief Executive: Judy Wilson
Part 3: Review of Quality Performance
3.1 Quality Management Systems
The Trust has a robust structure in place to govern quality of service provision. The Integrated
Governance Committee (IGC) reports directly to the Trust Board and is chaired by a NonExecutive Director. The IGC ensures that there are effective structures and systems in place
that support the continuous improvement of services and safeguard high standards of patient
care. The committee is responsible for monitoring and reviewing the Assurance Framework and
Corporate Risk Register. It is also responsible for reviewing all compliance, accreditation and
assessment submissions and action plans prior to endorsement by the Trust Board.
Membership includes Non-Executive Directors, Medical Director (Board Clinical Governance
Lead), Chief Executive and Finance Director.
The Trusts Clinical Governance Sub-Committees report to the IGC. These sub-committees
include Safeguarding Children and Adults, Infection Control, Information Governance, Health and
Safety, Hospital Managers and the Clinical Reference Group (CRG). The CRG is chaired by the
Medical Director and is responsible for providing advice on the receipt and implementation of
clinical standards, policy and practice matters. Functions include facilitating the receipt,
implementation and review of clinical guidelines (including NICE) and agreeing and overseeing
the Trusts Corporate Clinical Audit Programme.
The Trust is subject to a number of external visits, inspections and accreditations and uses tools
such as clinical audit and internal audit to govern the quality of service provision. The Trust is
implementing the Performance Accelerator, an internet based software programme that will
provide the Trust with a clear, real time view of progress against action plans following serious
untoward incidents, recommendations following service reviews and compliance against Care
Quality Commission Essential Standards for Quality and Safety and National Priorities. The
Trust uses a number of sources of assurance on the quality of service provision.

Care Quality Commission (CQC): In April 2010 the Trust was registered with the CQC
without conditions. The Trust considers the Trust Quality and Risk Profile published by
the CQC as an important source of assurance. The CQC conduct regular visits to assess
compliance against the Mental Health Act. Wards act on local action plans and the Trust
Board is responsible for monitoring actions against the CQC Mental Health Act Annual
Report.

Service User and Carer Feedback: The Trust Board monitors action plans following the
publication of the national patient survey results. The Trusts Improving User Experience
and Promoting Recovery Programme involves local surveys of community and inpatient
service users. The results are reported to the Trust Board annually and inform ward/team
improvement plans locally. The Trust has two Communication and Feedback Groups, one
for service users and one for carers. The Trust has established a robust process for
action learning following ‘amber’ incidents and the imminent development of a Customer
Service Steering Group will strengthen systems for learning from complaints.

Staff Feedback: The Trust Board monitors action plans following the publication of the
national staff survey results. This year the Trust opted to survey every member of staff.

Internal Audit: The Internal Audit Programme for 2009-10 has included a review of
arrangements for clinical supervision, Clinical Governance, Health and Safety and CQC
registration. The programme for 2010-11 includes audits on consent to treatment,
mandatory training and complaints.
Chair: John Rafferty
16
Chief Executive: Judy Wilson

Clinical Audit: The Trust has an approved Corporate Audit Programme overseen by the
Clinical Reference Group. The programme for 2009-10 included audits on infection
control, safeguarding children and clinical supervision. The programme for 2010-11 will
incorporate quality account priorities.
Other sources of assurance considered by the Trust include:
 Serious Untoward Incident Investigation Reports
 Key Performance Indicator Quarterly Reports
 ECT Accreditation
 Workforce Reports including training attendance, disciplinary cases and whistle blowing
 Patient Environmental Action Team (PEAT) Reports
3.2 An explanation of which stakeholders have been involved
To ensure transparency and partnership involvement South West London & St George’s Mental
Health NHS Trust asked key stakeholders to be involved in the development of the quality
account. The Trust has liaised with its PCTs, Overview and Scrutiny Committees, LINks, and
NHS London. The Trust has also liaised with its Heads of Profession, Consultants, Senior
Nurses, Senior Managers and Staff Side Representatives to ensure the content of this Quality
Account reflects their views and comments.
3.3 Statement from lead commissioning PCT
South West London Commissioners
SWL Commissioners welcome the report overall and most of the priority areas it covers. There
are just a few brief points to consider:
Point 2.3 – It would be helpful of results of the research work could be shared with PCTs and
Public Health colleagues.
An audit of children’s safeguarding has been done, although there is concern from Kingston in
respect of two audits regarding adult safeguarding. Both identified areas of concern in relation to
procedures not being followed and poor recording.
7 day follow up should also apply to people discharged from detox.
Improvements in services to people with a dual diagnosis are lacking.
Patient experience – regular issues that come to attention are concerns about the quality of food,
availability of activities on wards and dedicated time with the primary nurse. These need to be
addressed.
We hope this feedback will help the Trust maintain its focus on improving quality and the patient
experience.
3.4 Statement from LINks
Richmond LINk commented on the Trust’s proposed priorities during consultation and the
feedback was considered when the Trust agreed the final list of priorities for 2010-11.
Chair: John Rafferty
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Chief Executive: Judy Wilson
3.5 Statement from OSCs
Wandsworth Adult Care and Health Overview and Scrutiny Committee
The Overview and Scrutiny Committee recognises the centrality of quality to the role of the NHS
Trust Boards, and is fully supportive of openness with the public over the quality of service
offered by healthcare providers. However it remains sceptical as to whether Quality Accounts
are the best method of achieving this. Whilst the Quality Account contains much information on
the processes used to manage quality, it does not provide meaningful information on the aspects
of service quality that are of most interest to patients, namely the experience of services and
patient outcomes.
The Committee recognises the commitment of the Trust Board to service quality. The
standardised format describing the way in which priorities for improvement were selected and the
way in which improvements will be measured is a particularly helpful aspect of the Quality
Account, although it is a little disappointing that no comparative baseline information is provided.
It is something of a concern that the Trust’s response to the statement on service reviews is to
state that ‘The Trust has reviewed all the data on quality of care in all of [its] services. Frankly,
given the volume of data that should be available this is not believable. It is suggested that the
Trust should develop a systematic and timetabled approach to reviewing the quality of care in its
services.
Likewise, the statements on benefits of RiO and the provision of quarterly performance data are
not supported by hard information. It is suggested that, as part of its assurance process, the
Trust should monitor both the effectiveness of the way in which RiO is used and the timeliness
and accuracy of the quarterly performance data.
3.6 An explanation of any changes made to Quality Accounts
report
This is the first Quality Account published by South West London & St George’s Mental Health
Trust
3.7 Feedback
Feedback was received from South West London Commissioners, Richmond LINk, Wandsworth
OSC, five consultant psychiatrists, a nurse consultant and an associate director of nursing.
Feedback was also received from Simon Dannreuther, Board Advisor whose comments are
included below:
“The more I look at the quality account indicators, the more I like them. They do seem much
more relevant than some of the information and statistics the Trust provides. From your paper, I
assume that all the proposed indicators are measurable and you are confident improvements can
be achieved in the timescale. This is an achievement in itself. To take the broad areas one by
one:
Safety
Hospital acquired infections seems a bizarre one to take. I do not think patients have the same
concerns about MRSA, e coli, clostridium difficile etc...as they do in acute hospitals. Also (I may
be wrong!) I do not think the Trust has a bad record here and Kim always seems to have it under
control. Presumably there are all kinds of statutory and legislative controls anyway. What
improvements would the Trust be aiming for?
Chair: John Rafferty
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Chief Executive: Judy Wilson
Far more relevant, in my opinion, is how safe patients feel generally on the ward and the
atmosphere, especially as now people only go in to hospital as a last resort and are iller and
possibly more disturbed than used to be the case in the past. As you know from Rachel's and
Hilary's surveys of wards, up to 40-50% of patients can feel unsafe in our hospitals, which seems
an appalling statistic. Could you capture this indicator and have a target?
I agree with the follow up within seven days of discharge, especially now when people spend
less time in hospital.
Clinical Effectiveness
I particularly like the indicator Number of patients who have been cured, improved, are the
same, are worse, have died after treatment by the Trust. It is so nice to see the word "cured".
Clinicians and administrators seem to shy away from it. How would you capture this indicator?
Presumably the judgment would have to come from the patient him or herself and would have to
be covered at or shortly after discharge from hospital or the CMHT.
I prefer this indicator to the HoNOS one simply because it is more transparent and easy to
understand. The HoNOS measure is I am sure more scientific, but it seems rather technocratic
and gnostic. As far as I understand it, it is difficult enough just to record the HoNOS data, let
alone make meaningful use of it. Are you confident of being able to do that within a year? Or
are you just looking at more recording, which I do not think is good enough.
Is there any scope for having both indicators, the informal one and a more rigorous HoNOS
one?
I also wonder if more can be done around the first indicator Proportion of people discharged from
community services re-referred within six months and the whole subject of discharge. For me
the greatest success of the Trust would be the number of people the Trust manages to treat and
then gets out of the system, so that they can lead independent lives. I suppose this is what this
indicator is getting at. But could we have the average length of stay in the CMHT, the number
trapped within the system etc...?
I agree with the CPA indicator, but again I wonder if it could be more qualitative. Could we have
a judgment on whether the CP was implemented or if it was successful, before it is reviewed?
Was it actively reviewed and monitored in the meantime? Should there be interim targets and
milestones?
Patient Experience
Again there are many useful aspirations here and it seems a pity just to take two priorities. The
key will be the target, if they are to be at all meaningful. The Numbers of people with a copy of
their care plan seems very unambitious in the light of my previous comments. I like the one
about keeping patients and carers fully informed.
Chair: John Rafferty
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Chief Executive: Judy Wilson