Quality Accounts 2009-2010
The forward thinking provider
of high quality healthcare
A charity leading innovation in mental health
A charity leading innovation in mental health
Contents
Safety, effectiveness and recovery 02
Safety at St Andrew’s 04
Clinical effectiveness 04
Healthy Lifestyles 04
Recovery 06
Appendix A 08
Appendix B 10
Glossary 21
Appendix C 22
Appendix D 23
Safety, effectiveness
and recovery
St Andrew’s was founded as a charity dedicated
to an enlightened ideal of mental healthcare.
It has a long tradition of professional, innovative
care in the finest environments. For some years
St Andrew’s has been creatively integrating
into a robust healthcare governance structure
all clinical audit, quality assurance and outcome
data, using clinical Key Performance Indicators
for our range of specialist services, as part of
the Charity’s Balanced Scorecard. Last year
St Andrew’s became the first major UK mental
health provider to publish comprehensive
outcome data on all its services.
Since the Darzi report, NHS Commissioners have been pushing
on with a renewed focus on quality, in conjunction with the
Care Quality Commission. It is a great idea for the various
reporting frameworks and approaches to quality within mental
health to be wrapped up in one overarching view. At service
level the Charity is already accredited by many quality networks,
such as those run by the Royal College of Psychiatrists’ Centre
for Quality Improvement. These bring together a wide variety of
service-specific standards, and this is what Quality Accounts
promise to do, but at an organisational level.
As the boundaries of what is possible in safe and effective
mental healthcare are pushed back, more and more people
are cared for in recovery-orientated services. Evidence-based
treatment programmes are the core and shape of St Andrew’s
services. As the Charity becomes a national centre of
excellence, including research in partnership with King’s College
London, we are constantly discovering new ways to enable
safe and speedy recovery. We track and learn from all safety
and health events, and measure service users’ progress
from first contact, creating a virtuous circle of good practice.
Empowering service users is our prime goal, as we champion
healthy lifestyles and sustainable recovery. Ensuring we do
this is what quality is all about.
We share below a summary of some of our team’s work on
safety and quality at St Andrew’s.
Prof. Philip Sugarman, CEO & Medical Director
Caroline Rose, Director of Nursing
02 Safety, effectiveness and recovery Quality Accounts 2009-2010
A charity
dedicated to
an enlightened
ideal of mental
healthcare
Continually
raising standards
Safety, effectiveness
and recovery
Both our service users and our staff have the
right to safety as a priority. St Andrew’s new
Untoward Incident review system has been
highly effective in identifying and implementing
advanced learning points across different
services. The Charity has achieved a near 50%
reduction in incidents, by focusing particularly
on service user risk and environmental risk
assessments, and on staff training. Dramatic
reductions in self-harm have been achieved in
highly vulnerable groups, as well as reductions
in other challenging behaviours.
The British Safety Council awarded St Andrew’s its 5-Star
Safety Award for 2009. This is a unique achievement within
mental healthcare. The Charity has a network of 150 local Health
& Safety representatives, and has implemented in tandem with
service user safety a well co-ordinated strategy reducing the
number of injuries at work.
Clinical Effectiveness
Effectiveness in mental health treatment has consistently
proved difficult to establish. St Andrew’s has worked with the
Royal College of Psychiatrists to adapt the Health of the Nation
Outcome Scales specifically for service users in secure settings.
HoNOS-secure covers the range of clinical risks and is used
by St Andrew’s as an outcome measure within a “Balanced
Scorecard” generating 90-day improvement rates. St Andrew’s
was the first mental health provider in the UK to publish
comprehensive outcome data, appearing in 2009 in the Royal
College of Psychiatrist’s Psychiatric Bulletin, with strengthening
evidence of effectiveness over time. The Charity has also been
developing a number of other outcome tools, targeted at
specialist areas of challenging behaviour and service user
groups such as brain injury and dementia.
Healthy lifestyles
St Andrew’s has developed specialist programmes addressing
the needs of its service users for sustainable recovery.
These include a care pathway for healthy living involving
dieticians, pharmacists, nurses, psychiatrists, psychologists
and physiotherapists. This system automatically triggers
interventions for service users with unplanned weight gain,
including healthy lifestyle groups, good nutrition and portion
control, physical activity and exercise.
Incidents reported
1600
1400
1200
1000
800
600
400
200
0
Apr
2009
May
2009
Combined incidents
Jun
2009
Jul
2009
Staff incidents
Aug
2009
Sept
2009
Patient incidents
Oct
2009
Nov
2009
Previous Year combined
04 Safety at St Andrew’s Quality Accounts 2009-2010
Dec
2009
Jan
2010
Feb
2010
Mar
2010
An exceptional
heritage of effective
healthcare
Safety, effectiveness and recovery continued
Spurred on by feedback from services users, we have pursued
a step change in sustainable food procurement. Nearly 50% of
our food is now local, organic or ethically sourced (fair-trade, free
range etc). Fresh wholesome food is prepared by on-the-ward
chefs cooking close to service users, meeting healthy eating
guidelines. We have saved thousands of food miles, leading
St Andrew’s to win two categories at the DEFRA 2009
Sustainable Communities Awards.
Recovery
Every service at St Andrew’s has a plan for effective therapeutic
practice, using a treatment manual of evidence-based therapies
to promote recovery. St Andrew’s is also working closely
with the voluntary sector Mental Health Provider Forum in
implementing new approaches to recovery. For service users a
portfolio of recovery tools is available, and these are embedded
in service users’ programmes of treatment. We are currently
trialing “Recovery Star” in secure settings, and developing a
version adapted to secure services.
Ultimately the Charity aims to break new frontiers in service
user empowerment – a real challenge in secure care. Our
service users are involved in unique innovations, from organised
voluntary work with other needy service users, to Mental Health
Act training for staff, to interviewing potential recruits to the
Charity – including consultant psychiatrists and senior managers.
This helps us reinforce our mission to be a truly quality-focussed
and recovery-orientated provider of mental health care.
06 Safety at St Andrew’s Quality Accounts 2009-2010
Involvement of
service users plays
an important role
Appendix A
This information fulfils the requirements of Regulation 4(1)(6)
and the schedule of the National Health Service (Quality
Accounts) Regulations 2010. All references to ‘Provider’ relate
to St Andrew’s Healthcare. All information is given in respect
of the period 1 April 2009 – 31 March 2010.
Safer Lithium Therapy December 2009
2.6 A description of the action the provider intends to take to
improve the quality of healthcare following the review of
reports identified under entry 2.5.
1 During 2009/2010, St Andrew’s Healthcare provided clinical
services in the field of mental health to over 700 service
users, commissioned by over 140 different NHS and other
organisations.
1.1 St Andrew’s Healthcare has reviewed all the data available
to it on the quality of care in respect of all the services
under item 1.
1.2 The income generated by the NHS services reviewed
in 2009/2010 represents 100% of the total income
generated from the provision of NHS services by
St Andrew’s Healthcare for 2009/2010.
National and Local Clinical Audit
2 The number of national clinical audits which collected data
during the reporting period and which covered St Andrew’s
Healthcare services: One
2.1 The number, as a percentage of national clinical audits
identified under entry 2 that the provider participated in
during the reporting period: Zero
2.2 A list of the national clinical audits identified under entry
2 that the provider participated in: One
Prescribing Observatory for Mental Health (POMH)
2.3 A list of the national clinical audits identified under entry
2.1 that the provider participated in: N/A
2.4 A list of the national clinical audits that the provider
participated in, and which data collection was completed
for during the reporting period, alongside the number of
cases submitted to each audit, as a percentage of the
number required by the terms of the audit: N/A
2.5 The number of national clinical audit reports published
during the reporting period that were reviewed by the
provider during the reporting period: One
The Pharmacy has signed up to the Prescribing
Observatory for Mental Health and is about to
undertake its first audit, which covers the monitoring
of patients who are prescribed lithium. The audit
results will be fully reviewed and will determine any
action that needs to be undertaken in order to meet
the NPSA’s safer lithium advice by December 2010.
2.7 The number of local clinical audit reports that were
reviewed by the provider during the reporting period.
Reports from:
- Quality Network for Forensic Mental Health Services
(QNFMHS)
- Quality Network for Inpatient Child and Adolescent
Mental Health Services (QNIC)
Plus St Andrew’s Healthcare internal audit – see audit
calendar (Appendix B)
2.8 A description of the action the provider intends to take
to improve the quality of healthcare following the review
of reports identified under entry 2.7.
St Andrew’s Healthcare responses to key
recommendations to reports – Appendix C
National Confidential Enquiries
2 The number of national confidential enquiries which collected
data during the reporting period and which covered St
Andrew’s Healthcare services: One
2.1 The number, as a percentage, of national confidential
enquiries identified under entry 2 that the provider
participated in during the reporting period: Zero
2.2 A list of national confidential enquiries identified under
entry 2 that the provider was eligible to participate in:
Zero
2.3 A list of the national confidential enquires identified
under entry 2.1 that the provider participated in: N/A
08 Appendix A Quality Accounts 2009-2010
2.4 A list of the national confidential enquires that the
provider participated in, and which data collection was
completed for during the reporting period, alongside the
number of cases submitted to each enquiry, as a
percentage of the number required by the terms of
the enquiry: Zero
3 The number of patients who received NHS services provided
by St Andrew’s Healthcare in 2009/2010 that were recruited
during that period to participate in research approved by a
research ethics committee was 100.
4 Up to 0.5% of St Andrew’s Healthcare income during
2009/2010 was conditional upon achieving quality
improvement and innovation goals agreed between
St Andrew’s Healthcare and bodies that they entered into
a contract, agreement or arrangement with for the provision
of NHS services, through the Commissioning for Quality and
Innovation (CQUIN) payment framework.
4.1Further details of the agreed goals for the 2009/2010
reporting period and for the following 12-month period are
available upon request from Russell Jones, Deputy Director
Business Development (rjones@standrew.co.uk). Not all
NHS commissioners have elected to actively pursue a CQUIN
scheme with St Andrew’s Healthcare during 2009/2010,
but we as a Charity welcome the opportunity to have such
agreements going forward.
5 St Andrew’s Healthcare is required to register with the
Care Quality Commission and copies of current registration
certificates are available online at http://www.stah.org/
about-us/links-and-downloads.html and include all conditions
applicable to registration.
The Care Quality Commission has not taken enforcement
action against St Andrew’s Healthcare during 2009/10.
6 St Andrew’s Healthcare is not subject to periodic reviews
by the Care Quality Commission.
7 St Andrew’s Healthcare has not participated in any special
reviews or investigations by the CQC during 2009/2010.
8 St Andrew’s Healthcare did not submit records during
2009/2010 to the Secondary Uses Service for inclusion in
the Hospital Episodes Statistics, which are included in the
latest published data.
9 St Andrew’s Healthcare was not subject to assessment
using the Information Governance Toolkit during 2009/2010.
10 St Andrew’s Healthcare was not subject to the Payment
by Results clinical coding audit during 2009/2010 by the
Audit Commission.
Regulation 7 “Priorities for Improvement” (2010/11):
Safety:
Essen Climate Evaluation Scale will be introduced in all Medium
and Low secure services, with an implementation plan including
service user involvement, training and governance systems to
ensure actions and learnings are monitored.
Clinical Effectiveness:
To meet the needs of service users in Medium and Low secure
units throughout St Andrew’s Healthcare, a portfolio of recovery
planning tools is being developed. Some services have already
selected their tool of choice and it is embedded in the service
users’ programmes of treatment. Others are running trials which
will help when making the decision about which tool to adopt.
Service User Experience:
Responses to issues highlighted in a recent service user led
diversity audit throughout the Charity will be actioned and
monitored with full service user involvement.
Appendix B
Healthcare Audit Calendar 2010
April 2009
Audit title
Auditor/s
Additional information
Accident, Incident, PMAV, Seclusion
Event Form System/
Healthcare Governance
Individual report for each Hospital
Slip, Trip & Fall Report
Event Form System/
Healthcare Governance
National Brain Injury Centre (NBIC) & Services for older
people only
Self Harm, AWOL & Assaults Report
Event Form System/
Healthcare Governance
Charity -wide report
Patient Satisfaction ~ Admission
Clinical Audit Leads
On-going data collection
Summary report from Healthcare Governance Dept
(6 monthly)
Local report (6 monthly)
Patient Satisfaction ~ Discharge
Clinical Audit Leads
On-going data collection period
Summary report from Healthcare Governance Dept
(6 monthly)
Local report (6 monthly)
CPA ~ Carers’ Views
Healthcare Governance
Dept
Clinical Supervision
Healthcare Governance
Dept
Electronic questionnaire
Charity-wide report from Healthcare Governance Dept
Medicines Management (Ward)
Pharmacy
Includes availability of patient info leaflets.
Quality Network Inpatient CAMHS
Local & External
External audit programme running April 09 to March 10
Adolescent Service only
Health & Safety – Fire
H & S Team
Unannounced audit across St Andrew’s Healthcare
Health & Safety – 911 Emergency
Equipment
H & S Team
Unannounced audit across St Andrew’s Healthcare
Red: Clinical Audit Leads; Blue: Healthcare Governance; Green: Medical/Pharmacy; Brown: Facilities; Pink: Physical Healthcare Team;
Black: Medical library; Orange: Health & Safety; Lavender: Infection control; Grey: Dieticians;
10 Appendix B Quality Accounts 2009-2010
Healthcare Audit Calendar 2010
May 2009
Audit title
Auditor/s
Additional information
Accident, Incident, PMAV, Seclusion
Event Form System/
Healthcare Governance
Individual report for each Hospital
Slip, Trip & Fall Report
Event Form System/
Healthcare Governance
National Brain Injury Centre (NBIC) & Services for older
people only
Self Harm, AWOL & Assaults Report
Event Form System/
Healthcare Governance
Group-wide report
Patient Satisfaction ~ Admission
Clinical Audit Leads
On-going data collection
Summary report from Healthcare Governance
Dept (6 monthly)
Local report (6 monthly)
Patient Satisfaction ~ Discharge
Clinical Audit Leads
On-going data collection period
Summary reports from Healthcare Governance
Dept (6 monthly)
Local report (6 monthly)
CPA ~ Carers’ Views
Healthcare Governance
Dept
Clinical Safety (Ligatures)
Clinical Audit Leads
Local data collection & report with six monthly formal
review of the action Charity plan
Pressure Ulcer
Ward Managers
Quarterly Audit for all Hospitals
Charity-wide report from Physical Healthcare Team
Medicines Management (Ward)
Pharmacy
Includes availability of patient info leaflets.
Prescription Writing Standards
Medical/Pharmacy
(Northampton)
Local auditors other sites
Northampton site-wide report
Local report – other sites. Medical staff to audit
Emergency Equipment
Clinical Audit Leads
National Brain Injury Centre (NBIC) only. Local data
collection & report
Bed Rail, Frame and Mattress
Clinical Audit Leads
National Brain Injury Centre (NBIC) only Local data
collection & report
Health & Safety – Fire
H & S Team
Unannounced audit across St Andrew’s Healthcare
Health & Safety – 911 Emergency
Equipment
H & S Team
Unannounced audit across St Andrew’s Healthcare
Appendix B continued
Healthcare Audit Calendar 2010
June 2009
Audit title
Auditor/s
Additional information
CPA
Clinical Audit Leads
Clinical KPI
HoNOS
Electronic patient record
system / Clinical Audit
Leads
Clinical KPI
Therapeutic Activity
Clinical Audit Leads
Clinical KPI
Self Harm, AWOL & Assaults Report
Event Form System/
Healthcare Governance
Charity-wide report
Accident, Incident, PMAV, Seclusion
Event Form System/
Healthcare Governance
Individual report for each Hospital
Slip, Trip & Fall Report
Event Form System/
Healthcare Governance
National Brain Injury Centre (NBIC) & Services for older
people only
CPA ~ Care Co-ordinator Workload
Healthcare Governance
Electronic questionnaire
Clinical Audit Leads support local participation
Group-wide report from Healthcare Governance Dept
Patient Satisfaction ~ Admission
Clinical Audit Leads
On-going data collection
Summary report from Healthcare Governance Dept
(6 monthly)
Local report (6 monthly)
Patient Satisfaction ~ Discharge
Clinical Audit Leads
On-going data collection period
Summary report from Healthcare Governance Dept
(6 monthly)
Local report (6 monthly)
Patient Satisfaction ~ CPA (West Midlands Clinical Audit Leads
Patients)
Adolescent Service only
Commissioned by Specialised Commissioning Team
(West Mids)
Report from Healthcare Governance Dept
Medicines Management (Ward)
Pharmacy
Includes availability of patient info leaflets.
Medicines Management
Pharmacy
Blood Glucose Monitoring
Bayer Healthcare
Pharmacy co-ordinate the audit
Catering ~ Patient interviews
Facilities Manager
Nursing staff
Sample of patients audited from each Hospital
Clinical Audit Leads to support local process
Health & Safety – Fire
H & S Team
Unannounced audit across St Andrew’s Healthcare
Health & Safety – 911 Emergency
Equipment
H & S Team
Unannounced audit across St Andrew’s Healthcare
Policy Control System
Healthcare Governance
Dept
Charity-wide report from Healthcare Governance Dept
Red: Clinical Audit Leads; Blue: Healthcare Governance; Green: Medical/Pharmacy; Brown: Facilities; Pink: Physical Healthcare Team;
Black: Medical library; Orange: Health & Safety; Lavender: Infection control; Grey: Dieticians;
12 Appendix B Quality Accounts 2009-2010
Healthcare Audit Calendar 2010
July 2009
Audit title
Auditor/s
Additional information
Accident, Incident, PMAV, Seclusion
Event Form System/
Healthcare Governance
Individual report for each Hospital
Slip, Trip & Fall Report
Event Form System/
Healthcare Governance
National Brain Injury Centre (NBIC) & Services for older
people only
Self Harm, AWOL & Assaults Report
Event Form System/
Healthcare Governance
Charity -wide report
Patient Satisfaction ~ Admission
Clinical Audit Leads
On-going data collection
Summary report from Healthcare Governance Dept
(6 monthly)
Local report (6 monthly)
Patient Satisfaction ~ Discharge
Clinical Audit Leads
On-going data collection period
Summary report from Healthcare Governance Dept
(6 monthly)
Local report (6 monthly)
Patient Satisfaction ~ Environment
Clinical Audit Leads
1 month data collection period
Summary report from Healthcare Governance Dept
Local report
Handover
Clinical Audit Leads
Local data collection & report
Medicines Management (Ward)
Pharmacy
Includes availability of patient info leaflets.
Health & Safety – Fire
H & S Team
Unannounced audit across St Andrew’s Healthcare
Health & Safety – 911 Emergency
Equipment
H & S Team
Unannounced audit across St Andrew’s Healthcare
Appendix B continued
Healthcare Audit Calendar 2010
August 2009
Audit title
Auditor/s
Additional information
Accident, Incident, PMAV, Seclusion
Event Form System/
Healthcare Governance
Individual report for each Hospital
Self Harm, AWOL & Assaults Report
Event Form System/
Healthcare Governance
Charity-Wide report
Slip, Trip & Fall Report
Event Form System/
Healthcare Governance
National Brain Injury Centre (NBIC) & Services for older
people only
Patient Satisfaction ~ Admission
Clinical Audit Leads
On-going data collection
Summary reports from Healthcare Governance Dept
(6 monthly)
Local report (6 monthly)
Patient Satisfaction ~ Discharge
Clinical Audit Leads
On-going data collection period
Summary reports from Healthcare Governance Dept
(6 monthly)
Local report (6 monthly)
Use of Admin Codes on Prescription
Charts
Clinical Audit Leads
Local data collection & report
Pressure Ulcer
Ward Managers
Quarterly Audit for all Hospitals Clinical Audit Leads to
support data collection
Charity-wide report from Physical Healthcare Team
Section 17 Leave (Process)
Clinical Audit Leads
Local data collection & report
Section 17 Leave (Documentation)
Clinical Audit Leads
Local data collection & report
Accreditation for LD in-patient wards
Local & external
Medicines Management (Ward)
Pharmacy
Includes availability of patient info leaflets.
Health & Safety – Fire
H & S Team
Unannounced audit across St Andrew’s Healthcare
Health & Safety – 911 Emergency
Equipment
H & S Team
Unannounced audit across St Andrew’s Healthcare
Confidentiality audit
Healthcare Governance
Dept
Group-wide report from Healthcare Governance Dept
Safe Handing & Disposal of Sharps
Infection Control Link
Nurses
Local data collection and report from Infection Control
Link Nurses
Red: Clinical Audit Leads; Blue: Healthcare Governance; Green: Medical/Pharmacy; Brown: Facilities; Pink: Physical Healthcare Team;
Black: Medical library; Orange: Health & Safety; Lavender: Infection control; Grey: Dieticians;
14 Appendix B Quality Accounts 2009-2010
Healthcare Audit Calendar 2010
September 2009
Audit title
Auditor/s
Additional information
CPA
Clinical Audit Leads
Clinical KPI
HoNOS
Electronic patient record
Clinical KPI – Clinical Audit Leads to check data quality
system / Clinical Audit Leads before audit date
Therapeutic Activity
Clinical Audit Leads
Clinical KPI
Accident, Incident, PMAV, Seclusion
Event Form System/
Healthcare Governance
Individual report for each Hospital
Slip, Trip & Fall Report
Event Form System/
Healthcare Governance
National Brain Injury Centre (NBIC) & Services for older
people only
Self Harm, AWOL & Assaults Report
Event Form System/
Healthcare Governance
Charity -wide report
Patient Satisfaction ~ Admission
Clinical Audit Leads
On-going data collection period
Summary report from Healthcare Governance Dept
(6 monthly)
Local report (6 monthly)
Patient Satisfaction ~ Discharge
Clinical Audit Leads
On-going data collection period
Summary report from Healthcare Governance Dept
(6 monthly)
Local report (6 monthly)
Quality Network for Forensic Mental
Health Services
Local & external
External audit programme (RCP) running Sept 09 to
Feb10
Central & local co-ordination Clinical Audit Leads support
local participation
Participating units- Birmingham, GHU, Lowther, Malcolm
Arnold House, Robinson & Smyth House.
Compliance with Forms 38 & 39
Medical / Pharmacy
Northampton Site-wide report
Medicines Management ( Ward )
Pharmacy
Includes availability of patient info leaflets.
Catering ~ Patient interview
Facilities Manager
Nursing Staff
Sample of patients audited from each Hospital
Clinical Audit Leads to support local process
Emergency Equipment
Clinical Audit Leads
National Brain Injury Centre (NBIC) only
Local data collection & report
Health & Safety – Fire
H & S Team
Unannounced audit across St Andrew’s Healthcare
Health & Safety – 911 Emergency
Equipment
H & S Team
Unannounced audit across St Andrew’s Healthcare
White Board
Healthcare Governance
Dept
Charity -wide report from Healthcare Governance Dept
Appendix B continued
Healthcare Audit Calendar 2010
October 2009
Audit title
Auditor/s
Additional information
Accident, Incident, PMAV, Seclusion
Event Form System/
Healthcare Governance
Individual report for each Hospital
Slip, Trip & Fall Report
Event Form System/
Healthcare Governance
National Brain Injury Centre (NBIC) & Services for older
people only
Self Harm, AWOL & Assaults Report
Event Form System/
Healthcare Governance
Charity-wide report
Patient Satisfaction ~ Admission
Clinical Audit Leads
On-going data collection
Summary report from Healthcare Governance Dept
(6 monthly)
Local report (6 monthly)
Patient Satisfaction ~ CPA
Clinical Audit Leads
1 month data collection period
Summary report from Healthcare Governance Dept
(6 monthly)
Local report (6 monthly)
Patient Satisfaction ~ CPA (West Midlands Clinical Audit Leads
Patients)
1 month data collection period.
Data collected as part of the CPA survey but analysed
separately
Commissioned by Specialised Commissioning Team
(West Mids)
Group-wide report from Healthcare Governance Dept
Patient Satisfaction ~ Discharge
Clinical Audit Leads
On-going data collection period
Summary reports from Healthcare Governance Dept
(6 monthly)
Local report (6 monthly)
Quality Network for Forensic Mental
Health Services
Local & external
Medicines Management (Ward)
Pharmacy
Medicines Management
Pharmacy
Mental Health Act
Medical/Pharmacy
Charity -wide -report
MHA Section 62
Medical/Pharmacy
Charity-wide report
Bed Rail, Frame and Mattress
Clinical Audit Leads
National Brain Injury Centre (NBIC) only
Local data collection & report
Health & Safety – Fire
H & S Team
Unannounced audit across St Andrew’s Healthcare
Health & Safety – 911 Emergency
Equipment
H & S Team
Unannounced audit across St Andrew’s Healthcare
Includes availability of patient info leaflets.
Red: Clinical Audit Leads; Blue: Healthcare Governance; Green: Medical/Pharmacy; Brown: Facilities; Pink: Physical Healthcare Team;
Black: Medical library; Orange: Health & Safety; Lavender: Infection control; Grey: Dieticians;
16 Appendix B Quality Accounts 2009-2010
Healthcare Audit Calendar 2010
November 2009
Audit title
Auditor/s
Additional information
Accident, Incident, PMAV, Seclusion
Event Form System/
Healthcare Governance
Individual report for each Hospital
Slip, Trip & Fall Report
Event Form System/
Healthcare Governance
National Brain Injury Centre (NBIC) & Services for older
people only
Self Harm, AWOL & Assaults Report
Event Form System/
Healthcare Governance
Charity -wide report
Patient Satisfaction ~ Admission
Clinical Audit Leads
On-going data collection
Summary report from Healthcare Governance Dept
(6 monthly)
Local report (6 monthly)
Patient Satisfaction ~ Discharge
Clinical Audit Leads
On-going data collection period
Summary report from Healthcare Governance Dept
(6 monthly)
Local report (6 monthly)
Supportive Observations
Clinical Audit Leads
Local data collection & report
Pressure Ulcer
Clinical Audit Leads
Quarterly Audit for all Hospitals Clinical Audit Leads to
support data collection
Charity -wide report from Physical Healthcare Team
Quality Network for Forensic Mental
Health Services
Local & external
See additional information for September
Spillage Contamination with Blood/Body
Fluid
Infection Control Link
Nurses
Local data collection and report from Infection Control
Link Nurses
Hand Hygiene
Infection Control Link
Nurses
Local data collection and report from Infection Control
Link Nurses
Medicines Management (Ward)
Pharmacy
Includes availability of patient info leaflets.
Health & Safety – Fire
H & S Team
Unannounced audit across St Andrew’s Healthcare
Health & Safety - 911 Emergency
Equipment
H & S Team
Unannounced audit across St Andrew’s Healthcare
MHA Patient Rights
Clinical Audit Leads
Charity -wide report & local report
Appendix B continued
Healthcare Audit Calendar 2010
December 2009
Audit title
Auditor/s
Additional information
CPA
Clinical Audit Leads
Clinical KPI
HoNOS
Electronic patient record
Clinical KPI – Clinical Audit Leads to check data quality
system / Clinical Audit Leads before audit date
Therapeutic Activity
Clinical Audit Leads
Clinical KPI
Accident, Incident, PMAV, Seclusion
Event Form System/
Healthcare Governance
Individual report for each Hospital
Self Harm, AWOL & Assaults Report
Event Form System/
Healthcare Governance
Charity-wide report
Slip, Trip & Fall Report
Event Form System/
Healthcare Governance
National Brain Injury Centre (NBIC) & Services for older
people only
Patient Satisfaction ~ Admission
Clinical Audit Leads
On-going data collection
Group-wide & local report from Healthcare Governance
Dept (6 monthly)
Local report (6 monthly)
Patient Satisfaction ~ Discharge
Clinical Audit Leads
On-going data collection period
Group-wide & local report from Healthcare Governance
Dept (6 monthly)
Local report (6 monthly)
Patient Satisfaction ~ CPA (West Midlands Clinical Audit Leads
Patients)
See additional information for June
Quality Network for Forensic Mental
Health Services
Local & external
See additional information for September
Medicines Management (Ward)
Pharmacy
Includes availability of patient info leaflets.
MHA Monitoring & Maintaining Legality of Medical
Detention
Charity -wide report
MHA Assessments of Patients Held
Under Sections 2 and 3
Medical
Charity -wide report
MHA Use of Section 5(2)
Medical
Charity -wide report
No of appeals to Hospital Managers &
MHRT’s
Medical
Charity -wide report
Medication Errors
Medical/Pharmacy
Charity -wide report
Catering ~ Patient interviews
Facilities Manager
Nursing staff
Sample of patients audited from each Hospital
Clinical Audit Leads to support local process
Health & Safety - Fire
H & S Team
Unannounced audit across St Andrew’s Healthcare
Health & Safety - 911 Emergency
Equipment
H & S team
Unannounced audit across St Andrew’s Healthcare
NB: An infection control outbreak audit will be undertaken by the infection control nurse should an outbreak occur.
Red: Clinical Audit Leads; Blue: Healthcare Governance; Green: Medical/Pharmacy; Brown: Facilities; Pink: Physical Healthcare Team;
Black: Medical library; Orange: Health & Safety; Lavender: Infection control; Grey: Dieticians;
18 Appendix B Quality Accounts 2009-2010
Healthcare Audit Calendar 2010
January 2010
Audit title
Auditor/s
Additional information
Accident, Incident, PMAV, Seclusion
Event Form System/
Healthcare Governance
Individual report for each Hospital
Self Harm, AWOL & Assaults Report
Event Form System/
Healthcare Governance
Charity wide report
Slip, Trip & Fall Report
Event Form System/
Healthcare Governance
National Brain Injury Centre (NBIC) & Services for older
people only
Patient Satisfaction ~ Admission
Clinical Audit Leads
On-going data collection
Summary report from Healthcare Governance Dept
(6 monthly)
Local report (6 monthly)
Patient Satisfaction ~ Discharge
Clinical Audit Leads
On-going data collection period
Summary report from Healthcare Governance Dept
(6 monthly)
Local report (6 monthly)
Seclusion Room ~ Documentation
Clinical Audit Leads
Local report
Quality Network for Forensic Mental
Health Services
Local & External
External audit programme (RCP)
Clinical Audit Leads support local participation Central &
local co-ordination Participating units- Birmingham, GHU,
Lowther, Malcolm Arnold House, Robinson & Smyth
House
Medicines Management (Ward)
Pharmacy
Includes availability of patient info leaflets.
Medicines Management
Pharmacy
Use of Extra Care Area
Clinical Audit Leads
Women’s Service only Local data collection & report
Emergency Equipment
Clinical Audit Leads
National Brain Injury Centre (NBIC) only Local data
collection & report
Health & Safety – Fire
H & S Team
Unannounced audit across St Andrew’s Healthcare
Health & Safety - 911 Emergency
Equipment
H & S Team
Unannounced audit across St Andrew’s Healthcare
Accreditation for LD in-patient wards
Local & External
New external audit programme (RCP) rolling programme
Healthcare Governance link with RCP & co-ordinate
Women’s Services – selected wards only
Section 17 Leave (Process)
Clinical Audit Leads
Services for older people only Local data collection &
report
Section 17 Leave (Documentation)
Clinical Audit Leads
Services for older people only Local data collection &
report
Appendix B continued
Healthcare Audit Calendar 2010
February 2010
Audit title
Auditor/s
Additional information
Accident, Incident, PMAV, Seclusion
Event Form System/
Healthcare Governance
Individual report for each Hospital
Slip, Trip & Fall Report
Event Form System/
Healthcare Governance
National Brain Injury Centre (NBIC) & Services for older
people only
Self Harm, AWOL & Assaults Report
Event Form System/
Healthcare Governance
Charity wide report
Patient Satisfaction ~ Admission
Clinical Audit Leads
On-going data collection
Summary report from Healthcare Governance Dept local
report (6 monthly)
Local report (6 monthly)
Patient Satisfaction ~ Discharge
Clinical Audit Leads
On-going data collection period
Summary report from Healthcare Governance Dept (6
monthly)
Local report (6 monthly)
Patient Satisfaction ~ Treatment & Care
Clinical Audit Leads
1 month data collection period
Summary report from Healthcare Governance Dept &
local report
Quality Network for Forensic Mental
Health Services
Local & External
See additional information for January
Bed Rail, Frame and Mattress
Clinical Audit Leads
Local data collection & report
Infection Control ~ Environment
Facilities Managers &
Clinician
Local data collection & report
Infection Control ~ Ward/Departmental
Kitchens
Facilities Managers &
Clinician
Local data collection & report
Infection Control ~ Handling & Disposal of
Linen
Facilities Managers &
Clinician
Local data collection & report
Infection Control ~ Disposal of Waste
Facilities Managers &
Clinician
Local data collection & report
Medicines Management (Ward)
Pharmacy
Includes availability of patient info leaflets.
Medicines Management
Pharmacy
Management of Epilepsy
Medical/Pharmacy
Additional info audit based NICE guideline
Health & Safety – Fire
H & S Team
Unannounced audit across St Andrew’s Healthcare
Health & Safety – 911 Emergency
Equipment
H & S Team
Unannounced audit across St Andrew’s Healthcare
Weight Management
Dietiticians
Charity wide summary report
Red: Clinical Audit Leads; Blue: Healthcare Governance; Green: Medical/Pharmacy; Brown: Facilities; Pink: Physical Healthcare Team;
Black: Medical library; Orange: Health & Safety; Lavender: Infection control; Grey: Dieticians;
20 Appendix B Quality Accounts 2009-2010
Healthcare Audit Calendar 2010
March 2010
Audit title
Auditor/s
Additional information
CPA
Clinical Audit Leads
Clinical KPI
HoNOS
Electronic patient record
Clinical KPI – Clinical Audit Leads to check data quality
system / Clinical Audit Leads before audit date
Therapeutic Activity
Clinical Audit Leads
Clinical KPI
Accident, Incident, PMAV, Seclusion
Event Form System/
Healthcare Governance
Individual report for each Hospital
Slip, Trip & Fall Report
Event Form System/
Healthcare Governance
National Brain Injury Centre (NBIC) & Services for older
people only
Self Harm, AWOL & Assaults Report
Event Form System/
Healthcare Governance
Charity wide report
Restraint and Compliance
Clinical Audit Leads
National Brain Injury Centre (NBIC) only
Local data collection & report
Seclusion ~ Environment
Clinical Audit Leads
Local data collection & report
Patient Satisfaction ~ Admission
Clinical Audit Leads
On-going data collection
Summary report from Healthcare Governance Dept
Local report (6 monthly)
Patient Satisfaction ~ Discharge
Clinical Audit Leads
On-going data collection period
Summary report from Healthcare Governance Dept
Local report (6 monthly)
Medicines Management (Ward)
Pharmacy
Includes availability of patient info leaflets.
Medicines Management
Pharmacy
Catering ~ Patient interviews
Facilities Manager
Nursing staff
Sample of patients audited from each Hospital
Clinical Audit Leads to support local process.
Health & Safety – Fire
H & S Team
Unannounced audit across St Andrew’s Healthcare
Health & Safety – 911 Emergency
Equipment
H & S Team
Unannounced audit across St Andrew’s Healthcare
Glossary
PMAV - Prevention and Management of Aggression and Violence
SPR – Safe Patient Restraint
AWOL – Absent Without Leave
CPA – Care Programme Approach
CAMHS – Child and Adolescent Mental Health Service
H&S – Health and Safety
HoNOS – Health of the Nation Outcome Scale
KPI – Key Performance Indicators
LD – Learning Difficulties
GHU – Geoffrey Hawkins Unit
MHA – Mental Health Act
MHRT – Mental Health Review Tribunal
Appendix C
St Andrew’s Healthcare response to key recommendations for
QNFMHS report
The integration of 25 hours per week of planned service user
therapeutic activity in to the electronic patient record system
enabling planned and unplanned activity to be recorded and
evaluated
Providing formal structures to gain feedback and suggestions
from both service users and staff including Service User audits
and forums, staff annual survey and open communication events
St Andrew’s Healthcare response to key recommendations for
QNIC report
The audit covered two key areas of environment and facilities and
Information, consent and confidentiality
Full implementation of person centred plans for all service users
within Learning Disability services. This approach is fully
supported within the charitys overall Learning Disability strategy
Further enhance environment in line with national standards and
service user preferences
22 Appendix C Quality Accounts 2009-2010
Appendix D
Service Type Northampton Total beds 573
Service Description
Security Level Bed Number
Men’s
Mental Health
Mental Health
Mental Health
Mental Health
Mental Health
Mental Health
Mental Health
Learning Disability
Learning Disability
Learning Disability
Autistic Spectrum Disorder
Male Admission and Stabilisation
Male Slow Stream Rehabilitation Male Admission Male Rehabilitation and Recovery Male Rehabilitation and Recovery Male Step Down Pre-Discharge Active Rehabilitation Male Next Stage Supervised Independent Living
Male Admission and Stabilisation Male Enhanced Rehabilitation and Recovery for Challenging Behaviour
Male Transitional Rehabilitation into Community Male Autistic Spectrum Disorder (Higher Functioning / Aspergers) Assessment and Rehabilitation Medium Low Low Low Low Open Open Medium Enhanced Low Low Low 20
20
12
15
8
16
5
17
16
12
13
Women’s
Mental Health
Mental Health
Mental Health
Mental Health
Mental Health
Mental Health
Borderline Personality Disorder
Learning Disability
Learning Disability
Female Admission / Stabilisation
Female Treatment and Recovery
Female Rehabilitation and Recovery
Female Rehabilitation and Recovery
Female Rehabilitation and Recovery Hostel
Female Rehabilitation and Recovery Hostel Female Admission, Treatment and Recovery (DBT)
Female Admission, Treatment and Recovery
Female Rehabilitation and Recovery
Medium
Medium
Low
Open
Open
Open
Low
Medium
Low
13
15
17
9
2
3
23
13
10
Adolescent
Mental Health
Mental Health
Mental Health
Mental Health
Mental Health
Learning Disability
Learning Disability
Learning Disability
Learning Disability
Female High Risk/Assessment (13yrs +)
Female Trauma – Group Programmes (13yrs +)
Female Vulnerable – Individual Programmes (13yrs +) Male - Admission (13yrs +)
Male - Pre-Discharge (16-18yrs) Male Forensic (13-16yrs)
Male Forensic (16-18yrs)
Mixed Gender Neurodevelopmental Disability / ASD (13-16yrs)
Mixed Gender Neurodevelopmental Disability / ASD (16-18yrs)
Medium
Medium
Medium
Medium
Medium
Medium
Medium
Medium
Medium
14
12
10
12
12
10
10
10
10
Older people/HD
Mental Health
Mental Health / Forensic Mental Health
Mental Health
Mental Health
Mental Health
Mental Health
Male Neuropsychiatry
Male Forensic
Female Forensic Challenging Behaviour (55yrs +)
Mixed Gender Huntington’s Disease (26yrs +)
Male Challenging Behaviour / Dementia
Mixed Gender High Physical Health Needs / Palliative Care (55yrs +)
Male Open Rehabilitation
Low
Low
Locked
Locked
Locked
Locked
Open
25
15
16
11
13
21
21
National Brain Injury Centre
Acquired Brain Injury
Acquired Brain Injury
Acquired Brain Injury
Acquired Brain Injury
Acquired Brain Injury
Acquired Brain Injury
Male Admission / Neurobehavioural Rehabilitation
Male Admission / Neurobehavioural Active Rehabilitation
Male Neurobehavioural Service - Slow Stream Rehabilitation Female Admission / Neurobehavioural Rehabilitation Mixed Gender Longer Term Service
Mixed Gender Longer Term Service
Locked
Locked
Locked
Locked
Locked
Locked
13
16
14
14
29
6
Appendix D continued
Service Type Essex Total beds 92
Service Description
Security Level Bed Number
Men’s
Mental Health / Personality Disorder
Mental Health / Personality Disorder
Mental Health / Personality Disorder
Mental Health / Personality Disorder
Male Admission and Stabilisation [High Dependency]
Male Rehabilitation and Recovery
Treatment and Rehabilitation [includes DBT]
Male Community Rehabilitation
Low
Low
Low
Open
17
18
18
4
Women’s
Mental Health / Personality Disorder
Mental Health / Personality Disorder
Mental Health / Personality Disorder
Female Admission and Stabilisation [High Dependency]
Female Rehabilitation and Recovery [includes DBT]
Female Rehabilitation and Recovery [Intensive]
Low
Low
Low
13
16
6
Male Admission / Stabilisation
Male Treatment and Recovery
Male Treatment and Recovery
Male Rehabilitation and Recovery
Male Rehabilitation and Recovery
Male Admission and Treatment
Male Community Rehabilitation [opening January 2010]
Medium
Medium
Enhanced Low
Low
Low
Low
Locked
15
15
18
16
16
16
16
Women’s Community Rehabilitation [opening February / March 2010]
Locked
16
Medium
Medium
Medium
Medium
Medium
Medium
Medium
Medium
17
17
17
17
15
17
17
15
Medium
Medium
Low
Low
17
17
18
18
Birmingham
Total beds 128 Men’s
Mental Health / Personality Disorder
Mental Health / Personality Disorder
Mental Health / Personality Disorder
Mental Health / Personality Disorder
Mental Health / Personality Disorder
Autistic Spectrum Disorder
Mental Health
Women’s
Autistic Spectrum Disorder
William Wake, Northampton – Opening Autumn 2010
Men’s
Mental Health
Mental Health
Mental Health
Mental Health
Neuro Developmental
Neuro Developmental
Neuro Developmental
Neuro Developmental
Male Mental Health - Adults of working age
Male Deaf
Older Male Mental Health
Male Mental Health - Young Transitional
Male Autism
Male Higher Functioning Autism / Aspergers
Male Acquired Brain Injury
Male Learning Disability
Nottinghamshire – Opening Autumn 2010
Men’s
Learning Disability Autism
Learning Disability
Autism Total beds 132
Total beds 70
Male Learning Disability
Male Autistic Spectrum Disorder
Male Learning Disability
Male Autistic Spectrum Disorder 24 Appendix D Quality Accounts 2009-2010
Nottinghamshire
(September 2010)
Birmingham
Northampton
Essex
Getting in touch
For further information or to make a referral,
please contact us by telephone or email:
Freephone 0800 434 6690
E enquiries@standrew.co.uk
www.stah.org
St Andrew’s Healthcare
Northampton
Billing Road, Northampton NN1 5DG
T 01604 616000
E help@standrew.co.uk
St Andrew’s Healthcare
Birmingham
Dogpool Lane, Stirchley,
Birmingham B30 2XR
T 0121 432 2100
St Andrew’s Healthcare
Essex
Clare House, Pound Lane, North Benfleet,
Essex SS12 9JP
T 01268 723 800
St Andrew’s Healthcare
Nottinghamshire
Sherwood Oaks Business Park,
Southwell Road West, Mansfield,
Nottinghamshire NG18 4GW
T 01623 638064
Company number: 5176998
Registered Charity Number:1104951