Quality
Account
2009-10
Introduction to the 2009 - 2010 Quality Account
Welcome to our second annual Quality Account. This is the first to be published
under the new National Health Service (Quality Accounts) Regulations 2010. It brings
together information about the quality of our services in one place, and enables you,
the reader, to compare us with other providers of services.
Our Account is in four parts:
Part One is this introduction; it includes a signed statement that the Quality Account
represents an honest appraisal of our services, the areas we feel improvement is
required, and what we are doing to make that happen.
Part Two consists of standard statements that we are required, by the Regulations, to
complete; they allow you to compare us with every other Trust in England. There is
also a summary of our improvement plan for 2010-11.
Part Three brings together information about how we manage quality within the Trust,
how we identify and respond to issues and how we performed against our priorities
for 2009-10. We provide information about our 2010-11 improvement plan that
includes the results of our ‘What matters to you?’ survey. The survey identified 5
areas that were considered of most significance and, as promised, these will be
reviewed over the coming year to ensure that we deliver against your expectations of
us. There is also an extensive section on innovation. In a large organisation it can be
difficult for everyone to know what is happening. I think this is an inspiring review and
I hope it will encourage others to put their bright ideas into practice. I am pleased to
see how many of the innovations are the result of partnerships – between teams,
with service users and carers and with other organisations.
In Part Four we publish statements from key partners as required by the Regulations:
Suffolk LINk, NHS Suffolk, the Strategic Health Authority and the Health Scrutiny
Committee.
Publishing this Account marks a significant step forward in making the Trust
accountable for the quality of services that we provide.
What is quality?
The Trust believes there are three ways to think about ‘quality’. We want people to
have a positive experience of using our services. We want our services to be
provided in a way that is safe for service users, staff and communities. And we want
our services to provide care and treatment that is effective and up-to-date.
Our Quality Account provides information that helps you, and us, assess how well we
are doing. It draws on feedback and information from those who use our services,
their carers, our staff, our partner providers, commissioners and regulators to create
an account of our performance.
Our Mission statement sums up what we are trying to achieve as an NHS Trust:
Helping people make the most of their lives.
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How do we improve?
To achieve our ambition requires a commitment to continually review and improve
our services. The Board is accountable for the quality of our services and takes the
lead in our efforts to modernise and improve all that we do. The Board approves and
monitors our ‘Improvement Programme’; this brings together improvements we have
agreed with the Care Quality Commission, the learning that arises from our
management of risk and the feedback we receive from people across Suffolk. Every
complaint, incident and compliment offers us an opportunity to learn and improve.
Good governance means identifying areas for improvement, ensuring support and
resources are in place to support change, learning together, and demonstrating what
is different as a result. This can only be done in partnership with staff, service users
and their carers.
Identifying issues is never sufficient. We need to demonstrate that we learn from
what people tell us. That means we shall continue to invite comment and feedback,
whether about individual care or service planning and delivery. We shall continue to
encourage involvement with clinical audit, research and training. And we shall
continue to check that the quality of services is improving.
Over the last year we have moved from our traditional model of organising to
implement Service Line Leadership. This places senior clinicians as the main engine
for change in the Trust. The Service Lines are now directly responsible for
developing quality and are actively engaged in exploring ways to improve services.
The Board believes that this will make possible quicker and more effective change
and will ensure that resources are directed to support initiative and innovation.
What is our goal?
Our ambition is to be one of the top 10 mental health trusts in the country. To achieve
this we have to ensure that we meet those values embedded in the NHS
Constitution:
•
•
•
•
•
Put service users and customers first.
Measuring patient experience to inform us about the outcomes for SMHP
services.
Getting the service right first time
Reducing the cost of poor quality
Reinforcing and rewarding good performance
This Quality Account is designed to measure our progress year on year; many
people have contributed to its production and I invite you to participate in the
publication of next year’s account.
SIGNED:
Mark Halladay, Chief Executive, Suffolk Mental Health Partnership Trust
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Contents
Part Two
2.1
2.2
Trust Improvement Priorities for 2010-11
Statements of Assurance from the Board
5
5
Part Three
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
NHS Constitution and Values
Quality Highlights in 2009-10
CQC outcomes – a new framework for quality
Meeting the requirements of our Regulator
The Annual Health Check in 2009-10
Our Performance against National Indicators
CQC rating for SMHP October 2009
CQC assessment of SMHP performance against key targets in
2008 and 2009
National Surveys of Patients and staff in 2009-10
CQC national in-patient survey 2009: What service users told us
about their care in hospital
CQC staff Survey 2009
How do we measure the quality of our services?
Our Priorities for Improvement
Update on 2009-10 priorities
Our Priorities for 2010-04-29
What matters to you: A stakeholder survey
Innovation: new initiatives from 2009-10
Improving people’s experience
Keeping people safe
Providing effective services
Public Benefit
12
12
12
12
16
17
17
Performance against National Indicators
36
Glossary
38
Part Four: Statements from Stakeholders
39
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18
18
20
23
26
26
27
27
29
29
32
33
35
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SMHP Quality Account Part 2
Trust improvement priorities for 2010-2011
The Trust receives feedback on the quality of its services from many sources. People
who use services, their carers, staff and the general public comment on a broad
range of issues. Reviewing this feedback, a survey ‘What matters to you?’ defined no
less than 37 topics of interest and asked respondents to rate how important these
issues were to them and the results were presented to the Board.
The top 5 issues were
•
•
•
•
•
feeling welcomed and respected when visiting Trust premises
having information about what to do in a crisis
attending premises that are clean and tidy
being treated fairly and respectfully, with equality, dignity and autonomy
respected
having regular opportunities to comment on care and treatment
Identifying these issues as ‘most significant’ does not imply the Trust is performing
poorly. But quality is as much about maintaining standards as improving them.
Already, Crisis Cards and Patient-reported Outcome Measures (PROMs) have been
introduced in the last year. There are regular cleanliness and hygiene audits in all
premises to monitor standards, and all this information is reported to the Board.
Training in Equality Diversity and Human Rights issues has been widespread and all
our services are now subject to Equality Impact Assessments that can be accessed
on the website at www.smhp.nhs.uk. The staff induction programme and staff training
are being reviewed to ensure that people are treated courteously and appropriately at
all times.
Over the coming year the Board will continue to monitor performance in these areas.
It will provide updates on progress via the website, the ‘User/Carer Matters’
Newsletter and the User-Carer Reference Group.
Meanwhile action to implement last year’s priorities has continued, and section 3.5
summarises our progress. Every activity of the Trust has potential for improvement
and the Board will continue to monitor last year’s priorities to sustain change.
2.1
Statements of Assurance from the Board
Introduction and summary
The Regulations require us to complete specific statements that show how far we
comply with national indicators of quality. Every Trust provides the same information,
so you can compare our performance with others’. The statements show you
•
•
•
how our income increasingly relies on meeting quality objectives (CQUIN),
how we engage in and use clinical audit and research to improve services
how effectively we use the NHS number and clinical coding to keep people
safe, and
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•
how we use CQC reviews to improve our standards of care
Formal Statements of Assurance
During 2009-2010 the Suffolk Mental Health Partnership Trust provided and/ or subcontracted one NHS services.
The Suffolk Mental Health Partnership Trust has reviewed all the data available to
them on the quality of care in this NHS service.
The income generated by the NHS services reviewed in 2009-2010 represents
100% per cent of the total income generated from the provision of NHS services by
the Suffolk Mental Health Partnership Trust for 2009-2010.
Clinical Audit
During 2009-2010 eight national clinical audits and one national confidential enquiry
covered NHS services that Suffolk Mental Health Partnership Trust provides.
During that period Suffolk Mental Health Partnership Trust participated in 62% (5/8)
national clinical audits and 100% (1/1) national confidential enquiries of the national
clinical audits and national confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Suffolk Mental
Health Partnership Trust was eligible to participate in during 2009-2010 are as
follows:
Prescribing Observatory for Mental Health (POMH-UK) Audits:•
•
•
•
•
•
Topic 1: Prescribing high dose and combined antipsychotics on adult acute
and psychiatric intensive care wards
Topic 2: Screening for metabolic side effects of antipsychotic drugs in patients
treated by assertive outreach teams
Topic 5: Benchmarking the prescribing of high dose and combination
antipsychotics on adult acute and Psychiatric Intensive Care (PICU) wards
Topic 6: Assessment of side effects of depot antipsychotic medication
Topic 8: Medicines reconciliation
Topic 9: Use of antipsychotic medicine in people with Learning Disabilities.
In addition the Trust was eligible to participate in
•
•
•
National Audit of Psychological Therapies – Anxiety and Depression
(NAPTAD): Anxiety and Depression Pilot – The Trust is not a site for the initial
pilot but will consider participation in the substantive study
Royal College of Physicians (RCP) Continence Care – We do not participate
in this audit at present. Analysis of risk suggests this is not an area of
significant concern for the Trust
The National Confidential Inquiry into Suicide and Homicide by People with
Mental Illness.
The national clinical audits and national confidential enquiries that Suffolk Mental
Health Partnership Trust participated in during 2009-2010 are as follows:
POMH-UK Audits:6
•
•
•
•
•
Topic 1: Prescribing high dose and combined antipsychotics on adult acute
and psychiatric intensive care wards
Topic 2: Screening for metabolic side effects of antipsychotic drugs in patients
treated by assertive outreach teams
Topic 6: Assessment of side effects of depot antipsychotic medication
Topic 8: Medicines reconciliation
Topic 9: Use of antipsychotic medicine in people with Learning Disabilities.
We also participate in the National Confidential Inquiry into Suicide and Homicide by
People with Mental Illness
The national clinical audits and national confidential enquiries that Suffolk Mental
Health Partnership Trust participated in, and for which data collection was completed
during 2009-2010, 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.
POMH-UK Audits:• Topic 1: Prescribing high dose and combined antipsychotics on adult acute
and psychiatric intensive care wards - 52 cases submitted (100% of
requirement)
• Topic 6: Assessment of side effects of depot antipsychotic medication - 209
cases submitted (100% of requirement)
• Topic 8: Medicines reconciliation – 15 cases submitted (33% of requirement)
• Topic 9: Use of antipsychotic medicine in people with Learning Disabilities –
104 cases submitted (100% of requirement).
The Trust submitted details of 100% of relevant cases to the National Confidential
Inquiry into Suicide and Homicide by People with Mental Illness
The reports of one national clinical audit were reviewed by the provider in 2009-2010
and Suffolk Mental Health Partnership Trust intends to take the following actions to
improve the quality of healthcare provided
Topic 6: Assessment of side effects of depot antipsychotic medication - 209 cases
submitted
•
•
•
•
Ensure that clinical records systematically record information about
medication side effects
Ensure that clinical records show that physical examination to assess side
effects is conducted within the previous 12 months
Ensure that clinical records show formal assessment of side-effects within the
previous 12 months (including blood tests and appropriate rating scales).
Ensure that clinical records show an assessment of weight, Body Mass Index
(BMI) and waist circumference within previous twelve months.
The Trust is at present discussing how best to meet these objectives. Implementation
will be monitored by Service Lines and reported to the Board as part of its Quality
Report procedure.
The reports of four local clinical audits were reviewed by the provider in 2009-2010
and Suffolk Mental Health Partnership Trust intends to take the following actions to
improve the quality of healthcare provided’.
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The ‘hygiene audit’ demonstrated that, for participating areas, procedures for
hand hygiene were not followed consistently. The programme of monthly
audit will continue, all clinical areas will be required to participate, and a
standard audit tool and methodology will be introduced to ensure
comparability. The most recent results available show that 24 clinical areas
submitted 421 recordings (77% of the total possible). Of these the correct
technique was used ion 352 occasions (86% compliance. The target is 100%
2
The annual Suicide Audit for 2008 demonstrated modest progress against
the 8 National Institute for Mental Health in England (NIHME) standards,
whilst noting that the number of incidents had reduced from 22 (in 2007) to 9.
Comparison of results between 2007 and 2008 audit:2008
Met
Standard one –
Appropriate level
of care
Standard two –
In-patient suicide
prevention
Standard three–
Post discharge
prevention of suicide
Standard four –
Family/carer
contact
Standard five –
Appropriate
medication
Standard six –
Co-morbidity/dual
diagnosis
Standard seven – Post-incident
review
Standard eight – Training of staff
Criterion
met
2007
Met
Criterion
met
50%
2/4
50%
2/4
66%
4/6
33%
2/6
83%
5/6
67%
4/6
0%
0/3
0%
0/3
0%
0/1
0%
0/1
67%
2/3
67%
2/3
25%
1/4
25%
1/4
100%
3/3
67%
2/3
An action plan was approved to address identified issues:
•
•
•
•
•
A new Care Programme Approach (CPA) Policy would be implemented from
June 2009
A new evidence-based risk assessment module would be added to electronic
record-keeping; Staff would be trained to use the new FACE risk assessment
toolkit
Reviews of serious untoward incidents, including suicides, would be
completed within 45 days; this standard to be part of the Commissioning for
Quality and Innovation (CQUIN) contract with NHS Suffolk
Additional training in suicide prevention strategies would be made available.
The findings of the audit would be widely-shared with Clinicians and
Managers
All these objectives have now been achieved and will be subject to a further audit to
assess impact.
3
The Cardio-Pulmonary Resuscitation (CPR) audit reviews availability and
suitability of equipment, staff training and competencies, Issues were
identified relating to the ordering and checking of equipment; increasing
availability of CPR kit for community staff; and improving access to training to
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increase the proportion of staff with up-to-date CPR skills. As a result, training
venues and places have been reviewed, procedures for ordering and
checking equipment updated and standardised, and additional equipment
provided. Each clinical area now has a ‘crash bag’.
4
The annual Record-keeping audit identified four key areas for improvement.
Some hand written records did not comply with Trust standards, different
medication cards were in use across the Trust, there were no standardised
filing conventions for clinical records; and there were no standards specifically
for electronic record-keeping. As a result, peer audit has been adopted to
improve the standard of written records, new medicine cards have been
introduced and a standardised approach to record keeping has been adopted.
Research
The number of patients receiving NHS services provided or sub-contracted by Suffolk
Mental Health Partnership Trust in 2009-10 that were recruited during that period to
participate in research approved by a research ethics committee was 105.
Suffolk Mental Health Partnership NHS Trust approved 12 new research projects in
2009-10; 67% of these research projects required a Research Passport or Letter of
Access. In 2009-10 the National Institute for Health Research (NIHR) supported 7 of
these studies through its research networks.
CQUIN
A proportion of Suffolk Mental Health Partnership Trust income in 2009-2010 was
conditional on achieving quality improvement and innovation goals agreed between
Suffolk Mental Health Partnership Trust and any person or body they entered into a
contract, agreement or arrangement with for the provision of NHS services, through
the Commissioning for Quality and Innovation payment framework (CQUIN).
In 2009 the Trust’s CQUIN scheme covered four areas. These are listed below with
the progress made so far with implementation.
•
•
•
•
Demonstrating that action plans arising from Serious Untoward Incidents
(SUI) had been implemented and that improvement had happened as a result
(Patient Safety). The Trust has agreed a new investigation process that
requires a report to be submitted to NHS Suffolk within 45 days
Conducting service user surveys at least quarterly based on the CQC patient
survey toolkit (Patient Experience). Surveys were conducted in Quarters one
and four; The Trust is committed to undertake a survey for each quarter in
2010-11 and to support the use of surveys in specific clinical areas
Implementation of Patient Reported Outcome Measures for every clinical area
of the Trust (Effectiveness of Care). Every clinical area of the Trust has now
agreed which measures are to be used. In 2010-11 these will be implemented
and evaluated. Lesson learned will be reported to the Board through the
Quality account and incorporated into the Quality Improvement Plan
Implementation of the enabling strategies set out in the SMHP Clinical Quality
Strategy (Innovation). The Trust has invested in quality improvement and
innovation. Reviewing systems and improving skills and practice through
training and audit has improved decision-making, communications and
leadership at all levels. Service line management offers better use of
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resources, effective clinical leadership and improved design and marketing of
services in partnership with service users, carer’s and staff
Further details of the agreed goals for 2009-2010 and for the following 12 month
period are available on request from robert.bolas@smhp.nhs.uk
CQC Registration
Suffolk Mental Health Partnership Trust is required to register with the Care Quality
Commission and its current registration status is ‘Registered without conditions.
The Care Quality Commission has not taken enforcement action against Suffolk
Mental Health Partnership Trust during 2009-2010.
Suffolk Mental Health Partnership Trust is subject to periodic review by the Care
Quality Commission and the last review was on 1 July 2009. The CQC’s assessment
of the Suffolk Mental Health Partnership Trust following that review was that the
Trusts self assessment of Standards C1b and C4d should be amended to noncompliant.
Suffolk Mental Health Partnership Trust intends to take the following action to
address the points made in the CQC’s assessment
•
Safety Alerts (C1b): The Trust has changed its procedures for managing
alerts.
•
Medicines Management (C4d): The Trust is investing in extra pharmacy
capacity to provide better support to clinicians and reviewing procedures to
improve information and quality assurance in this area.
Suffolk Mental Health Partnership Trust has made the following progress by 31st
March 2010 in taking such action:
•
C1b: Procedures have been reviewed and changed. All Safety Alerts are
subject to monitoring and tracking. This means that we know whether the
necessary actions have been taken, and by whom. The Trust is now
compliant with this standard.
•
C4d: recruitment for additional Pharmacy support is well-advanced;
procedures have been reviewed and a programme of audit for medicines
management in 2010 has been adopted.
Suffolk Mental Health Partnership Trust has not participated in special reviews or
investigations by the Care Quality Commission relating to any areas during 20092010. Suffolk Mental Health Partnership Trust therefore has no actions to undertake
arising from reviews in this period.
NHS Number and Quyality of Information
Suffolk Mental Health Partnership Trust submitted records during 2009-2010 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:
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- which included the patient’s valid NHS number was:
• 99.2% for admitted patient care; for April to December 2009
• 99.8% for out patient care; for April to December 2009
• Mental Health Minimum Data Set - 98.1%
- which included the patient’s valid General Medical Practice Code was:
• 100% for admitted patient care; April to December 2009
• 100% for out patient care; April to December 2009
• Mental Health minimum Data Set - 98.7%
These figures will be updated to include January-March 2010 when the information
becomes available.
Everybody has their own, unique, NHS number. Used consistently in all health
records, the number ensures that people are correctly identified and receive the
treatment meant for them
Suffolk Mental Health Partnership Trust score for 2009-2010 for Information Quality
and Records Management, assessed using the Information Governance Toolkit was
77% as per last interim submission at 31st October 2009 and that will be the likely
score as at 31st March 2010.
Suffolk Mental Health Partnership Trust was not subject to the Payment by Results
clinical coding audit during 2009-2010 by the Audit Commission.
Clinical Coding is already used in the Trust to identify why people use the NHS and
which treatments are used. Coding helps managers and clinicians learn more about
how NHS resources are used. Accurate coding helps us to compare resource use
with other Trusts; they will also help us learn more about which treatments are most
effective for particular problems. In 2009-10 coding in the Trust was 100% complete
and validated for accuracy for all inpatient episodes of care.
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SMHP Quality Account Part 3
3.1 NHS Constitution & Values
The NHS Constitution sets out the key values that underpin the way we provide
services. The Trust Board is committed to ensure that these values inform how we
provide services. The Board monitors our compliance with the NHS Constitution,
assessing performance against its 39 rights and pledges.
Respect and dignity
We value each person as an individual, respect their aspirations and commitments in
life, and seek to understand their priorities, needs, abilities and limits.
Commitment to quality of care
We earn the Trust placed in us by insisting on quality and striving to get the basics
right every time.
Compassion
We respond with humanity and kindness to each person’s pain, distress, anxiety or
need.
Improving lives
We strive to improve health and well-being and people’s experiences of the NHS.
Working together for patients
We put patients first in everything we do, by reaching out to staff, patients, carers,
families, communities, and professionals outside the NHS.
Everyone counts.
We use our resources for the benefit of the whole community, and make sure nobody
is excluded or left behind. Developing a robust quality account with valid
measurements will take time but the Trust Board believes that the Quality Account is
just as important as the well established publishing of the annual financial accounts.
3.2 Quality Highlights in 2009-2010
Care Quality Commission Outcomes – a new framework for Quality
From 1 April 2010 the Trust has been registered (without conditions) by CQC as a
provider of mental health and learning disability services. To achieve registration the
Trust had to satisfy the CQC that we met the Essential Standards of Quality and
Safety. The Trust is expected to meet all these standards. Failure to do so may result
in improvement notices or even the withdrawal of our registration.
Meeting the requirements of our regulators
This section briefly describes the outcomes and how we are working to continuously
improve our performance for the benefit of service users and their carers.
Outcome 1 Respecting and involving people who use services
This means people understand the care, treatment and support choices available.
People can express views, in so far as they are able to do so, and are involved in
12
making decisions about care, treatment and support. Privacy, dignity and
independence respected and people’s views and experience are taken into account
in the way in which the service is provided and delivered.
The Trust works with a range of representative groups to improve feedback and
understanding. We shall continue to improve access to advocacy services and
involve patient groups in the planning and delivery of services. . For example, the
Equality & Human Rights Reference group has a wide membership that uses service
user & family carer feedback to support the implementation of action plans that
improve services
Outcome 2 Consent to your care and treatment
Where people are able, they give valid consent to the examination, care, treatment
and support they receive. People understand and know how to change any decisions
about examination, care, treatment and support that has been previously agreed.
People can be confident that their human rights are respected and taken into
account.
The Trust will continue to work closely with partners such as Stepping Forward to
ensure that we continue to meet the highest standards. The Mental Health Act
Standards Group is now part of the Trust’s Governance arrangements, bringing
together clinicians, managers and the Chair of the Hospital Managers Committee.
Outcome 4 Care and welfare of people who use services
People experience effective, safe and appropriate care, treatment and support that
meets their needs and protects rights.
The Public and Patient Involvement Group (PPIG) is an example of how the Trust
works with people to sustain and improve service quality. In 2010 the Trust is placing
particular emphasis on improving access to mental health services for people with a
learning disability. In section 3.6 we outline some of the ways we are working to
provide effective services. The User and Carer Reference Group meets quarterly and
is an opportunity for wide-ranging discussion and information sharing about all
aspects of Trust’s services and clinical practice
Outcome 5 Meeting nutritional needs
People are supported to have sufficient food and drink and a choice of food and drink
to meet diverse needs.
We shall continue to monitor the quality of nutrition provided, and continue to actively
seek feedback from users and carers.
Outcome 6 Co-operating with other providers
People receive safe and coordinated care, treatment and support where more than
one provider is involved, or where they are moved between providers.
The Trust will continue to look at how we share information with partner providers to
the benefit of all. People will receive a full explanation as to why treatment is to be
given either by more than one, or a different, provider.
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Outcome 7: People who use services are safeguarded from abuse
People are protected from abuse or the risk of abuse and their human rights are
respected and upheld.
The Trust will continue to welcome complaints and representations; we actively
support the work of Safeguarding in Suffolk, for both Children and Adults and are
committed to learning when things go wrong and improving services as a result.
Actively encouraging access to and use of Advocacy services is a key part of
ensuring all service users and their carers can find a voice.
Outcome 8: Cleanliness and infection control
People experience treatment, care and support in a clean environment, controlled
against infection.
The Trust is subject to regular independent inspection but also involves service users
and carers in helping us maintain and improve standards. Results from the Staff
survey and the Trust handwashing audit suggest that there are issues both with
technique and availability of gels. This will be subject to continuing audit in 2010-11.
Outcome 9: Management of medicines
People will have the medicines they are prescribed, at the times they need them, and
in a safe way. Wherever possible they will have information about the medicines
being prescribed made available to them or to others acting on their behalf, and in a
format they are able to understand.
The Trust is investing in additional pharmacy staff to enhance the support available
to clinicians. A new system of responding effectively to medical safety alerts has
been implemented.
Outcome 10 Safety and suitability of premises
People receive care and treatment in safe, accessible surroundings that promote
wellbeing.
The Trust is presently investing in new facilities on the Ipswich Hospital, St.
Clement’s Hospital and West Suffolk Hospital sites. The new facilities should be
available from summer 2011. Re-provision of hospital accommodation for people with
a learning disability will be completed in 2010. Our premises now meet the standards
for providing single-sex accommodation.
Outcome 11 Safety, availability and suitability of equipment
Service users, carers and people who work in or visit our premises, are not put at risk
of harm from unsafe or unsuitable equipment (medical and non-medical equipment,
furnishings or fittings). People benefit from furnishings and equipment that is
comfortable and meets their needs.
The Trust has invited widespread involvement in the design of our new facilities. We
will continue to invest in equipment wherever necessary.
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Outcome 12 Requirements relating to workers
People are safe and health and welfare needs are met by appropriate and competent
staff with the right qualifications, skills and experience.
The Trust will continue to involve service users and /or family carers in recruitment.
Outcome 13 Staffing
People are safe and their health and welfare needs are met by sufficient numbers of
appropriately trained, qualified staff.
The Trust is undertaking a significant workforce planning exercise. This will ensure
that the right numbers of staff with the right skills are in place, reducing vacancies
and turnover.
Outcome 14 Supporting workers
People are safe and their health and welfare needs are met by staff who are trained,
well supervised, and receive the development opportunities they need to carry out
their role and keep their skills up to date.
The Trust has significantly improved the information available to managers and staff
about training opportunities and will continue to improve the numbers of staff with
appraisals and personal development plans as well as looking at ways in which
service users and family carers can be involved.
The Trust actively supports
diversity and equality within its own workforce, and encourages participation in the
three employee network groups for now established within the Trust.
Outcome 16 Assessing and monitoring the quality of service provision
People benefit from effective decision-making and the management of risks to health,
welfare and safety.
The Trust continues to review how it monitors quality. We want to involve more staff
in clinical audit. Our developing partnership with representative service-user and
carer organisations is providing rich feedback on people’s experiences, helping
teams to learn how to identify and meet needs effectively. We have continued to
seek ways to increase our involvement in research.
Outcome 17 Complaints
People can have confidence that complaints and comments will be listened to and
acted on by the Trust in a timely manner. People can be confident that they will not
be discriminated against for making a complaint.
The Trust has reviewed the way it investigates complaints and incident. We are
committed to making prompt and effective responses and ensuring that learning is
implemented across the Trust. Complaints are an opportunity to improve our service
provision.
Outcome 21 Records
15
People are confident that personal records including medical records are accurate, fit
for purpose, held securely and remain confidential. Other records required to be kept
to protect safety and wellbeing are maintained and held securely where required.
The Trust has continued to review the quality of care records. We are committed to
continually improving standards through better use of electronic record-keeping.
Clinical records are regularly audited.
Outcomes 5, 15, 18-20 and 22-28 relate to technical issues not directly relevant to
safety and quality of services.
The Annual Health Check in 2009-10
In June 2009 CQC reviewed our 2008-09 self-assessment and declared the Trust
non-compliant with C1b Safety Alerts and C4d Medicines Management. The
declaration submitted by the Trust in December 2009 was the last of its kind,
anticipating the new system for regulating Health and Social Care Providers put in
place from 1 April 2010.
For the December declaration, the Trust went through a comprehensive process of
self-assessment. Every team completed a workbook, exploring in detail how well we
measured up to each standard, what evidence we had to support our assessment
and what, if anything, needed to be done to improve quality. The Board had
extensive discussion of the results, deciding that the Trust would declare ‘noncompliance’ with five standards and approving action plans to improve quality of
service as a result. The five standards were:
•
Safety Alerts (C1b): Procedures have been reviewed and changed. All Safety
Alerts are subject to monitoring and tracking. This means that we know
whether the necessary actions have been taken, and by whom. The Trust is
now compliant with this standard..
•
Medicines Management (C4d): The Trust has invested in extra pharmacy
capacity to provide better support to clinicians and reviewed procedures to
improve information quality assurance.
•
Clinical Audit (C5d): The Trust is supporting clinicians to be more involved in
the design and conduct of audits, and to ensure that improvements in service
occur as a result of audit.
•
Quality of Environment (C20b) and Privacy and dignity (C21): The Trust has a
major building programme underway to create modern in-patient facilities that
meet all modern standards. There is also a significant programme to improve
community-based facilities. Together these will result in major improvements
over the next few years that will leave the Trust compliant.
These objectives are now part of a Trust-wide improvement plan to ensure we fully
comply with all the CQC Essential Standards of Quality and Safety. In January 2010
we submitted our self-assessment and action plans for CQC Registration We
declared ourselves to be not fully compliant with five outcomes.
16
•
Care and welfare of service users (Regulation 9: Outcome 4): The Trust will
improve access to mental health services for people with a learning disability.
•
Assessing and monitoring quality of service provision (Regulation 10:
Outcome 16): The Trust will involve more clinicians in the design and conduct
of audits.
•
Management of medicines (Regulation 13: Outcome 9): The Trust has
invested in extra pharmacy capacity to provide better support to clinicians and
reviewed procedures to improve information quality assurance.
•
Safety and suitability of premises (Regulation 15: Outcome 10): The Trust has
a major building programme underway to create modern in-patient facilities
that meet all modern standards. There is also a significant programme to
improve community-based facilities. Together these will result in major
improvements over the next few years that will leave the Trust compliant.
•
Supporting workers (Regulation 23: Outcome 14): Ensuring 75% of staff have
appraisals by the end of the financial year, publishing a training and
development programme by April 2010 and improving communications
between staff and senior managers. By year end, 63% of staff had a current
appraisal and this is now a major priority for all service lines, with further
measures to support compliance under consideration.
3.3 Our performance against National Indicators
Care Quality Commission rating for SMHP October 2009
The overall rating is made up of a range of assessments the Care Quality
Commission carry out throughout the year. They assess how well the Trust has
performed against key targets and standards the Government has set for the NHS.
The CQC use a variety of methods including analysis of data and self-declaration
from Trusts, which is crosschecked against other sources, for example information
from surveys of patients who have recently used the Trust.
Quality of Services: This score covers a range of areas, including the safety of
patients, cleanliness, access to services and ensuring people’s individual needs are
met.
2008/09 FAIR
2007/08 GOOD
2006/07 GOOD
2005/06 FAIR
Use of Resources: This score is based on how well a Trust manages its finances.
2008/09 GOOD
2007/08 GOOD
2006/07 FAIR
2005/06 FAIR
17
Care Quality Commission’s assessment of Suffolk Mental Health
Partnership’s performance against key targets 2008 and 2009
Category
2008
Safety and cleanliness
9/11
Standard of care
10/11
Waiting to be seen
2/2
Dignity and respect
9/9
Keeping the public healthy
3/4
Good management
14/14
In 2009-10 the criteria were changed to mirror the shift from ‘Annual Health Check
Standards’ to the ‘Essential Standards of Quality and Safety’.
Provider Wide Information - Summary
Category
2009
Provider-wide Information
6/8
Involvement and information
7/7
Personalised care, treatment and support
16/20
Safeguarding and safety
15/22
Suitability of staffing
31/38
Quality and management
21/23
One consequence of changing from the ‘Annual Health Check’ to the new system of
Registration is that CQC will not be publishing their ‘ratings’ for Trusts as in previous
years. They have taken the view that the information assessed for registration is
more up-to-date and detailed and therefore provides a better summary of the current
quality performance of our Trust. CQC publish information for all Trusts on their
website at www.cqc.org.uk
3.4 National surveys of patients and staff in 2009-10
CQC national in-patient survey 2009: what service users said about care in
hospital
CQC use national surveys to find out about the experience of service users when
receiving care and treatment from mental health care providers. At the start of 2009,
a questionnaire was sent to people who had recently had an inpatient stay for acute
mental health problems. Responses were received from 114 service users.
Summary scores for patient survey questions:
18
For questions about
Based on service
users' responses to
the survey, this Trust
scored:
How this score
compares with other
Trusts
Introduction to the ward
6.1/10
About the same
About the ward
7.5/10
About the same
Psychiatrists
7/10
About the same
Nurses
6.6/10
About the same
Medications
4.8/10
About the same
Care and treatment
6.4/10
About the same
Talking therapies
6.6/10
About the same
Activities
3.4/10
About the same
Physical Health Checks
7.5/10
About the same
Rights
6.3/10
About the same
Leaving hospital
7.1/10
About the same
Overall
5.8/10
About the same
About these scores
CQC asked people to tell them what they thought about different aspects of the care
and treatment they received. Each section is scored out of 10, based on the
responses given by people. A higher score is better.
The results take into account the age and sex of respondents, compared with the age
and sex of all people across England that returned the questionnaire. This helps to
19
remove any differences in results that may simply be due to differences in the type of
people responding.
The full report can be found on the CQC website at
http://www.cqc.org.uk/_db/_documents/AAB_NHS_MH_survey_2009_RT6.pdf
CQC staff survey 2009
This national survey draws on answers from a random sample of Trust staff, asking
them a range of questions about the four national ‘Staff Pledges’. The answers are
used to rate the Trust against other providers and gives us useful information about
our strengths and weaknesses as an employer. The survey is confidential and has
now been done for seven consecutive years.
The survey tells us how well we are doing for each pledge and, for the first time this
year, two additional themes.
•
Staff Pledge 1: To provide all staff with clear roles and responsibilities and
rewarding jobs for teams and individuals that make a difference to patients,
their families and carers and communities.
•
Staff Pledge 2: To provide all staff with personal development, access to
appropriate training for their jobs and line management support to succeed.
•
Staff Pledge 3: To provide support and opportunities for staff to maintain their
health, well-being and safety.
•
Staff Pledge 4: To engage staff in decisions that affect them and the services
they provide, individually, through representative organisations and through
local partnership working arrangements. All staff will be empowered to put
forward ways to deliver better and safer services for patients and their
families.
•
Additional themes:
Staff satisfaction
Equality and diversity
The majority of scores remain the same or similar to that of the 2008 survey as
demonstrated in below:
Change of 40 key standards compared with Trusts 2008 score
No
No Equivalent
Negative Change
Score
1
9
0
1
5
0
2
10
2
0
3
0
0
2
2
0
2
0
Significant Change
Survey Section (number of key standards)
Staff Pledge 1 (10)
Staff Pledge 2 (6)
Staff Pledge 3 (14)
Staff Pledge 4 (3)
Additional Theme: Staff satisfaction (4)
Additional Theme: Equality and Diversity (3)
Positive
0
0
0
0
0
1
20
Total (40)
1
4
31
4
Source: National staff Survey 2009, Care Commission 2009
Staff responses placed the Trust in the top performing 20% of mental health and
learning disability Trusts for the following areas:
•
Percentage of staff having equality and diversity training in the last 12 months
(significant increase since 2008 survey);
•
Trust commitment to work-life balance (no significant change since 2008
survey)
•
Lowest percentage of staff feeling pressure in last 3 months to attend work
when feeling unwell (new question for the 2009 survey)
•
Lowest score - impact of health and well-being on ability to perform work or
daily activities (new question for the 2009 survey)
The Trust also performed well (above average) when compared to other mental
health and learning disabilities Trusts with regard to the following areas:
•
Percentage of staff feeling valued by their work colleagues (no significant
change since 2008 survey)
•
Percentage of staff working in a well structured team environment (no
significant change since 2008 survey)
•
Percentage of staff using flexible working options (no significant change since
2008 survey)
•
Percentage of staff receiving job-relevant training, learning or development in
last 12 months (no significant change since 2008 survey)
•
Percentage of staff receiving health and safety training in last 12 months (no
significant change since 2008 survey)
•
Staff motivation at work (new question for the 2009 survey)
•
Low score with regard to work pressure felt by staff (no significant change
since 2008 survey)
•
Low percentage of staff suffering work-related injury in last 12 months (no
significant change since 2008 survey)
•
Low percentage of staff suffering work-related stress in the last 12 months (no
significant change since 2008 survey)
•
Low percentage of staff witnessing potentially harmful errors, near misses or
incidents in last month (no significant change since 2008 survey)
•
Low percentage of staff experiencing physical violence from patients /
relatives in last 12 months (no significant change since 2008 survey)
21
•
Low percentage of staff experiencing harassment, bullying or abuse from
patients / relatives in last 12 months (no significant change since 2008
survey)
•
Low percentage of staff experiencing harassment, bullying or abuse from staff
in last 12 months (no significant change since 2008 survey)
However, the Trust was ranked in the worst 20% of mental health and learning
disability Trusts for the following areas:
•
Percentage of staff feeling satisfied with the quality of work and patient care
they are able to deliver (no significant change since 2008 survey)
•
Quality of job design (clear job content, feedback and staff involvement (no
significant change since 2008 survey)
•
Percentage of staff appraised in last 12 months (no significant change since
2008 survey)
•
Percentage of staff appraised with personal development plans in last 12
months (no significant change since 2008 survey)
•
Percentage of staff reporting errors, near miss or incidents witnessed in the
last month (no significant change since 2008 survey)
•
Percentage of staff agreeing that they understand their role and where it fits in
(no significant change since 2008 survey)
•
Percentage of staff able to contribute towards improvements at work (no
significant change since 2008 survey)
The Trust also performed poorly in the following areas:
•
Percentage of staff agreeing that they have an interesting job (no significant
change since 2008 survey)
•
Percentage of staff feeling there are good opportunities to develop their
potential at work (no significant change since 2008 survey)
•
Percentage of staff having well structured appraisals in last 12 months (no
significant change since 2008 survey)
•
Percentage of staff saying hand washing materials are always available (no
significant change since 2008 survey)
•
Perception of staff that there is fairness and effectiveness of incident reporting
procedures (no significant change since 2008 survey)
•
Higher than average percentage of staff experiencing physical violence from
staff in last 12 months (no significant change since 2008 survey)
22
•
Percentage
of
staff
reporting
good
communication
between
senior
management and staff (no significant change since 2008 survey)
•
Below average score regarding staff recommendation of the Trust as a place
to work or receive treatment (new question for the 2009 survey)
The full staff survey is available on the CQC website at www.cqc.org.uk
The Trust also uses its own measures:
•
Training compliance – measures whether staff have undertaken the
required statutory and mandatory training
•
Recruitment and workforce planning – how successful we are in designing
and recruiting to new posts and vacancies
•
Turnover – how successful we are in retaining experienced staff
•
Appraisal – what proportion of staff have current Personal Development
Plans
•
Leadership development opportunities – identified staff can participate in
the Trusts leadership programme; over 50 staff are benefitting from this
opportunity
You can see a summary of all the information that CQC has collected about the Trust
in our Quality and Risk Profile. A copy is available on the Trust website at
www.smhp.nhs.uk and at www.cqc.org.uk
3.5 How do we measure the quality of our services?
We believe there are three elements to defining quality. These are
• How people experience our services (whether service users or carers)
• How safe our service is for people
• Clinical services are up-to-date and effective
The better we do in each of these areas, the better the quality of our services.
Each of the three areas have different types of measures, some qualitative (views
and experiences) and some quantitative (numbers)
•
People’s experience
o Patient Reported Outcome measures (PROMS)
o Complaints
o Compliments
o Feedback from Service User and Carer groups
o Feedback from in-patient and community-based meetings
o Local surveys of Users and/or carers
o CQC National in-patient survey
o CQC national Community Mental Health survey
o Staff survey
o PEAT (Patient Environment Action Team) inspections
o Stonewall Diversity audit
23
•
Patient safety
o Hygiene Inspections
o Audit of Hygiene code (eg Handwashing)
o Serious Untoward Incidents
o AQMAR – Assessing the Quality of Medical Appraisal for Revalidation
has been undertaken on a regular basis, and that the board has
agreed and monitored a development plan, building on the findings
o Safety alert audits
o Pharmacy Audit
o Medicines reconciliation
o Health and safety Inspections
o Untoward Incidents reporting system
•
Clinical effectiveness
o National and local Clinical audit
o Clinician Reported Outcome measures (CROMS)
o Statutory and mandatory training
o Clinical supervision
o Annual appraisal and personal development plans
o Research
o implementing clinical guidelines
The Trust Board, both directly and through its governance arrangements, has the
responsibility for reviewing and evaluating this feedback in order to influence
priorities, decision-making and improve clinical performance. The Board receives a
monthly ‘Quality Report’ that summarises new information and helps the Board
monitor improvement plans arising.
The Trust has four Governance committees, bringing together clinicians and
managers. Their task is to ensure that learning is shared and that change happens.
They advise the Board on progress.
In the past year the Board has approved a new
•
Patient and Public Involvement Strategy
•
Clinical Audit Strategy
•
Equality and Human Rights Strategy and Single Equality Scheme
•
Information Strategy (updated)
•
Records Management Strategy
Together these represent a comprehensive shift in the way the Trust thinks and acts.
Alongside the continuing modernisation of services and the major programme for
modernising facilities, they provide a basis for further moves towards partnership and
collaborative working – with communities, partner organisations, service users and
carers and our staff.
The Board receives a Quality Report each month. Through the Audit Committee the
Board also agrees an annual programme with Internal Audit. Internal Audit provides
an independent and objective opinion to the Board on the degree to which risk
24
management, control and governance support the achievement of the organisation’s
objectives. Through the year this process provides assurance to the Board that the
necessary controls are in place to identify and manage risks that might challenge the
safety and quality of Trust services.
Internal Audit systematically reviews and evaluates the policies, procedures and
operations in place to:
•
•
•
•
•
•
Establish, and monitor the achievement of the organisation’s objectives
Identify, assess and manage the risks to achieving the organisation’s
objectives
Ensure the economical, effective and efficient use of resources
Ensure compliance with established policies, procedures, laws and
regulations
Safeguard the organisation’s assets from losses
Ensure the integrity and reliability of information, accounts and data.
25
3.6 Our Priorities for Improvement
Update on 2009-10 priorities
Priority
Implementation of Patient Reported
Outcome Measures (PROMs) across all
clinical services.
Outcome
All clinical areas have identified
appropriate PROMs and are
implementing them.
Establish service user feedback
arrangements in all services as part of
our public and patient involvement
strategy
All in-patient areas have feedback
arrangements (including patient groups)
in place. A pilot to hold ward-based
advice sessions is underway in
partnership with Suffolk User Forum.
Reducing harm to service users and staff
All In-patient areas now have electronic
systems to manage access and egress.
The Trust Board has approved a new
Access and Egress Policy to replace the
former ‘Locked-door’ Policy.
Enhance the use of external
accreditation and clinical audit to provide
independent assurance on meeting
standards
The Trust Board has approved a new
Clinical Audit Strategy and Plan that
prioritises key areas and enhances
clinical involvement in audit.
To improve the working environment to
enhance satisfaction of our staff
A continuing programme to monitor and
improve the quality of working
environments is in place
Reduce wastage through sickness and
injuries and turnover
The workforce planning governance
group is reviewing all the ways in which
the Trust supports its staff. The Trust
encourages flexible working, supports the
work-life balance team and is looking to
improve the support to staff available
through Occupational Health
arrangements
Implementation of the Trust’s Equality
and Human Right’s strategy
The Board has approved a ‘Single
Equality Scheme’ creating a cohesive
approach to equality, diversity and
human rights. An intensive training
programme for staff has been supported
by the production of ‘Equality Impact
Assessments’ for all clinical areas and
key policy documents - available on the
Trust website at www.smhp.nhs.uk
26
Our Improvement Priorities for 2010
What Matters To You? A stakeholder survey
Every year the Trust receives many comments and suggestions about how practice
and services can be improved. They come from service user meetings, suggestions
boxes, complaints and compliments. They also come from national surveys of
patients and staff.
In publishing its Quality Account for 2010 the Board is keen to know what people
think matters most. A survey was commissioned, and completed by 184 individuals
and organisations, to help capture these views.
The survey asked people to respond to 37 statements by indicating which were most
important, and which improvements seemed most possible to achieve. Each
statement reflected issues and concerns that had been raised with the Trust in 200910. These issues may have been expressed by one person or many; each were
given equal weight because unlike most surveys, this one was designed to help the
Trust focus and prioritise its efforts. The inclusion of a statement does not imply
that the Trust necessarily performs poorly in that area, but it does reveal that
concern and/or dissatisfaction has been expressed and that people feel that the Trust
could readily act to improve or sustain standards. The statements reflect the three
quality areas of safety, people’s experience and clinical effectiveness.
Responses have now been analyzed and show that the top 5 issues are (scores out
of 100)
•
•
•
•
•
People should feel welcomed and respected when arriving at Trust premises–
95
People (and those close to them) should be informed about how they can get
help in a crisis or when urgent help is needed – 85
People should receive care and treatment in premises that are clean and tidy
- 80
People should be treated by staff using the 5 principles of the Human Rights
Act – Fairness, Respect, Equality, Dignity and Autonomy - 60
People should be offered regular opportunities to comment on their care and
treatment - 32.5
These are the areas that the Board will be closely monitoring over the coming twelve
months; look to the Trust websites for updates on our progress. The next five highest
scoring issues were:
•
•
•
•
•
People should be asked to show that they agree with their care plan and be
given a copy to keep.
People should be encouraged to say how they wish to be treated at those
times when they cannot make their own decisions (advance directives)
People should not be disadvantaged or discriminated against if they make a
complaint
People should be confident that staff have the skills and training to practice
safely
People should feel safe when on Trust premises.
You can see the full list of statements and scores at www.smhp.nhs.uk
27
These priorities echo many of the key elements in the CQC’s Essential Standards of
Quality and Safety. Teams and Service Lines can use them as a simple check list for
thinking about performance and areas of improvement. They can also register clinical
audits where they wish to assess existing performance.
28
3.7 Innovation: New initiatives from 2009-2010
We are proud of the innovative culture that is taking root in SMHP. In this section we
have reviewed the three areas of quality – people’s experience, patient safety and
clinical effectiveness – and summarised many of the ways that we are encouraging
initiatives that improve services. You can learn more from the Trust’s website where
you can sign up to receive Trust Newsletters. Even better, join us as a Foundation
Trust member and make a real contribution to the future of Mental Health and
Learning Disability Services in Suffolk.
Improving people’s experience
A significant moment in the modernisation of services for people with a Learning
Disability arrives in the summer of 2010. The reprovision of Stourmead and
Lothingland will mark the end of long-term hospital-based accommodation. A range
of individually planned solutions will be in place giving residents and their carers
choice and control of their living arrangements.
People thought to be suffering mental health problems can now use a new Section
136 Assessment Unit. In a joint venture with Suffolk Constabulary, the suite - at
Wedgwood House in Bury - provides refuge for mentally distressed and vulnerable
people found by the police and acts as an alternative to custody. The suite is
designed to meet the needs of both adults and young people needing assessment.
Launched in July 2009, the Respect for dementia - If you only knew anti stigma
campaign describes the reality for people living with dementia. Experiences were
gathered as part of a joint project with Suffolk Alzheimer’s Society, Suffolk Family
Carers, and Suffolk Age Concern. ‘User Views’ held discussion groups with people
either caring for someone with dementia or diagnosed with the condition. A
widespread poster campaign has been followed by two ‘diaries’ that tell the story of a
fictional couple, Jim and Sally, living in Suffolk as they come to terms with dementia.
The stories are full of tips and resources that many people have found useful. A
second printing has been needed to meet demand! You can find out more at
http://www.ifyouknew.co.uk
Service users have been restoring a Victorian walled garden in Suffolk as part of a
project to aid recovery. They have been digging, weeding and planting their way to
mental wellbeing as they maintain the once neglected garden at a Stowmarket
museum. The project – called Living Valued Lives – is in partnership with the
Museum of East Anglian Life.
Staff, users and carers have been working together to identify how library and
information resources can be made more accessible, and better used. A Trust
survey had identified low usage and a lack of knowledge about what is available at
libraries. The group want resources that are accessible and useful to service users
and carers. The project is run jointly with the Public Library service and Suffolk
County Council.
A new user and carer reference group has been meeting since July 2009. It is well
supported by local user and carer group representatives, Trust managers and
clinicians and Board members. The group helps ensure that we
• Consult properly about changes to services
• Ask people how our services could be improved
29
•
•
•
•
•
Base service improvements on what people tell us
Are consulting properly when implementing change
Really involve service users and family carers in the day-to-day running of
services
Are asking service users and family carers about the quality of our services –
and how to make improvements
Have services that are accessible to all our diverse communities
The Board and Executive receive regular reports from the group highlighting issues
raised and monitors the actions taken to address them.
The Suffolk Early Intervention in Psychosis (SEIPS) service has been running a
football training group at Ipswich Town Football Club since July 2009. The facilities
and coaching staff have been provided by the excellent Ability Counts team of the
Community Trust based at the club itself. Apart from the obvious benefits of team
working and physical exercise, the group allows clients the opportunity to develop
new friendships and skills. It helps rebuild confidence and self esteem through an
activity which is not associated with the stigma of mental health. to the group will
stage an Early Intervention football tournament for East Anglia to help raise public
awareness of psychosis in a more positive and less stigmatised way.
The 8th annual Five-a-side football tournament in Bury St Edmunds involved over
16 teams made up of staff and service users from different organisations. Staff,
service users and carers battle it out for medals and the Trophy. With widespread
participation and sideshows and stalls in addition this has become a significant event
in the annual calendar.
In the East of the County, Ipswich Town Football Club Community Trust and Ability
Counts hosted ‘Breaking down Barriers’, a five-a-side football tournament aiming to
bring a sense of pride to those taking part. The diverse nature of the teams reflected
increased interest in the positive role that physical exercise can play in building and
sustaining good mental health. Several mental health organisations including Suffolk
Family Carers, Suffolk User Forum, Stepping Forward, Suffolk Business Minded and
Employment Support Partnership were involved, providing advice and guidance on a
range of topics.
The Trust joined with Service organisations and specialist charities to improve
understanding and develop support networks for serving military personnel and
veterans with mental health problems. The workshop explored themes and issues to
help meet the needs of people returning to civilian life, particularly the role of
psychological therapies in primary care.
A customer survey in the Terrace Restaurant at St Clements is helping Suffolk
Support services plan further improvements. There was high praise for the menu, the
cooking, its value for money and cleanliness. Responding to the survey, the
restaurant, used by staff, patients and visitors, has been working to reduce delays,
widen the range of food on offer and be more environmentally-friendly.
Learning disabilities staff have developed an innovative way of learning about
dignity in care. They use role-play to explore the best ways of protecting the rights
of vulnerable adults. Safeguarding champions lead sessions that improve service
quality by encouraging staff to think about how best to respect the dignity and human
rights of clients by looking at practical situations. 95% of based at Oulton have
received Protection of Vulnerable Adult (POVA) training in this way. Peter Tempest,
30
chair of Suffolk's Adult Safeguarding Board said: The board wishes to congratulate
staff in the Trust for their commitment to developing innovative safeguarding training
to make its customers safer. The staff’s motivation and team building skills provide us
all with a best practice model for future service development.
The Trust’s lesbian, gay and bisexual (LGB) network has drawn up new practice
guidelines for supporting LGB colleagues and service users. The guidelines advise
other staff about the journey of ‘coming out’, self acceptance and being accepted.
They touch on how to ask service users about their sexuality and how to then build a
care plan around their needs. They also examine issues of being lesbian, gay or
bisexual within different faith or race communities, across different age ranges and
within other health areas, such as learning disability services.
The Trust first registered as a Stonewall Diversity Champion in 2008 (Stonewall is
the leading national charity that promotes LGB equality), thanks to the work of the
LGB employee network group. A survey carried out within the group shows that 91%
of those people asked agreed that the workplace culture of the Trust is inclusive of
LGB people compared with a national average of only 72%. In 2009 we came a
creditable 14th out of 43 Trusts assessed by Stonewall.
A launch event showcased a redesigned service for vulnerable children in
Suffolk. The innovative service, called Connect, provides mental health care for
‘looked after’ and adopted children. Connect is a joint venture between The Trust and
Suffolk County Council. The occasion highlighted guest speaker Dr Margot
Sunderland from the Centre for Child Mental Health in London, an internationally
acclaimed expert in child mental health and parenting. Other presentations came
from Connect staff and there was a moving personal story from an adoptive parent.
The Crisis Card (one for East Suffolk and one for the West) is a useful way of
keeping essential information to hand. There may be times when Service users are
unable to communicate their needs and get the help required. That’s where the card,
available from care-coordinators, comes in. It’s small enough to go in a purse or
wallet and includes basic information such as who to contact in a crisis.
Each team working across the Trust is assessing how their practice matches the
aspirations of our Patient and Public Involvement (PPI) strategy. The informal audit
helps show whether service users’ and family carers’ experience of the Trust match
the PPI strategy. The results of these team audits are shared with the User Carer
Reference Group. Teams are being asked whether they provide information, how
they involve service users and family carers in planning and evaluating services and
whether users are involved in recruitment.
Ward Walks by Suffolk User Forum provide invaluable feedback to staff and
managers on a regular basis. The walks not only help staff learn what patients think
about standards of care, but also assess facilities, cleanliness and the environment.
The ‘walk’ idea is now being extended to all Trust premises.
The Releasing Time to Care: Productive Ward programme could allow ward
nurses up to 40% more time on direct patient care. The programme is led by frontline staff in co-operation with patients and carers. It allows change to working
practices on the wards, releasing more time to be spent on direct patient care. The
programme has four basic objectives –
• to improve patient safety and reliability of care,
• to improve the patient experience,
31
•
•
to improve staff well-being and
To improve the efficiency of care.
Eleven wards across the Trust are taking part in the initiative and are already seeing
the benefits in terms of staff spending more time with service users.
‘Get Out and Live!’ is an initiative to develop partnerships that involve service users
and family carers in activities that will benefit their health and well-being. It promotes
all aspects of healthy living, from smoking cessation to diet management. A steering
group is made up of healthcare professionals and representatives from a wide range
of partner organisations from the NHS and the Voluntary sector.
Keeping people safe
All in-patient facilities across the Trust now have electronic systems to manage
‘access and egress’. The board has approved a new access-egress policy to
replace the former ‘locked-door’ policy.
The adoption of a new remote access solution to support remote/mobile working is
now well advanced and planned to be introduced from summer 2010 onwards.
Through Suffolk Support Services the Trust has agreed to fund a new post to lead on
all aspects of waste management including recycling and other initiatives.
Mentorship is an essential part of ensuring that nursing staff practice safely. The
Trust mentor register is an IT system that records all relevant information, including
the results of the new triennial reviews required by the Nursing and Midwifery
Council. The system has been commended and has attracted the interest of other
NHS Trusts.
The new Antipsychotic Depot Injection medicine record card is now used in all
clinical areas throughout the Trust replacing a variety of existing documents. The
card enables the accurate recording of side effects that is crucial for good care. It
also helps us contribute to a national audit of side effects of depot medication.
The card complements the new in-patient medication card; the Board believe these
new tools will make a real contribution to improved record-keeping, enhancing the
safety of care.
Northgate and Southgate Wards in Bury St Edmunds have been awarded
accreditation from the Royal College of Psychiatrists AIMS Programme for the
quality of their in-patient services. The scheme provides independent evaluation of
clinical quality
Both of the services in the east and the west which provide electroconvulsive therapy
(ECT) achieved accreditation following an assessment by the Royal College of
Psychiatrists and the Royal College of Anaesthetists.
The Suffolk Support Services Mental Health Informatics Team has led our local
project to ensure we use the NHS Number as the unique patient identifier. Using the
NHS number helps ensure the right patient is getting the right service and treatment.
Audits show that the Trust is 99% compliant.
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The Trust is educating staff in Life Support and the use of defibrillators. Almost eight
hundred people have trained in Basic Life Support; over 50% of those have gone on
to train in Intermediate Life Support, which covers the use of Automated External
Defibrillators, airway adjuncts, emergency oxygen therapy and suction.
Suffolk Support Services has a new website highlighting its services. Visitors to
www.thesupportservice.co.uk access up-to-date information about services and an
opportunity for feedback. SSS has also encouraged feedback on cleanliness and
catering through surveys and ward meetings at St. Clements.
The Foundation Trust project office has been running another series of free mental
health talks. The informal and friendly series runs all year with dates in Ipswich,
Stowmarket and Bury. Topics range from psychosexual issues to dementia and all
are welcome – service users, family carers, Foundation Trust members, staff and the
general public.
The AMHP (Approved Mental Health Practitioner) service, in conjunction with ESAN
(East Suffolk Advocacy Network) and Suffolk User Forum, has set up a project called
‘Learning from your experience’. This project offers detained patients the
opportunity to raise issues regarding Mental Health Act Assessments and other
aspects of treatment they wish to address. This project requires AMHPs to attend
training, to be available for interview work and to review decisions and processes.
These meetings take place on all wards where patients are detained under the
Mental Health Act.
Providing effective services
Service line management is a new way of organising our services that gives frontline staff the significant voice in the planning, delivery and monitoring of services.
Each Service Line Lead is an experienced and senior clinician. Across the Trust
Service Lines are re-assessing how services can be organised and delivered more
effectively, laying the basis for a devolution of decision-making within the Trust.
Implementation is supported both by the leadership development programme and
training in the use of lean principles that enable teams to identify effective ways of
re-designing care pathways. One example is the collaborative work between hospital
and community services to rethink the ways that services respond to people with
acute mental health needs.
The Trust has transferred the provision of its bank and temporary staffing from the
current internal bank system to NHS Professionals (NHSP).
Payment by Results is a system already used by NHS Hospitals for regulating the
flow of resources in the NHS. It is based on an analysis of the costs involved in
providing particular treatments and services and aims to help us use income as
effectively as possible. The Trust, in cooperation with NHS Suffolk is actively
preparing for this significant change in the way service contracts are negotiated.
Big Red Button Prize Fund - improving the quality of our information
Each quarter prizes are awarded to the most improved and the most consistently
high achieving Service Line. Winners in July 2009 were CAMHS (for the greatest
improvement) and Community East for the best overall performance. Each won £10K
to invest in their service. The prize is focussed on improving data recording in areas
where the Trust most needs to improve, driving up standards to the benefit of the
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Trust and its patients. Good data quality helps us show to commissioners and
regulators what we are doing and ensures that our resources are being well-spent.
Enabling easier access to learning opportunities is reflected in the steadily increasing
use of e-learning in the Trust. The Programme now covers safeguarding, legal
aspects of care such as the Mental Capacity Act and diversity training. E-learning is
proving to be a useful adjunct to traditional learning methods.
An improved layout, a better presentation and a whole host of additional data greets
users of the Trust’s updated management information system – MIS. Teams have
suggested improvements to the way that performance data can be displayed so that
they can quickly and easily find out how well they are performing. Collecting up-todate patient data is absolutely essential for the quality care provision and informs
commissioners around our activity and performance. The Care Quality Commission
and the Department of Health (DH) also use this information to judge the standards
of our organisation. No data – no activity! A new ‘breaches’ section which highlights
the key performance areas that the Trust has to achieve such as referral to treatment
time. All information within the MIS is reportable at Trust Board, directorate, service
line or team level. The Trust ‘Intranet’ has also undergone a major re-design helping
staff to access information more quickly.
A research open day raised the profile of research in the Trust and showcased the
work of The National Institute for Health Research (NIHR) networks across East
Anglia. Staff were invited to ‘drop in’ during the day to visit stands and talk to
research staff. There were also presentations of current research projects.
Participating in research and using the knowledge gained contributes to effective
treatment and patient safety. The message is that “help is at hand”, even for the most
novice of researchers. This past year has seen a significant growth in research
activity. Staff have contributed to 12 new journal articles and books; presented
papers and seminars at a variety of national conferences; contributed to course
design and development nationally and internationally; 14 staff have received
academic awards and recognition.
The Birmingham Treatment Effectiveness Initiative (BTEI) is being adopted by our
Substance Misuse Services. It is helping deliver the SMS mission statement’s
ambition to respect individual needs, promote recovery and foster social inclusion.
Eager to explore new ideas and model, SMS have been training in ‘Node-link
mapping’, a technique for discussing issues with clients and visualising them in a
series of ‘maps’ to develop awareness of the relationship between thoughts, feelings
and behaviours. The training goes beyond introducing the clinical tools to discuss the
need for changing all aspects of services. Feedback has been extremely positive,
and SMS has the support of the National Treatment Agency. New ways of working
support the changes which will continue over the coming year with clinical and
research links being developed with the University of Birmingham.
A leadership development programme delivered by the Advisory Board Company
is providing an opportunity for the Trust to improve the abilities and capacities new
and established leaders across all clinical areas. The programme, due for completion
in 2011 has so far explored improving staff performance, problem solving and
innovation and leading through vision. Learning together makes a significant
contribution to continuously improving the quality of leadership across the Trust
All Service Lines are preparing Business and Marketing Plans. These will help us
to focus on what communities in Suffolk need and identify gaps in provision; they will
also help us use resources as efficiently as possible.
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Public Benefit
Suffolk Business Minded is a ground-breaking partnership between the Trust and
local businesses. Almost 100 delegates from local employers attended the two
launch training events, called ‘How to avoid stress and benefit your business’. The
initiative aims to help managers by providing them with the knowledge and skills to
manage mental well-being at work. A successful follow-up forum has increased
awareness of mental health in the workplace. Organisations and companies can sign
up to become a ‘mindful employer’ at www.mindfulemployer.net
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3.8 Indicators used by the Board for assessing our Quality
Performance
Each month the Trust Board reviews the Trusts performance against a range of
national indicators. These provide key measures for assessing whether we meeting
targets for quality and safety and that our resources are being directed as effectively
as possible.
Target
2008/09
2009/10
90%
91%
97%
Green
Green
Green
7.00%
9.90%
2.90%
40
66
56
37
62
50
38
64
54
900
1135
907
N/A
46%
N/A
4%
95%
96.40%
95.10%
95%
94.40%
95.20%
N/A
100%
5.30%
5.20%
People’s experience
Proportion of adult acute
admissions gate-kept by crisis
resolution teams
Progress against PEAT action
plan
Occupied Bed Days lost to
delayed transfers of care as
proportion of available OBDs on
adult and older people's acute
IP wards
Overall average length of stay
in days(including delayed
transfers of care patients) on
adult and older people's acute
IP wards
Adult Acute
OPMH Acute
Total
Number of home treatment
episodes delivered by CRHT
teams
MH16 - NI 149: Adults receiving
secondary mental health
services on Care Programme
Approach (CPA) in settled
accommodation
MH17 - NI150: Adults receiving
secondary mental health
services on Care Programme
Approach (CPA) in employment
Patient Safety
Percentage of people on
enhanced Care Programme
Approach (CPA) seen within 7
days of discharge from trust IP
Data quality - ethnicity
recording of all service users
Improved continuity of care for
prisoners subject to CPA Prisoners followed up
Clinical effectiveness
Percentage of available staff
5%
36
time lost as a result of staff
sickness absence
Percentage of substantive
posts where staff member has
left the trust in previous 12
months
Readmission of adults to Trust
In-Patient wards within 28 days
of discharge
The number of people who are
moving to recovery as a
proportion of all those who have
completed a course of
psychological treatment
received from IAPT (‘Omnibus
Survey’
Percentage of Substance
Misuse Service clients – where
a decision to retained in
treatment or with a discharge
care plan care within 12 weeks
of first contact
Target
2008/09
2009/10
11%
11.50%
12.00%
7.50%
8.20%
7.00%
N/A
75.40%
81%
86%
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Glossary
Care Programme Approach – a way of ensuring that people’s care is planned and
reviewed, and that people are kept safe consistent way
Clinical audit – a method for ensuring that clinicians follow best practice and learn
from mistakes
CQC (Care Quality Commission) – the organisation that ensures the Trust’s services
comply with required standards
CQUIN (Commissioning for Quality and Innovation) is a process for ensuring that the
Trust’s income is in part dependent on delivery improvements in the quality of
services. NHS Suffolk will look for evidence from Users and carers that specific
quality objectives are met.
CROMS (Clinician Reported Outcome Measures) are a method for measuring the
effectiveness of clinical services
EPEX – The trust’s electronic Health records system
Essential Standards of Quality and Safety – The key outcomes that CQC use to
assess the quality of our services
FACE (Functional Assessment of Clinical Environment) – a method for assessing the
needs of people by identifying risks to their well-being
Governance committees – Groups of senior managers and Clinicians who review
the work of the Trust and provide information to the Board about successes and risks
(and what is being done about them)
National Confidential Inquiries – Collection of information about serious incidents
such as suicide. They are confidential to encourage full and open reporting by
clinicians
NHS Number – Everyone has a unique number that ensures that treatment is given
to the right person.
PEAT (Patient Environment Assessment team) – a national programme for
assessing the quality of clinical environments provided by the Trust
POMH-UK (Prescribing Observatory for Mental Health) - design and evaluate
national clinical audits. The Trust submits data to many of these
PROMS (Patient Reported Outcome Measures) – standard ways of recording what
people think of the treatment they have received and whether it made a difference.
Service Line Management – a way of organising services used by many Trusts.
Each Service Line is led by a senior clinician (the Service Line Lead) and supported
by a Service Line Manager
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Part 4: Comments from Stakeholders
Suffolk LINk:
Suffolk Link thanks Suffolk Mental Health Partnership NHS Trust for the opportunity
to comment on the Quality Accounts for 2009/2010 at this time.
The Report is clearly presented with its wide patient and user base in mind. However,
it would be helpful to have the acronyms spelled out initially with the initials in
brackets for further clarity for the public. The results of outside inspections and audits
are clearly presented in a readable format to enable questions to be asked.
User’s comments have been addressed and it is encouraging to see that progress
has been made in addressing issues with future work clearly identified against
required outcomes and services for both patients and staff in the eight national
audits.
The Suffolk Link looks forward to hearing of the progress of the Suffolk Mental Health
Partnership NHS Trust against these audits and working with the Trust in the year
ahead.
Our response: All acronyms are now spelled out, and a glossary has been added to
explain technical terms.
NHS Suffolk:
‘NHS Suffolk, as the commissioning organisation for Suffolk Mental Health
Partnership Trust, has been involved in determining the content of this Quality
Account to ensure it concentrates on information on the provision of services which
are of local priority. In producing this report, Suffolk Mental Health Partnership Trust
have consulted with patient and public groups, staff and statutory bodies to make
certain that their opinions are taken into consideration.
In reviewing this final document NHS Suffolk are confident that it reflects accurately
the quality, safety and effectiveness of the services provided and are pleased to
support its publication.’
Carole Taylor-Brown
May 2010
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Health Scrutiny Committee:
The Suffolk Health Scrutiny Committee has decided not to comment on any of the
Suffolk provider NHS Trust's Quality Accounts for 2009/10 and would like to stress
that this should in no way be taken as a negative comment. The Committee has
taken the view that it is appropriate for Suffolk’s Local Involvement Network to
consider the Quality Account and comment accordingly
40