Quality Account
2010/11
Contents
Tables, Diagram and Chart Index
3
1.
PART 1: Statement on Quality from the Chief Executive
4
2.
5
2.1
2.2
2.2.1
2.2.2
2.2.3
2.2.4
2.2.5
2.2.6
2.2.7
PART 2: Priorities for Improvement, Performance against 2010/11 Priorities
and Statements of Assurance from the Board
Priorities for Improvement
Performance against 2010/11 Priorities
Priority 1: Standards of Clinical Supervision (Patient Safety)
Priority 2: Performance of Community Mental Health Teams
Priority 3: Standards in Inpatient Units
Priority 4: Ensuring NICE compliance (Patient Safety)
Priority 5: Developing Care Pathways (Effectiveness)
Priority 6: Clinical Risk Assessment (Patient Safety)
Priority 7: Therapeutic Activity (Effectiveness)
2.3
2.3.1
2.3.2
2.3.3
2.3.4
2.3.5
2.3.6
Statements of Assurance from the Board
Review of Services
Participation in Clinical Audits
Participation in Clinical Research
Commissioning for Quality and Innovation (CQUIN)
Care Quality Commission (CQC)
Data Quality
17
3.
PART 3: Review of Quality Performance
Patient Safety
Improved Safety Culture
Drug Errors
Violent Incidents
Serious Untoward Incidents (SUIs)
Mandatory Training
Staff Appraisal
23
23
3.2
3.2.1
3.2.2
3.2.3
27
3.2.5
3.2.6
Clinical Effectiveness
National Indicators: Indicators for Quality Improvement (Effectiveness)
Royal College of Psychiatrists Peer Review
Peer Review by Quality Network for Inpatient CAMHS (QNIC) and
Qualitative Data
National Minimum Standards for General Adult Services in
Psychiatric Intensive Care Units (PICU) and Low Secure Environments
Advancing Quality
Carer’s Assessments
3.3
3.3.1
3.3.2
3.3.3
3.3.4
3.3.5
3.3.6
3.3.7
Patient Experience
Service User Experience
Contributions of Stakeholders
Video Booths
Patient Complaints
Age Appropriate Services
Privacy and Dignity Single Sex Accommodation
Peer Support Group
32
3.4
Performance Against Key Mental Health Indicators
40
3.5
3.5.1
Quality Management Systems
Quality Initiatives
41
4.
Annexes
44
5.
Independent Auditor’s Report to the Board of Governors
52
3.1
3.1.1
3.1.2
3.1.3
3.1.4
3.1.5
3.1.6
3.2.4
5
6
Table, Diagram and Chart Index
Table 1
Table 2
Table 3
Table 4
Table 5
Table 6
Table 7
Table 8
Table 9
Table 10
Table 11
Table 12
Table 13
Table 14
Table 15
Table 16
Table 17
Table 18
Table 19
Table 20
Table 21
Table 22
Table 23
Table 24
Table 25
Quality Overview with comparison against previous year’s data
Clinical Supervision
National Community Patient Survey Results
Adult and Older Adult Inpatient Surveys
National Inpatient Survey Results
NICE Implementation Gap Analyses
Outcome from POMH-UK Audits
PTSD Clinical Outcomes
Participation in Clinical Audits
National Confidential Enquiries
CQC Registration
Data Quality
Clinical Coding Accuracy
Drug Errors
Highest Incidents per Category
Indicators for Quality Improvement
Royal College of Psychiatrists Peer Review of Guild Lodge
QNIC Report for The Junction
QNIC Report for The Platform
Low Secure Self-Assessment Toolkit
Advancing Quality Indicators
Carers’ Assessment Outcomes
LCFT Secure Services Satisfaction Survey
Ombudsman Requests
Performance against Key Mental Health Indicators
7
7
8
9
10
12
13
14
18
18
21
22
22
24
25
27
28
29
29
31
31
32
35
38
40
Diagram 1
Diagram 2
Diagram 3
Diagram 4
Diagram 5
Diagram 6
Diagram 7
Diagram 8
Diagram 9
Diagram10
Never Events Target
Recovery Star
SUIs reported within 2 working days
SUI reviews completed (45 days)
Staff Mandatory Training
Staff Appraisals
What young people and parents said in the QNIC Report
PTSD Service Users’ Questionnaire
What young people are saying about The Junction
LCFT Secure Services Satisfaction Survey: service user comments
12
15
26
26
26
27
30
33
34
36
Chart 1
Chart 2
Chart 3
Chart 4
Falls resulting in a fracture
Number of patients colonised with MRSA
Number of patients C.difficile Toxin Positive
Percentage of staff witnessing potentially harmful errors, near misses
or incidents
Percentage of staff that reported a near miss witnessed in the
previous month
Number of Violent Patient Against Patient Incidents
Number of Occupied Bed Days per Violent Patient Against
Patient Incident
Violence Against Staff (rate per 1,000 Staff)
Number of compliments or complaints received
Young Person Admissions to Adult Wards
10
11
11
23
Chart 5
Chart 6
Chart 7
Chart 8
Chart 9
Chart 10
24
25
25
26
38
39
Quality Account
Part 1: Statement on Quality from the Chief Executive
The delivery of high quality services to the local community is our core purpose as a
Foundation Trust and we strive to make improvements year on year. This report
provides an account of our services over the last 12 months, including many
examples of excellent practice. We met all our major targets and performance has
improved in a number of areas. There are also a number of areas which require
improvement and these have been identified in the report. It also sets out the plans
we have to improve in those areas where we feel higher quality is demanded and
aims to provide you with assurance on our policy of continual improvement.
The Council of Governors and the Trust Board have approved this Quality Account
which covers the full range of Trust services. The information contained in this
account is accurate to the best of our knowledge.
During 2010/11 we have continued to emphasise our core values as we believe these
promote the type of behaviours, which we need to deliver the standard of service
to which we aspire. In 2011/12 we expect to move forward on our journey by taking
on services from the provider arms of the Primary Care Trusts in Blackburn with
Darwen, Central and East Lancashire. Our belief is that, through this integration of
mental health services with community services, we will be able to deliver changes
that will improve the lives of the people of Lancashire.
Professor Heather Tierney-Moore
Chief Executive
Part 2: Priorities for Improvement, Performance against 2010/11 Priorities and
Statements of Assurance from the Board
2.1 Priorities for Improvement
Lancashire Care NHS Foundation Trust has an approach to quality which is based on the three
domains of quality, using national and local metrics to identify performance and where required,
a range of improvement techniques. The Trust has also produced a programme of innovation
based on the seven dimensions as described by the NHS Institute for Innovation and Improvement.
The Quality Account aims to provide the reader with information in relation to this approach. The
diagram below illustrates the main components of quality. Next year, as a result of Transforming
Community Services (TCS), the Quality Strategy and Programme of Innovation will be reviewed
and this will be reflected in next year’s report.
Quality
Safety
Effectiveness
Patient Experience
National Requirements
Compliance Framework
Benchmarking
Priorities for Improvement
Focus on Outcomes
Views of Stakeholders
Quality Strategy
Quality Metrics
The priorities for improvement were defined in
the Quality Strategy which was approved by the
Board in February 2009. The Strategy is a three
to five year strategy and progress against the
priorities was reported in the 2009/10 Quality
Account. The priorities were reviewed last year
to include two new priorities (clinical risk
assessment and therapeutic activity) and the
removal of the leadership priority. The decision
to remove leadership as a quality priority was
taken as the Trust had invested additional
resources to support this programme of work
and it had a wider focus than the quality
strategy. The priorities are as follows:
• Priority 1 - Standards of clinical supervision
• Priority 2 - Performance of community
mental health teams
• Priority 3 - Standards on inpatient units
• Priority 4 - Ensuring National Institute for
Health and Clinical Excellence
(NICE) compliance
• Priority 5 - Developing care pathways
• Priority 6 - Clinical risk assessment
• Priority 7 - Therapeutic activity
The Trust has been very clear about the
reasons for choosing these priorities:
• All services must be delivered through care
pathways based on the most up-to-date
evidence
• Work nationally, and experience locally,
demonstrates the need to focus attention
on the work of Community Mental Health
Teams and inpatient units
• Research has demonstrated how the
performance of staff has a significant
impact on the experience of service users
and the quality of care provided. For this
reason, there has been a focus on
supervision as an integral part of the
improvement work
• Regular reviews of performance and
learning from serious incidents that
occurred led to the identification of
clinical risk assessment as a key area
for improvement
• Feedback from service users on ways
to improve the service identified
access to therapeutic activity
Lancashire Care NHS Foundation Trust Annual Report and Accounts 2010 - 2011
5
The Trust has a structured programme of
engagement with service users, carers,
governors and other key stakeholders in
the quality agenda. This includes the
development and implementation of the
service user engagement strategy of
which elements are discussed in Part 3, a
series of presentations, workshops and
educational sessions focusing on quality
and quality governance to governors,
and implementation of the GP plan
including a survey and a workshop. The
Trust
has
also
implemented
a
programme of quality reviews and the
assessment teams have included
governors and non-executive directors.
Input from service users and staff is
included. The priorities for quality
improvement have also been reviewed
by staff, service users and governors
through a variety of meetings and
events, including coffee mornings, to
enable service users’ involvement. It has
been agreed that they will remain the
same priorities during 2011/12 to ensure
further improvements can be made.
They have also been reviewed in light of
the significant changes to the
organisation during 2011/12 with the
transfer of community services. All the
priorities are applicable to the
community services and the performance
of Community Mental Health Teams will
be expanded to include community
teams.
In making improvements across such a
range of priorities, the Trust understands
it is setting itself significant challenges.
However, the areas identified will have a
significant impact on the quality of
service provided and are fundamental to
the implementation of the Quality
Improvement Strategy.
2.2 Performance against
2010/11 Priorities
The
Trust
delivers
services
primarily through four service networks.
There are systems and processes in place
to ensure the delivery of quality and this
is reported to a sub-committee of the
Board. This structure gives the Trust the
opportunity to cascade information to
all levels and seek assurance regarding
standards. In addition, the Trust has a
dashboard system in place, accessible to
all staff through the intranet. These
systems cover both national and local
indicators.
During 2010/11, the Trust has not had
any major problems with data quality
and has been successful in improving the
data quality systems to ensure data is
reliable and improvements are made
where required. The development and
implementation of an online data
monitoring tool ensures up-to-date
information is available for use by the
Board, wards and teams. This in turn has
led to improvements in monitoring the
quality of care.
The performance against each of the
priorities is identified in this section of
the report. Progress against the priorities
during 2011/12 will continue to be
monitored using the three domains of
quality
and monthly or quarterly
reviews of the data. Metrics will be
reviewed to ensure they remain
appropriate and new measures will be
developed, where required. The Trust
Board will receive this information via a
variety of mechanisms including the
Director of Nursing’s governance report
and the monthly quality report.
Table 1 provides an overview of the
quality performance compared with
data from previous years. Further
detailed information is included
throughout the report.
Table 1: Quality Overview with comparison against previous year’s data
Quality Measures Reported
2007/08
2008/09
2009/10
2010/11
Trend
Service users with colonised MRSA
43
28
21
17
Improved
Service users with C.difficile Toxin Positive
17
9
8
4
Improved
SUI reported in 2 days
-
-
71%
72%
Improved
SUI completed in 45 days
-
-
68%
84%
Improved
Falls resulting in fracture
10
4
11
13
Improvement
Planned
61%
67%
63%
79%
Improved
Staff received mandatory training
-
-
53%
67%
Improved
Complaints referred to Ombudsman
5
2
13
9
Improved
Young people admitted to adult units
17
27
39
21
Improved
Improving safety culture
28%
32%
27%
26%
Improved
Violent incidents against staff
157
146
80
Not
available
until Nov
2011
Improved
2009/10
Staff with up-to-date appraisal
2.2.1 Priority 1: Standards of Clinical Supervision (Patient Safety)
The measurement of clinical supervision has been a clinical audit to identify practice against
the standards listed in table 2. The results represent a sample of staff and the response increased
by 100 staff in the 2010/11 audit.
Table 2:
Clinical Supervision
Inpatient staff
Community Staff
2009/
10
2010/
11
Variance
between
2009/10 &
2010/11
2008/
09
2009/
10
2010/
11
All staff have a right to regular
formal supervision
85%
71%
14%
81%
85%
75%
10%
Supervision will take place in
line with professional codes of
conduct
86%
88%
2%
82%
89%
87%
2%
86%
77%
9%
95%
88%
75%
13%
80%
75%
5%
86%
76%
73%
3%
47%
55%
8%
76%
60%
60%
0%
81%
98%
17%
64%
77%
94%
17%
79%
95%
16%
75%
79%
95%
16%
Supervision meetings will be
made in advance and
prioritised and held in a
suitable private room free from
interruptions
A record of each session will be
held confidentially in line with
local supervision protocols
All supervisory relationships
will be governed by the
supervision contract
Allocating/prioritising work
during managerial supervision
2008/
09
Community staff supervision started 2009
Standard
Identifying & acknowledging
good practice during
managerial supervision
Variance
between
2009/10 &
2010/11
Data Source: LCFT Clinical Governance Department
Lancashire Care NHS Foundation Trust Annual Report and Accounts 2010 - 2011
7
The results demonstrate some improvements from last year and areas that require further
attention1, 2. Clinical supervision remains a challenge which is why it remains a priority.
The Trust is performing well against the management supervision standards which can
include discussion on clinical issues such as caseload management. There are areas of
good practice within the Trust e.g. Occupational Therapy, and work is underway to try
and ensure best practice is routine practice. The focus on supervision has been on formal
one-to-one discussions. What the data has not included is regular forums in community
teams where peer support and supervision are undertaken, for example, complex care
panels. A number of training initiatives are being implemented including the
development of in-house clinical supervision training, a pilot of group supervision training
and external training via Lancaster University. During 2011/12 a review of monitoring
systems will be undertaken to identify clear definitions and the level of uptake.
2.2.2 Priority 2: Performance of Community Mental Health Teams (Patient Experience)
Community Patient Surveys (Patient Experience)
The 2010 Community Mental Health Service Users Survey was undertaken by the
Care Quality Commission (CQC). National surveys help the Trust compare itself
against national data on an annual basis.
Whilst the Trust is continuing to perform above the national average in the majority
of indicators listed below, the performance compared to last year has deteriorated.
This is disappointing and further work is being undertaken to understand the
position and improve services. For example, the Trust would want to ensure that all
service users have good access to crisis care. This is also being addressed by ensuring
focused attention is given to these key areas by each service network3.
Table 3: National Community Patient Survey Results
Indicator
Were the purposes of medication
explained to you?
Criteria
Yes definitely
61%
66%
61%
68%
7%
Do you have a number of someone
from your local NHS MH service
that you can phone out of hours?
Yes
51%
70%
63%
50%
13%
In the last 12 months have you had
a care review meeting to discusss
your care plan?
Yes I have had
more than one
& Yes I have
had one
57%
71%
69%
49%
20%
Overall how would you rate the care
you have received from Mental
Health Services in the last 12 Months?
Excellent,
Very good
& Good
82%
86%
79%
79%
0%
Have you been given (or offered) a
written or printed copy of your
care plan?
Yes in the
last year
52%
39%
13%
Did this person (Health and Social
Care Workers) treat you with respect
and dignity?
Yes definitely
& Yes to some
extent
97%
98%
1%
Data Source: CQC National Community Patient Survey Results
1
National National National
National
Variance
Survey
Survey
Survey
Average (All between LCFT
Results Results Results
MH/LD Trusts) and National
(LCFT)
(LCFT)
(LCFT)
2010
Average 2010
2008
2009
2010
Data governed by Standard National Definitions
Small inaccuracies reported in 2009/10 have been updated to reflect the true figures. A review and strengthening
of the checking process has been undertaken. Numbers affected are:
• Inpatient Staff 2009/10 ‘Right to have formal supervision’
• Community Staff 2009/10 ‘All supervisory relationships will be governed by the supervision contract’
2
Community Staff 2009/10 ‘Supervision will take place in line with professional codes of conduct’. This figure was
published as 46% when it should have been 86%. The figure was taken from the wrong standard. 3 Due to changes
in the wording of these two indicators, the data from previous years is no longer comparable.
When comparing the 2010 results with the national average, it can be seen that the Trust has
scored well above the national average with regard to the service user having a copy of their
care plan. The Trust, however, was just below the national average on Respect and Dignity (1%)
and 7% below the purposes of medication being explained. It is not clear why the medication
question has decreased, however, work is being undertaken to address this.
2.2.3 Priority 3: Standards in Inpatient Units
Inpatient Surveys (Patient Experience)
The internal survey commenced in May 2009 as a questionnaire given to all older adults and
adult inpatients on discharge. It consists of nine key indicators that cover all aspects of a
patient’s inpatient stay. The data from the internal survey provides useful information which
is used in the quality review of services. The response rate has been disappointing and to
increase the rate is a key challenge. The questions have been reviewed and the number of
questions in the survey reduced. Alternative ways of disseminating the survey, e.g. through
inpatient ward meetings and advocacy, are also being reviewed and implemented.
Table 4: Adult & Older Adult Inpatient Surveys
Indicator
Criteria
2009/10
2010/11
Variance between
2009/10 & 2010/11
Was the ward clean?
‘always’ and ‘mostly’
94%
95%
1%
Could I get a hot drink when I wanted?
‘always’ and ‘mostly’
76%
85%
9%
The ward felt a safe place to be in
‘good’ and ‘satisfactory’
82%
80%
2%
I got as much information as I wanted about
my treatment
‘good’ and ‘satisfactory’
74%
84%
10%
I knew how to make a complaint if I needed to
‘good’ and ‘satisfactory’
68%
81%
13%
I was satisfied with how I was involved in
planning my hospital care
‘good’ and ‘satisfactory’
80%
82%
2%
‘always’ and ‘mostly’
80%
80%
0%
I was satisfied with how I was involved in
planning my discharge
‘good’ and ‘satisfactory’
81%
81%
0%
I experienced discrimination on the ward
‘No’
89%
83%
6%
My privacy was respected
Would you recommend us to a friend
Scored out of 10
7
Data Source: LCFT Clinical Governance
The annual results are being reviewed and where there has been a decrease in performance,
further work will be undertaken to make improvements. In addition, the increased response
rate during the last two quarters may have impacted on the results.
The National Community Survey findings in Table 5 compare the results for the Trust over the
last two years and with the national average for this year. The Trust has scored better than the
national average with two indicators, achieved the same results with one indicator and is below
the national average for three indicators. Work is continuing on inpatient units to make
improvements in these areas.
Lancashire Care NHS Foundation Trust Annual Report and Accounts 2010 - 2011
9
Table 5: National Inpatient Survey Results
Criteria
National
Survey
Results
(LCFT)
2009
National
Survey
Results
(LCFT)
2010
National
Average
(All MH/LD
Trusts)
2010
During your most recent stay, did
you feel safe?
Yes always and
Yes sometimes
83%
88%
85%
3%
In your opinion, how clean was
the hospital room or ward that
you were in?
Very clean and
Fairly clean
87%
91%
91%
0%
Were you given enough privacy
when discussing your condition
or treatment with the hospital
staff?
Yes always and
Yes sometimes
81%
85%
87%
2%
Were you involved as much as
you wanted to be in decisions
about your care and treatment?
Yes definitely
and Yes to
some extent
71%
71%
74%
3%
Yes
37%
45%
39%
6%
Excellent,
Very good
and Good
67%
72%
73%
1%
Indicator
During your most recent stay,
were you made aware of how
you could make a complaint if
you had one?
Overall, how would you rate the
care you received during your
recent stay in hospital?
Data Source: CQC National Inpatient Survey Results
Falls resulting in a fracture
(Patient Safety)
The falls resulting in a
fracture are categorised as a
serious incident and are
reported monthly to the
Board. Chart 1 identifies the
number of falls compared to
previous years.
Variance
between LCFT
and National
Average
(2010)
Data governed by Standard National Definitions
Chart 1:
Falls resulting in a fracture
14
13
12
10
11
10
8
6
4
4
60%
reduction on
2007/08
2007/08
2008/09
175%
increase on
2008/09
2009/10
18%
increase on
2009/10
2
0
2010/11
Data Source: LCFT Internal Information System (Datix)
Data governed by Standard National Definitions
Falls resulting in a fracture have increased for the second year and all occur with older adult
service users who have a higher risk of falling compared to other service users in the Trust. Each
fall is reviewed in detail and there is no evidence of any trends or clusters which would indicate
there are service delivery issues. The Trust will continue to monitor this data on a monthly basis.
The safety of service users is a priority for the Trust, and the Older Adult Network undertakes
regular analysis on all types of falls and implements service changes if any issues are identified.
The data suggests there continues to be improvement in reducing the number of falls.
Investment in new beds which are adjustable has contributed to this improvement.
Health Care Associated Infections (Patient Safety)
The information below identifies two different health care associated infections, which are of
importance to the Trust.
Chart 2:
Number of patients colonised with MRSA
It can be seen in Charts 2 and 3 that over
the last four years the Trust has seen a
continued fall in the number of Health
Care Associated Infections (HCAI). Chart
2 identifies the number of patients who
are colonised with MRSA (MRSA present
on the patient’s skin without causing an
infection). The Trust has not had any
cases of MRSA bacteraemia. The Trust is
confident that it has effective systems in
place to manage HCAI. Infections are a
high priority from a patient safety
perspective with the rates being
continually monitored via the Board
Report during 2011/12.
50
45
40
43
35
30
28
25
20
21
15
17
35%
reduction
on
2007/08
2007/08
2008/09
25%
reduction
on
2008/09
2009/10
19%
reduction
on
2009/10
10
5
0
2010/11
Data Source: LCFT Infection Prevention & Control Dept.
Data is governed by Standard National Definitions
Chart 3:
Number of Patients C.difficile Toxin Positive
18
16
17
14
12
10
9
8
8
6
47%
reduction
on
2007/08
2007/08
2008/09
11%
reduction
on
2008/09
2009/10
4
4
50%
reduction
on 2009/10
2
0
2010/11
Data Source: LCFT Infection Prevention & Control Dept.
Data is governed by Standard National Definitions
Lancashire Care NHS Foundation Trust Annual Report and Accounts 2010 - 2011
11
Never Events (Patient Safety)
High Quality Care for All proposed that
a policy for ‘Never Events’ should be
introduced in the NHS in England from
April 2009. The Never Events framework
includes a description of a core list of
Never Events for use during 2010/11. The
core list is eight in total and three relate
to mental health:
• Inpatient suicides using noncollapsible rails
• Escape from within the secure
perimeter of medium or high secure
mental health services by service users
who are transferred prisoners
• Misplaced naso or orogastric tube not
detected prior to use
The Trust did not have any ‘Never
Events’ as indicated in Diagram 1
Diagram 1:
Never Events Target
2010 / 2011
Target
0%
0%
Data Source:
LCFT Clinical Governance Department
Talbot Ward Project (Patient Safety)
In mid-2010, there was a concern about
the high level of patient issues on Talbot
Ward, Lytham, a ward for people with
dementia and challenging behaviour.
There was high acuity in service users
admitted to the ward, low staff morale
and lack of positive engagement /
activities. Following a report, a multi-
disciplinary project group was formed to
work on actions at a number of levels.
These included increased liaison with
outside agencies, particularly the Prince’s
Trust who improved the garden area for
outside activities and the creation of
‘Activity Champions’ for the ward with a
daily
activity
programme
and
information / feedback from service
users via our Service User / Carer
Involvement Worker. The project has
resulted in a significant reduction in
the number of incidents reported on
the ward. The overall approach was
to change the focus of intervention to
support
a
more
therapeutically
orientated model.
2.2.4 Priority 4: Ensuring NICE
compliance (Patient Safety)
The importance of ensuring NICE
compliance was identified in the Quality
Strategy as a key priority for the Trust. A
programme was developed and is being
implemented to ensure the Trust has:
• Identified all the relevant guidelines
• Completed a gap analysis on each
relevant guideline to identify progress
against implementation
• Developed action plans for guidelines
which were not implemented or were
partially implemented
• A robust monitoring system in place
Table 6 below outlines the number of
completed and ongoing gap analyses,
and the level of implementation
identified.
Table 6: NICE Implementation Gap Analyses
Type of guideline
Gap analyses Gap analyses Number not
completed
in progress implemented
Number
Number fully
partially
implemented
implemented
Prioritised clinical guideline
16
8
2
9
5
Relevant technology appraisal
5
1
0
0
5
Relevant public health guideline
7
0
0
1
6
Number of guidelines (all types)
published since Jan 2011
0
5
TBD
TBD
TBD
Total:
28
14
2
11
15
Source: NICE Implementation Lead
The Trust also undertakes and participates in a number of local and national audits which
review practice against NICE guidelines. The Prescribing Observatory for Mental Health – UK
(POMH-UK) enables the Trust to benchmark its performance against national data. Table 7
identifies two of the audits which the Trust has participated in, and the results compared to
the national position for key standards.
Table 7: Outcome from POMH-UK
Audit
(Publication Date)
Assessment of the
side effects of Depot
Antipsychotics
(Re-Audit 2010)
Prescribing of high
dose and
combination
antipsychotics on
adult acute and
intensive care wards
(Re-Audit April 2010)
Audit /
Re-audit
Variance
Re-Audit
Results
Documented
evidence of side
effect monitoring
58%
99%
41%
76%
23%
Evidence of physical
assessment of side
effects
6%
79%
73%
19%
60%
Documentation
regarding
measurement of
weight / BMI / waist
circumference
11%
50%
39%
15%
35%
Total dose
prescribed is within
BNF limits
86%
86%
0%
N/A
Standard
National
Average
Re-Audit /
National
Average
Variance
Audit
Results
N/A
Reconciliation process within seven days:
Medicine
Reconciliation
(Re-Audit
October 2010)
Screening of
metabolic side effects
of antipsychotic drugs
in patients treated by
Assertive Outreach
Teams (AOT)
(Re-Audit May 2010)
Data Source: POMH-UK
Patient asked
85%
75%
10%
79%
4%
Medication
examined
100%
53%
47%
66%
13%
Carer asked
30%
43%
13%
33%
10%
GP contacted
83%
89%
6%
66%
23%
CMHT
62%
78%
16%
56%
22%
Care home
52%
79%
27%
35%
44%
Stop smoking –
help offered
55%
17%
38%
41%
24%
Data is governed by Standard National Definitions
The audits demonstrated improvements in a number of areas, however, the antipsychotic drugs
and lithium re-audits did identify a number of areas of practice which the Trust is focusing
attention on in order to make improvements. This has included the use of a physical health
care monitoring tool to facilitate improvements in the physical assessments completed.
Lancashire Care NHS Foundation Trust Annual Report and Accounts 2010 - 2011
13
2.2.5 Priority 5: Developing Care Pathways (Effectiveness)
There are different types of mental illness and each is associated with evidencebased interventions which are included in the condition-specific guidelines produced
by NICE. During 2009/10 the Trust developed 20 NICE-compliant Care Pathways and
this year the focus has been on developing measurements and outcomes of these
pathways from both the clinician’s and service user’s perspective. Information on
the experience of service users will also be collected for each pathway. An example
of a pathway and its measures is reported below and also the progress against a
number of other pathways. The service user experience data has been included in
Part 3. The 2011/12 Quality Account will include the outcome and experience data
on a number of other pathways.
The Lancashire Traumatic Stress Service (LTSS)
The Lancashire Traumatic Stress Service (LTSS) collects information about symptoms
prior to the start of, and on completion of, treatment. This information is included
in Table 8.
Table 8: PTSD Clinical
A comparison of average pre and post CAPS scores
for completed treatment cases between the period
April 2008 to February 2011
0
10
20
30
40
50
60
70
80
73
Average Initial CAPS
40
Average Final CAPS
A comparison of average pre and post BDI and BAI
scores for completed treatment cases between the
period April 2008 to January 2011
0
5
10
15
20
25
35
36
Average Pre BDI
19
Average Post BDI
28
Average Pre BAI
Avaerage Post BAI
30
15
40
This graph provides
information on the
levels of symptoms at
the time of the initial
assessment and at the
time of the completion
of treatment. It is
based on the scores
from the Clinician
Administered
PTSD
Scale (CAPS) for DSM
IV. The graph shows
that for those patients
who do complete
treatment, there is a
significant reduction in
symptoms.
This graph illustrates
changes in symptoms
of depression (Beck
Depression InventoryBDI) and anxiety (Beck
Anxiety Inventory-BAI)
for those patients who
complete treatment.
Again the graph shows
that for those patients
who do complete
treatment, there is a
significant reduction in
levels of anxiety and
depression.
This graph shows changes in
scores on the three assessments
that all patients complete at every
appointment they attend. The
scores on all three of these
measures show that there are, on
average, positive improvements in
the areas assessed.
A comparison of average initial and final PHQ-9, GAD-7
and WSAS scores for completed treatment cases between
the period April 2008 to January 2011
0
5
Average Final PHQ-9
10
15
25
10
Average Initial PHQ-9
Average Final GAD-7
20
17
There are three separate
assessments:
PHQ-9 This assessment helps to
determine the level of severity
of depression.
GAD-7 This assessment helps
to determine the level of
anxious feelings.
WSAS This assessment helps
to determine changes in levels
of social inclusion, work,
leisure and relationships
8
Avaerage Initial GAD-7
Average Final WSAS
14
15
24
Average Initial WSAS
Source: LCFT Lancashire Traumatic Stress Service (LTSS)
Data governed by Standard National Definitions
CAPS
BAI
BDI
Clinician’s Administrated PTSD Scale
Beck Anxiety Inventory
Beck Depression Inventory
PHQ9
GAD7
WSAS
Patient Health Questionnaire
Generalised Anxiety Disorder
Work and Social Adjustment Scale
&
Post-Traumatic Stress Disorder (PTSD) – non-specialist services
Work is being undertaken to pilot the PTSD Pathway in East Lancashire and this will include
reporting on a number of measures from the Improving Access to Psychological Therapies (IAPT)
programme. A number of measures are used for each
service user, for example, the Patient Health
Diagram 2:
aging Mental Health
Questionnaire (PHQ9). In addition, a number
Recovery
Man
Phy
sic
e
p
of Patient Reported Outcome Measures
a
Star
lH
Ho
ea
&
lt h
(PROMS) and Patient Reported
st
u
Tr
1
Experience Measures (PREMS) are also
2
3
1
1
being developed.
2
8
10
5
6
7
2
190
7
8
e
iliti
nsib
7
6
s
5
4
3
1
5
6
2
8
8
7
6
5
4
3
2
So
cia
l Ne
two
rk
s
4
3
4
9
3
1
4
10
10
9
lf-e
ste
e
& se
2
kills
Identity
ng S
Livi
5
7
10
5
3
1
9
8
10
8
6
Respo
10
3
4
190
10
190
9
7
10
9
8
2
10
6
10
2
9
10
190
5
8
1
8
7
6
7
8
7
6
5
7
6
4
4
6
5
3
3
5
4
1
re
Ca
lf-
m
Se
3
10
In services where IAPT data is not
collected, the use of the Recovery
Star is being piloted. The
Recovery Star focuses on the ten
key areas listed below which are
felt to be crucial to recovery.
The tool measures the service
user’s perspective on the degree
of difficulty they experience in
each of the areas on a scale of one
to ten, with ten being the optimum
score. Service users and practitioners
are provided with guidance explaining
what the numbers (1-10) on each point of
the star denotes.
4
2
1
2
Ad
di
ct
ive
Be
ha
vio
ur
1
k
or
W
Relationships
Source: London Housing Foundation and Triangle Foundation
Data governed by Standard National Definitions
Lancashire Care NHS Foundation Trust Annual Report and Accounts 2010 - 2011
15
Crisis Patient Reported Outcome
Measures (PROMS) / Patient
Reported Experience Measures
(PREMS)
Work has been undertaken to develop
draft PROMS / PREMS for the Crisis
Pathway using examples from other
trusts. The eight measures are being
piloted in one of the crisis teams in
Central Lancashire. Both clinicians and
service users were involved in the
development of the measures. The
findings from the pilot will be used to
make service improvements and to agree
the measures for use in all services across
Lancashire.
Vocational Pathway
The Vocational Pathway aims to help
care co-ordinators and named workers
identify the vocational aspirations of
service users and set vocationally focused
goals which address the service user’s
priorities. These could include paid work,
volunteering, education and training or
being involved in other meaningful
activities.
The Trust has a regularly updated online
Directory of Vocational Services which
operates in conjunction with the
Pathway by providing information and
contacts for key external agencies who
may be able to help service users address
their vocational needs.
The Pathway was piloted in Blackpool
and Wyre with more than 25 service
users and data is currently being
evaluated. Input and feedback from
service users and care co-ordinators has
been, and will continue to be, an
integral part of the Pathway. In
particular, service users have helped
design and compile the Pathway and
Directory, participate in and co-facilitate
focus groups, and co-author the project
report. Both the Pathway and Directory
are being rolled out across the Trust from
April 2011.
2.2.6 Priority 6: Clinical Risk Assessment
(Patient Safety)
During 2010/11 work has been
undertaken on this new priority to
develop a more tailored clinical risk
assessment which is integrated with the
Payment by Results (PbR) clustering tool
and built into the Trust’s clinical system.
This will enable a more focused approach to
clinical risk assessment using key standards
across the Trust.
The next stage of the project is to update the
clinical risk policy to include key standards in
preparation for the clinical system going live,
and agree the implementation process within
the networks. An audit will be undertaken
during 2011/12 to identify if the standards
have been met.
2.2.7 Priority 7: Therapeutic Activity
(Effectiveness)
Following the identification of this area as a
new priority, a working group of clinical leads
was established to define therapeutic activity
and identify robust measures. A mini study in
August 2010 was undertaken to understand
the current activities provided during service
users’ inpatient experience. The measuring
tool developed assisted ward staff to record
activities and this proved very successful. The
benefits and issues which emerged in relation
to therapeutic activity were very positive.
The findings of the mini study were shared
with the Council of Governors. The working
group agreed that building on this mini study
would be a good way forward and a thematic
analysis is currently being undertaken to
translate it into meaningful data. Work is also
being undertaken with the Trust’s service user
involvement leads to ensure measures are also
identified by service users. This work will
continue during 2011/12 and data on the
measures will be reported to the Board.
Mindfulness (Effectiveness)
Mindfulness is a therapeutic approach which
can help people to cope with stress, anxiety
and depression and help manage chronic
pain. There is strong evidence to suggest
that it is effective at reducing relapse of
depression. Mindfulness can be taught on an
individual basis or through groups by
psychologists. The Trust has set up and run a
Mindfulness group for service users which was
held in Blackburn Hospital between December
2010 and January 2011. Feedback from service
users suggests that this was a success and the
Trust is planning to run more groups in North
and East Lancashire.
A group for service users in Lancaster and
Morecambe has also been established and
training is being provided for staff. This will
help improve the psychological skills of team
members and help staff to develop their
thinking styles in a psychological way.
2.3 Statements of Assurance
from the Board
This section includes a number of nationally
mandated statements from the Trust Board
which relate strongly to the drive for quality
improvement. The aim of these statements is
to offer assurance to the reader that the Trust is:
• Performing to essential standards e.g.
meeting Care Quality Commission (CQC)
registration
• Measuring clinical processes and
performance via participation in national
clinical audits
• Involved in cross-cutting projects and
initiatives aimed at improving quality such
as recruitment of service users to clinical
research trials
2.3.1 Review of Services
During 2010/11 the Trust provided one NHS
service (mental health) and reviewed all the
data available on the quality of care in this
service. The income generated by this service
represented 100% of the total income
generated from the provision of this NHS
service.
The Board’s approach to the management of
quality and the collation of data is based on
the Quality Improvement Strategy and the
Trust’s performance management framework.
Data is provided on a monthly basis through
the performance and quality report and
clinical audit which covers the three main
dimensions of quality i.e. safety, effectiveness
and experience. The clinical audit programme
is reviewed in detail by the Audit Committee
on a quarterly basis and the results of the
audit inform the quality account.
Lancashire Care NHS Foundation Trust Annual Report and Accounts 2010 - 2011
17
2.3.2 Participation in Clinical Audits
During 2010/11, three National Clinical Audits and one National Confidential Enquiry
covered NHS services that the Trust provides.
During 2010/11, the Trust participated in all (100%) National Clinical Audits and
National Confidential Enquiries of the National Clinical Audits and National
Confidential Enquiries which it was eligible to participate in.
The National Audits and National Confidential Enquiries that the Trust participated
in, and for which data collection was completed during 2010/11, are listed in Table
9 alongside the number of cases submitted to each audit or enquiry as a percentage
of the number of registered cases required by that audit or enquiry.
Table 9: Participation in Clinical Audits
LCFT
Participation
% Cases
Submitted
Assessment of side effects of depot antipsychotics re-audit
Yes
100%
Monitoring of patients prescribed lithium re-audit
Yes
100%
Prescribing of high dose and combination antipsychotics on adult acute
and intensive care wards re-audit
Yes
100%
Medicine reconciliation re-audit
Yes
100%
Screening of metabolic side effects of antipsychotic drugs in patients treated
by AOT re-audit
Yes
100%
2. Psychological Therapies for Anxiety & Depression
Yes
-
National Clinical Audits
1. Prescribing Observatory for Mental Health – UK (POMH-UK)
Contextual questionnaire
100%
Therapists questionnaire
58%
Retrospective audit
95%
Service users survey
5.2% to date
3. Falls and Bone Health in Older People - Round 2 Organisational Audit
4. National Audit Schizophrenia
Yes
Sections
completed
100%
Registered
-
The response to the Service Users Survey for the national audit of psychological
therapies and depression was low and the reasons for this are not clear. A total of
1,000 service user survey packs were posted directly or given to therapists to
distribute individually but the actual number given out was not collected. Service
users were given two ways to complete the survey, either by using the paper
questionnaire with pre-paid envelope or online.
Table 10: National Confidential Enquiries
National Confidential Enquiries-Suicide and Homicide by People with
Mental Illness (NCI/NCISH)
LCFT
Participation
% Cases
Submitted
Suicide
Yes
72%
Homicide
Yes
100%
Source: LCFT Clinical Governance Department
Data is governed by Standard National Definitions
One of the reasons for the lower response rate
for the suicide audit is that a number of
questionnaires (six) were only sent out in
February and March 2011 and are still going
through the normal reminder process. They
are not expected to be returned by the end of
March. There are also still three outstanding
questionnaires due to problems with getting
the case notes.
The reports of two national clinical audits
were reviewed by the Trust in 2010/11 and a
number of actions are being implemented to
improve the quality of healthcare provided
including:
• Implementation of the physical health
module on the electronic patient system
• Further review of the Trust policy on falls to
support practice development
In addition to the national programmes
mentioned above, the Trust has a significant
local programme of clinical audit focusing on
a number of priorities. These include clinical
supervision, carers assessments, violence and
aggression and the Mental Capacity Act, of
which a number are reported in this Quality
Report. The reports of 23 local clinical audits
were reviewed by the Trust in 2010/11 and the
Trust intends to take the following actions to
improve the quality of healthcare provided:
• Arrangements to ensure there are
designated members of staff to take
responsibility for transferring photographs
to the prescription chart as detailed in the
relevant policy
• The development and implementation of
an electronic version of the Trust’s Mental
Capacity Act (MCA) checklist
• All wards to have a standard protocol for
handovers which ensures that all staff are
present, a record is kept, that there is a
physical handover of patients new to the
ward and that a procedure is in place if
staff miss the handover
• The Dual Diagnosis Liaison Workers must
keep all relevant, up-to-date information in
a resource folder that is available to their
team and this folder is to be regularly
updated
• Development and implementation of a
robust recording system that section 132
rights have been given and understood via
the electronic system and amendment to
the form used to record the patient has
been given his/her rights, to include a space
for the patient’s signature
• Raising awareness and promoting the Self
Directed Support (SDS) process to service
users and carers
2.3.3 Participation in Clinical Research
The number of patients receiving NHS services
provided by the Trust in 2010/11 that were
recruited during that period to participate in
research approved by a research ethics
committee was 382.
Participation in clinical research demonstrates
the Trust’s commitment to improving the
quality of care offered and to making a
contribution to wider health improvement.
Clinical staff are abreast of the latest possible
treatment possibilities and active participation
in research leads to successful patient
outcomes.
In 2010/11 the Trust:
• Was actively involved in conducting a total
of 85 research projects of which 43 were
UK Clinical Research Network (UKCRN)
portfolio studies, 31 were student and the
remaining 11 were Trust funded pilot
studies. This is an increase from 55 studies
in 2009/10 and an increase of 10 UKCRN
portfolio studies
• Worked closely with Cumbria and
Lancashire Comprehensive Local Research
Network (CLRN) to implement the National
Institute for Health Research (NIHR) Central
System for Permissions (CSP) and has a 20
day median approval time, the quickest
median approval time in the CLRN
• Worked closely with the CLRN, Mental
Health Research Network, and the
Dementias and Neurodegenerative
Diseases Network (DeNDRoN) to lead and
host an increased number of portfolio and
NIHR funded projects
• Significantly increased its activity in
portfolio commercial clinical drug trials
• Led on one NIHR Programme Grant, and
three NIHR Research for Patient Benefit
Grants, and is a key applicant on an
awarded Programme Grant
Lancashire Care NHS Foundation Trust Annual Report and Accounts 2010 - 2011
19
• Submitted regular NIHR grant
applications
• Had a senior nurse awarded an NIHR
three-year Clinical Doctoral Research
Fellowship and two further
submissions have been made by
consultant psychiatrists
• Has led or been actively involved in
research studies that have produced
114 publications over the last three
years
2.3.4 Commissioning for Quality and
Innovation (CQUIN)
A proportion of the Trust’s income in
2010/11 was conditional on achieving
quality improvement and innovation
goals agreed between the Trust and
commissioning PCTs / North West
Specialised Commissioning Group 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. The amount for 2010/11 was
£2.63 million and the Trust was successful
in achieving the indicators and receiving
the payment.
The Trust works to a number of different
targets, including nationally mandated
ones such as the national performance
indicators reported in Part 3 and locally
driven indicators through the contract
such as CQUIN. The CQUIN indicators
were in line with the Next Stage Review
High Quality Care for All and focused on
improving the information the Trust
collected and reported in relation to key
areas of Patient Safety, Patient
Experience and Effectiveness. The
indicators impacted on all of the Trust’s
Older Adult and Adult Networks.
The
North
West
Specialised
Commissioning Group had a separate set
of CQUIN criteria for the Secure Services
and Children and Adolescence Mental
Health Service (CAMHs).
Further details of the agreed goals for
2010/11 and for 2011/12 are available
electronically at the link below:
http://www.lancashirecare.nhs.uk/
communications/Publications/
Corporate-Publications.php.
2.3.5 Care Quality Commission (CQC)
The Trust is required to register with the
CQC and its current registration status is
‘registered without conditions’. A
number of minor concerns were
identified during the registration process
and are included in table 11. An action
plan to address these minor concerns
was developed and implementation has
been monitored quarterly by the Trust’s
Executive Management Team (EMT)
Governance. All the actions have been
implemented with the exception of
arrangements being made for service
users to self-administer their medication.
This action was completed in April 2011.
The concerns identified under Outcome
1(respecting and involving people who
use services) required monitoring by the
CQC. In December 2010, the CQC
undertook a review of compliance for
ten locations in relation to Outcome 1
and judged the Trust to be compliant
with the Outcome.
The CQC has not taken any enforcement
action against the Trust during 2010/11
and the Trust has not participated in any
special reviews or investigations by the
CQC during the reporting period.
The CQC produce a Quality & Risk Profile
(QRP) for each Trust using a number of
different data sources such as the
national patient and staff surveys and
the Mental Health Act visits. The QRP is
an essential tool for monitoring
compliance with the essential standards
of safety and quality mentioned above.
The profile is updated on a monthly basis
by the CQC and the Trust reviews the
profile to identify any areas for
improvement.
Table 11: CQC Registration
Outcome
Minor Concern
Lack of information provided to adult service users on wards
and in the community
Privacy and dignity and environmental issues at Ribbleton
Hospital
Outcome 1 –
Respecting & involving people who use services
Lack of service user groups in the Early Intervention Service
(EIS), Substance Misuse Service (SMS) and Child and Adolescent
Mental Health Services (CAMHS)
Incomplete Mental Health Act (MHA) consent forms
Outcome 2 – Consent to treatment
Implementation of advanced directives
Implementation of the learning disability toolkit
Outcome 4 –
Care and welfare of people who use services
Lack of standardised older adult inpatient and community
operational procedures
Outcome 5 – Meeting nutritional needs
Variation in the provision of dieticians across older adult
inpatient wards
Lack of staff trained in food hygiene
Outcome 7 –
Safeguarding people who use services from abuse
Lack of older adult staff trained in adult safeguarding
Outcome 9 – Management of medicines
Lack of self-administration of medication on inpatient wards
Outcome 10 – Safety and suitability of premises
Environment for EIS staff not fit for purpose
Outcome 11 –
Safety, availability and suitability of equipment
Implementation of the medical devices procedure and testing
of the Service Level Agreement (SLA)
Outcome 14 – Supporting workers
Mandatory training and Personal Development Plan (PDP)
compliance in older adult staff
Source: Care Quality Commission
Data is governed by Standard National Definitions
The CQC annual statement relates to the
Mental Health Act visits to inpatient units and
confirmed that progress had been made in a
number of areas in relation to the Mental
Health Act. It did raise a number of issues
around the environment and practice which
the Trust is taking into account in its service
improvement work.
2.3.6 Data Quality Statement on Relevance of
Data Quality and Improvement Objectives
The Trust will be taking the following actions
to improve data quality:
• Continued development and deployment
of interactive data quality reports for use
by all relevant staff, covering a range of
key performance targets, both clinical and
administrative
• Benchmarking performance for key data
quality areas using externally produced
comparative information (e.g. the NHS
Information Centre)
• A regular audit cycle to ensure systems and
processes relating to data quality are
robust and fit for purpose
Lancashire Care NHS Foundation Trust Annual Report and Accounts 2010 - 2011
21
NHS Number and General
Medicine Practice (GMP)
Code Validity
Clinical Coding Accuracy
The Trust submitted records during
2010/11 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 is included
in table 12:
Table 12: Data Quality
Record Type
Patients valid NHS
number
Patients valid General
Medicine Practice
(GMP) Code
Area
Trust
Compliance
Admitted
Patient
Care
100%
Outpatient
Care
100%
Admitted
Patient
Care
100%
The Trust was not subject to the Payment
by Results clinical coding audit during
2010/11 by the Audit Commission
because it was a Mental Health Trust.
The Trust, however, participated in the
Connecting for Health Clinical Coding
Audit in February 2011. The audit looks
at the accuracy of diagnosis and
procedure coding recorded for all
inpatient episodes. The results should
not be extrapolated further than the
actual sample audited and the services
reviewed in the sample included Adult,
Older Adult, Secure Services and CAMHS.
Table 13: Clinical Coding
Coding Field
Outpatient
Care
100%
Source: SUS Data Quality Dashboard
Data is governed by Standard National Definitions
Information Governance Toolkit
Attainment Levels
The Trust Information Governance
Assessment Report Scores overall score
for 2010/11 was 66% and was graded
green.
% Incorrect
Primary diagnoses
incorrect
25%
Secondary diagnoses
incorrect
83%
Primary procedures
incorrect
0%
Secondary procedures
incorrect
0%
Data source: Connecting for Health Clinical Coding Audit
Data is governed by Standard National Definitions
This audit measures the discrepancies
between the clinical diagnosis recorded
in the patient’s notes and the conversion
to a coded format on the clinical system.
The audit is not suggesting there are any
misdiagnoses and is aimed at improving
the consistency and use of codes
between manual and electronic records.
The original diagnosis made by the
clinician is unaffected by, and outside the
scope of, the original audit.
The Trust takes its data quality
responsibilities very seriously and
recognises that clinical coding is
insufficiently robust.
A training
programme is being rolled out to the
appropriate staff to improve the
accuracy of recording which will be
combined with periodic audits to
provide assurance that data quality
improvement measures are effective.
Part 3: Review of Quality Performance 3.1 Patient Safety
This section of the report provides an
overview of the Trust’s performance in
relation to a series of quality standards. The
indicators used address significant quality
issues and provide the Trust with data on
which to judge performance in relation to the
key components of quality - patient safety,
effectiveness and patient experience. These
indicators have a direct or indirect link with
the improvement priorities identified in Part
2 and were chosen as part of the work
programme supporting the delivery of the
Quality Improvement Strategy. They also
meet national and contractual requirements
and follow best practice where applicable.
Discussions internally through the Trust’s
governance system, and an event held with
staff, service users and governors, contributed
to the identification and agreement of the
indicators. All stakeholders agree that these
are the most relevant metrics to use in
each category. Further work in the
involvement of stakeholders in developing
new metrics to measure quality improvement,
implementation of the Quality Strategy
during 2011/12 and regular reporting will
ensure improvements to the quality of care
continues. The indicators include:
Patient Safety
• Serious Untoward Incidents
• Improved safety culture
• Violence against staff and service users
• Staff appraisal
• Mandatory training
• Drug errors
This section explains the evidence the Trust
has regarding current levels of safety, and
work being undertaken to provide a safer
environment for service users.
3.1.1 Improved safety culture
The Trust is committed to ensuring there is a
strong safety culture. The National Patient
Safety Agency (NPSA) uses the level of
reporting in an organisation as an indicator of
good practice in safety. A mature culture of
reporting is demonstrated by the higher the
number of incidents reported and the Trust is
a high reporter as demonstrated in the
following charts.
Chart 4: Percentage of staff witnessing
potentially harmful errors, near misses or
incidents in last month (the lower the score
the better)
100
90
80
70
60
50
40
28%
30
32%
27%
26%
28%
20
10
Effectiveness
• Peer review
• Medium and Low Secure Health Checks
• Advancing Quality
• Quality Improvement National Indicators
Patient Experience
• Service User Experience
• Patient complaints
• Age appropriate services
• Single sex accommodation
2007
2008
2009
2010
Source: CQC National NHS Staff Surveys
Data is governed by Standard National
Definitions
0
National
average
2010
Chart 4 shows that 26% of staff at the Trust
said that in the previous month they had
witnessed at least one error, near miss or
incident which could have hurt staff, patients
or service users. This is slightly below the
national average.
Lancashire Care NHS Foundation Trust Annual Report and Accounts 2010 - 2011
23
Chart 5: Percentage of staff reporting
errors, near misses or incidents
witnessed in the last month
(the higher the better)
100
98%
99%
96%
97%
90
88%
80
70
60
50
40
trusts of a similar type and was a
significant improvement on 2009
outcome of 88%.
3.1.2 Drug errors
Last year the Trust identified that
drug errors were important to monitor
and to make improvements where
necessary. Table 14 identifies the types
of drug errors reported. The analysis
of the reported incidents of drug
errors is undertaken on a bi-annual
basis and is used to provide the Network
Governance Groups with information to
manage the process.
30
20
2007
10
2008
2009
2010
Source: CQC National NHS Staff Surveys
Data is governed by Standard National
Definitions
0
National
average
2010
Chart 5 shows that in 2010 98% who had
witnessed an error, near miss or incident
in the last month said that they, or a
colleague, had reported it. The Trust's
score was marginally better than the
national average when compared with
The total number of reported
medication incidents occurring across
the Trust from April 2010 to September
2010 was 193. Previous years’ results
were:
• April - September
• April - September
• April - September
• April - September
2010: 193
2009: 168
2008: 161
2007: 167
Table 14 shows the drug errors broken
down by types of incidents, with Table 15
showing the highest incidents per
category.
Table 14: Drug Errors
Number of Incidents
Type of Incident
Quarter
1&2
2009
Quarter
1&2
2010
119
120
Prescribing
29
Pharmacy
Percentage of Total
Quarter 1
&2
2009
Quarter 1
&2
2010
1
71%
62%
9%
31
2
17%
16%
1%
9
27
18
5%
14%
9%
Other
11
14
3
7%
8%
1%
Total
168
192
24
100%
100%
Administration
Source: LCFT Chief Pharmacist
Year on
year
variance
Year on
year
variance
Table 15: Highest Incidents per Category
Category of Incident
No. of Incidents
April – Sept 2010
Total Incidents
% of Total
Administration
Failure to administer medication
24
120
20%
Prescribing
Prescription of drug not covered by
current consent to treatment
6
31
19%
Pharmacy
Hospital Pharmacy supply problems
10
27
37%
Other
Security issues with medication
9
14
64%
49
192
26%
Total
Source: LCFT Chief Pharmacist
The most visible type of incident was
pharmacy-related, which has seen a 9%
increase on the same period in 2009. Hospital
pharmacy supply problems accounted for 37%
of the incidents in this category. The Chief
Pharmacist and the Director of Nursing are
working with staff to reduce these figures and
are concentrating on three main areas:
• Pharmacy interventions to be more strictly
monitored and the mapping of clinicians to
incidents will be run from reporting systems
• Two medicine management technicians
have now been recruited in Lancaster and
East Lancashire
• Administers of medication are required to
sign the medicines card, with ward staff
monitoring the cards to ensure sign off is
completed
3.1.3 Violent Incidents
The Trust includes violent incidents against staff
and patients as an important indicator and this
data is reported on a regular basis to the Board.
Charts 6 and 7 identify the annual data.
Number of Violent Patient Against Patient Incidents
Chart 6: Number of Violent Patient Against
Patient Incidents
Chart 7: Number of Occupied Bed Days per
Violent Patient Against Patient Incident
600
900
800
500
771
546
700
400
600
470
500
533
300
523
400
423
2%
reduction
on
2007/08
2007/08
2008/09
454
19%
reduction
on
2008/09
2009/10
Source:
LCFT Internal Data Source: (Datix)
300
82%
increase
on
2009/10
200
100
2007/08
0
2010/11
4%
reduction
on
2007/08
2008/09
257
20%
increase
on
2008/09
2009/10
Source:
LCFT Internal Data Source: (Datix)
53%
reduction
on
2009/10
200
100
0
2010/11
The ‘number of violent patient against patient incidents’ has increased since 2009/10 (Chart 6).
Due to reclassification of services there has been a fall in the number of Occupied Bed Days (OBD)
and as such the number of OBD per incident has fallen (Chart 7). The Trust reviews the data in
detail on a quarterly basis and identifies trends and hotspots. There are some specific challenges
around older people with challenging behaviour associated with organic illness. In addition a
disproportionate number of incidents are as a result of a small number of individuals. The approach
to reducing the number of incidents is focused on improving clinical environments, increasing
therapeutic activity, good risk assessment and staff training. This links to the Trust’s key quality
priorities relating to inpatient standards, clinical risk and therapeutic activity.
Lancashire Care NHS Foundation Trust Annual Report and Accounts 2010 - 2011
25
Violent Incidents Against Staff
The NHS security management service
produces annual data on violent incidents
against staff. The Trust is required to
provide the number of violent incidents
against staff and the number of staff. This
is then calculated nationally into a rate as
shown in chart 8.
Incidents of violence against staff have
fallen steadily since 2007 and have made
a significant decrease from 2008/09 to
2009/10. This can be attributed to the
implementation of the Violence and
Aggression Strategy and the increased
number of staff included in the data
submitted.
3.1.4 Serious Untoward Incidents (SUIs)
The metrics used for SUIs are reported
in Diagram 3 and Diagram 4. In addition,
a quarterly report is presented to the
Trust Board which gives a detailed
breakdown of all patient safety SUIs.
These focus on a number of themes
including attempted suicides, falls
resulting in a fracture and violent
incidents. They are also included in the
monthly quality report and the latter
two have been included as separate
measures in this report. Both the
quarterly SUI report and quality report
are made publicly available on the Trust’s
internet site.
Diagram 3: SUIs reported within 2
working days
Target
2009 / 2010
71%
80%
2010 / 2011
Chart 8: Violence Against Staff
(rate per 1,000 Staff)
192
180
160
184
157
140
146
120
100
80
80
15%
reduction
on
2007
2006/07
2007/08
7%
reduction
on
2008
60
40
45%
reduction
on
2009
2008/09
20
0
2009/10
2009/10
Data Source:
Sector Total
NHS Security Management Service
Data governed by Standard National Definitions
The target for the number of SUIs
reported within two working days was
not met but the target for SUI reviews to
be completed within 45 working days
was. The reasons why have been
analysed and relate to required
improvements in administrative systems.
This has been resolved and the last two
quarters showed an improvement of
95% and 89%. This indicator will continue
to be monitored during 2011/12.
3.1.5 Mandatory Training
It is a requirement for all staff to complete
the Mandatory Training Workbook. It is
divided into sections followed by an
assessment on each subject area.
Diagram 5: Staff Mandatory Training
Target
2008 / 2009 29%
2009 / 2010
53%
72%
Source: LCFT Internal Data Source: (Datix)
Data is governed by Standard National Definitions
200
2010 / 2011
80%
67%
Source: LCFT Internal Data Source (Training Dept)
Diagram 4: SUI reviews completed
(45 days)
Target
2009 / 2010 68%
80%
2010 / 2011
84%
Source: LCFT Internal Data Source: (Datix)
Data is governed by Standard National Definitions
The percentage of people who were
compliant for a 12 month period ending
March 31st 2011 was 67%. The results
have improved since last year, however, it
is still unsatisfactory and the Trust is
accelerating the action to achieve
improvement. All mandatory training is
under review to support this improvement.
3.1.6 Staff Appraisal
Staff appraisal is measured through the National Staff Survey and work has been undertaken
to improve the overall figures since last year. These included:
• A dedicated email address for all Personal Development Review (PDR) returns to help
improve the accuracy of recording and a flexible process for electronic returns to
suit team / individual needs
• Increased communications, dedicated section on the Training Intranet Page and PDR
Training sessions available to staff
Diagram 6: Staff appraisals
2007
The 2010 staff survey shows 79% of staff had an
appraisal in the last 12 months which is a
significant improvement on last year with an
overall increase of 16% bringing the Trust to 1%
below its target of 80%. The PDR procedure is
under review and it is envisaged that the new
process will seek to improve staff engagement
further by making clear links to the
organisational aims and their personal business
objectives, whilst embracing the Trust’s values.
61%
Target
2008
67%
2009
63%
2010
80%
79%
2010 National Average
82%
Source: CQC National NHS Staff Survey
Data governed by Standard National Definitions
3.2 Clinical Effectiveness
This section explains the indicators the Trust has on clinical effectiveness, and work that is being
undertaken to make improvements.
3.2.1 National Indicators: Indicators for Quality Improvement (Effectiveness)
The National Indicators for Quality Improvement were introduced in 2010 with the aim of
providing all trusts with data that can be used for benchmarking with a view to improving quality.
Table 16: Indicators for Quality Improvement
Description of Indicator
2009/10
Indicators for Quality
Improvement
2010/11
All
Quarter Quarter Quarter Quarter
Quarters
1
2
3
4
MH06: The proportion of those
service users on Care Programme
Approach (CPA) discharged from
inpatient care who are followed
up within 7 days
The suicide prevention strategy sets out
ways to reduce risk in key groups which
includes early follow up by mental health
providers of people discharged from
inpatient care
MH16: Adults receiving
secondary mental health
services on Care Programme
Approach (CPA) in settled
accommodation
This indicator was defined in the Socially
Excluded Adults Public Service Agreement
(PSA 16). The indicator is intended to
improve settled accommodation outcomes
for adults with mental health problems –
a key group at risk of social exclusion.
MH17: Adults receiving
secondary mental health
services on Care Programme
Approach (CPA) in
employment
This indicator was defined in the Socially
Excluded Adults Public Service Agreement
(PSA 16). The indicator is intended to
measure improved employment outcomes
for adults with mental health problems –
a key group at risk of social exclusion
95%
98%
98%
100%
100%
N/A4
83%
83%
84%
85%
N/A5
17%
17%
17%
16%
Indicators definitions available from Information Centre website (http://www.ic.nhs.uk/services/measuring-for-quality-improvement)
Data source: LCFT Internal Information System (eCPA)
Data is governed by Standard National Definitions
4,5
The Trust commenced reporting against the National Indicators
during 2010/11. No comparative data is available from previous years
Lancashire Care NHS Foundation Trust Annual Report and Accounts 2010 - 2011
27
The
first
two
indicators
show
improvements throughout the year but
the third indicator MH17: Adults
receiving secondary mental health
services on Care Programme Approach in
employment has not improved. A
significant amount of work is being
undertaken to improve these figures
including
the
development
and
implementation of an Employment
Strategy that aims to improve the ability
of staff to support service users to find
employment and to maintain their roles.
Traditionally across the adult network
the numbers have been low except for
East Lancashire Restart which has
exceeded targets set by commissioners
since employment specialists were
employed. In order to increase numbers
the Trust is beginning to embed
vocational pathways across the network
and has been successful in a joint bid
with Shaw Trust for employment
specialists in other areas of Lancashire.
3.2.2 Royal College of Psychiatrists
Peer Review
The secure unit at Guild Lodge took part
in the Royal College of Psychiatrists Peer
Review which allows the Trust to
benchmark services against other
organisations in order to identify areas
for improvement.
Of the 123 standards, the Secure Service
partly met six standards and fully met
117. All bar one of the standards related
to services for women were fully met.
The service scored highly in a number of
areas; more than 80% of the criteria
were fully met in nearly all areas except
one and 100% of the criteria were met
in the six areas listed in table 17 and are
shown compared to last year’s results.
The lowest scoring criterion was
Accessible and Responsive Care which
only partially met one of the two criteria
in this section and shows a significant
Table 17: Royal College of Psychiatrists Peer Review of Guild Lodge
Criteria met
by Trust
2009/10
Criteria met
by Trust
2010/11
1. Physical Security
91 %
100 %
9%
2. Procedural Security
92 %
100 %
8%
3. Relational Security
83 %
97%
14 %
4. Serious and Untoward Incidents
100 %
100 %
0%
5. Safeguarding Children and Visiting policy
100 %
100 %
0%
Clinical and Cost Effectiveness
92 %
80 %
12 %
Governance
93 %
100 %
7%
Patient Focus
69 %
89 %
20 %
Accessible and Responsive Care
100 %
50 %
50 %
Environment and Amenities
85 %
89 %
4%
Public Health
83 %
100 %
17 %
Review Area
Percentage
variance
Safety and Security
Data source: Royal College of Psychiatrists
Data is governed by Standard National Definitions
decline on last year’s result. The partially-met
criterion regarded Privacy and Dignity. It was
found that privacy and dignity was
compromised in the male toilet facilities in
one part of the oldest building. An action
plan is being developed and implemented to
address this area and other areas identified in
the review.
3.2.3 Peer Review by Quality Network for
Inpatient CAMHS (QNIC) and Qualitative
Data QNIC Report - The Junction
A review was undertaken on February 11th
2011 by QNIC, Royal College of Psychiatrists’
Centre for Quality Improvement. A visiting
team spent one day at the unit speaking to
staff, young people and parents about the
service, focusing on:
• Care and treatment
• Information, consent and confidentiality
The Junction is performing well across all
sections of the service standards, and is
continuing to improve compliance with the
standards year on year. The team has
undertaken many changes since their last
QNIC review. In particular, the unit has
introduced progress meetings which are
working well and the team is looking to
continue to build on this. The team has also
started to allocate multi-disciplinary mini
teams to each young person to get them more
involved in the care and planning of their
treatment. The results are included in table 18
with comparisons to the previous year.
Table 18: QNIC Report for The Junction
Section
Overall Overall Percentage
score
score
variance
2010
2011
Environment and Facilities
99%
100%
1%
Staffing and Training
92%
98%
6%
Access, Admission and
Discharge
98%
100%
2%
Care and Treatment
88%
96%
8%
Information, Consent and
Confidentiality
90%
98%
8%
Young People’s Rights and
Safeguarding Children
100%
100%
0%
Clinical Governance
97%
94%
3%
Location within a Public
Health Context and
Commissioning
88%
90%
2%
Clinical Governance is the area that has seen
a reduction since the last review in October
2009, partly due to a lack of local policies on
‘bullying’ and ‘locked door’, which young
people, in collaboration with staff, are
working to develop. Other areas relate to
learning lessons from SUIs and the absence of
a clinical risk management lead. Work is
underway to review these areas. The Junction
has its own internal service user questionnaire
which can be seen within the Patient
Experience section.
QNIC also carried out its first peer review of
The Platform on March 15th 2011 with the unit
taking part in a review covering all sections of
the service standards listed in Table 19.
The Platform is a new service that opened in
April 2010 in response to the amendments to
the Mental Health Act and provides a specific
service for 16 to 17-year-olds. The Platform is
performing well against the QNIC standards,
and there is a lot of excellent work being
undertaken to ensure comprehensive service
user participation. Comments from the young
people and parents throughout this report
reflect improvements made to the service.
Table 19: QNIC Report for The Platform
Section
Initial
Review
2011
Environment and Facilities
96%
Staffing and Training
89%
Access, Admission and Discharge
94%
Care and Treatment
78%
Information, Consent and Confidentiality
97%
Young People’s Rights and Safeguarding
Children
98%
Clinical Governance
92%
Location within a Public Health Context
and Commissioning
92%
Table 18 & 19 - Source: Quality Network for Inpatient CAMHS (QNIC)
Data governed by Standard National Definitions
Lancashire Care NHS Foundation Trust Annual Report and Accounts 2010 - 2011
29
Diagram 7 identifies a range of positive and negative comments from the young
people and their parents collected as part of the review.
Diagram 7: What Young People and Parents said in the QNIC Report
Staffing & Training:



There seems to be enough staff on the unit,
and all staff are ok
There are plenty of staff on the unit, and all
the staff have been great
The staff have a good rapport with the
young people
Access, Admission & Discharge:



!
The staff were nice and welcoming when I
was first admitted
The other young people helped me to settle
on to the unit
The admission process was very smooth, and
the team were aware of our needs and
always kept the parents involved throughout
the process
There are some anxieties around discharge
and how this will be achieved for my child as
they are over 16 years
Information, Consent & Confidentiality:


I received a welcome pack and a DVD when I
first arrived
The staff have spoken to me and provided
me with written information about my
diagnosis and treatment

I’m aware of how to make a complaint and
believe all complaints would be taken
seriously

The staff always inform us who information
is passed on to, and they always check before
this information is passed on
We have access to an advocate on a regular
basis

On admission we were given lots of
information about the services on offer at
The Junction




We are provided with regular updates from
the staff and made aware of any incidents
they have been involved in

Staff have spoken to me about my child’s
diagnosis and treatment
Environment & Facilities:




!
There is a payphone for us to use
The unit is a safe place to stay
The unit is a safe place for my child, and the
team have managed to provide a relaxed
atmosphere on the unit
There are private rooms to use when we
come and visit, the staff are very aware of
dignity and respect
There is no temperature regulation; it is
either too hot or too cold
Source: QNIC
Young People’s Rights &
Safeguarding Children:
I feel listened to by the staff on the unit,
and the staff respect my rights and opinions
I am aware of how to make a complaint
Care & Treatment:





There is a weekly timetable of activities,
groups and education available to all of us

!
!
We meet my child’s key team at all review
meetings
There are things for us to do in the evenings
and on weekends
I have a written care plan and have been
involved in developing it
Having the staff around to talk to has really
helped me
I’m aware that my child has a care plan and I
have been able to be involved in the
development of this
I would like to be able to do PE on the unit
The food is not very good on the unit, and
there is limited choice for vegetarians. Some
of the food is out of date by the time we get it
3.2.4 National Minimum Standards for
General Adult Services in Psychiatric
Intensive Care Units (PICU) and Low Secure
Environments
The Self Evaluation, Assessment and
Development tool has been produced to
ensure Psychiatric Intensive Care Units (PICUs)
and Low Secure facilities are able to
benchmark themselves against the national
minimum standards (2002).
Three units were reviewed and the results are
included in Table 20:
Table 20: Low Secure Self-Assessment Toolkit
Fairoak
Secure
Unit
Standards
Physical environment/
security
Service structure
Pathway of care
Policies and procedures
NW Standards
Key

All criteria
met






Dutton
Low
Secure
Unit






Criteria
partially met
Langden
Low
Secure
Unit





None of the
criteria met
Source: LCFT Low Secure Units
Data is governed by Standard National Definitions
Of the 41 standards, two standards were rated
as only being partially met. They were the
same standard for the wards Dutton and
Landgen and related to ‘There is a carer
support group that meets regularly’. At the
time of the assessment there was no carer
support group. This issue has been addressed
and at present there is a DVD that is available
to service users prior to their admission to the
service, which they can share with their
relatives / carers, and also an information
booklet. This details what service users and
carers can expect from the service, from
visiting arrangements and the environment
and facilities to the roles of the multidisciplinary team.
Carers are also encouraged to attend
significant meetings with the service users in
order to provide support for them and also to
give them the opportunity to ask relevant
questions.
The Family and Friends forum has recently
been set up for all carers of service users. They
are encouraged to develop and direct the
group to ensure that they get the most out of
it. They have requested help, guidance and
education about the service, ‘someone to talk
to confidentially’, to have reassurance and
guidance from the moment the service user is
admitted to their discharge. As the forum is in
its infancy, the group members are aware that
they need to raise the profile of it and have
produced posters in order to promote it across
the service.
3.2.5 Advancing Quality
Advancing Quality (AQ) is a joint venture
between NHS North West & Advancing Quality
Alliance (AQuA). The Aims of AQ are to:
• Give a better experience of health services
by promoting high standards of care,
professional guidance and best practices
• Ensure these standards of care are
consistently delivered in the North West
• Use PROMs / Patient Experience feedback
to gain the whole picture of service users
As part of CQUIN, the Trust is participating in
the pilot of AQ in Mental Health and this
includes reporting on the indicators listed
below (five in Dementia and three in Early
Intervention Services). The data will start to be
submitted at the end of April 2011.
Table 21: Advancing Quality Indicators
AQ Indicators
Indicator Detail
Assessment of functional capacity
before discharge from hospital
Assessment of cognitive ability within
14 days of hospital admission
Dementia
Indicators
Assessment of physical health within
14 days of hospital admission
Assessment for depression and
anxiety within 7 days of hospital
admission
Tailored care plan for carers upon
discharge from hospital
Assessment of the risk of harm to
themselves and others
Early
Intervention
Service (EIS)
Care Coordinator
Antipsychotic medication review
within 6 weeks of antipsychotic
medication being prescribed
Source: Advancing Quality Data Dictionaries
Data governed by Standard National Definitions
Lancashire Care NHS Foundation Trust Annual Report and Accounts 2010 - 2011
31
3.2.6 Carers’ Assessments
The importance of carers is recognised by the Trust and a Carer’s Strategy is being
implemented. An annual audit has been undertaken through consultation and
involvement with carers. Table 22 identifies the findings from two of the standards
to ensure Carer’s Assessments are offered and completed.
Table 22: Carers’ Assessment Outcomes
January March 2010
January March 2011
Has a carer been identified in this assessment?
75%
83%
8%
If a carer’s assessment was offered and accepted,
was it completed?
75%
83%
8%
Indicator
Year on Year
Comparison
Source: LCFT Clinical Governance Department
There has been a significant improvement in the number of carers’ assessments
offered and completed since the 2008 Audit. Although there has been improvement
there is still work to be undertaken to maintain and improve these figures.
3.2.7 Accredited Services
A number of Trust services including Electroconvulsive Therapy and Memory
Assessment continue to maintain their external accredited status.
3.3 Patient Experience
This section includes information from
service users on the quality of their
experience and identifies areas for
improvement.
3.3.1 Service user experience
Service user experience is very important
to the Trust and provides valuable
information on the experience of
the services provided. Information is
collected through several sources
mostly through questionnaires, surveys,
complaints,
compliments
and
stakeholder forums. The findings of a
number of service user experience
methods follow.
Surveys - The Lancashire
Traumatic Stress Service (LTSS)
Service users' treatment is affected by
how well the team interact with the
service user. To monitor this, service users
are asked a few questions at the end of
each session including the following:
1. Relationships – did you feel heard,
understood and respected?
2. Goals and Topics – did we work with
you on areas that were important to
you?
3. Approach and Method – did the
therapist’s approach work well for
you?
4. Overall – was today’s session right
for you?
Each question is scored out of 10, so the
highest score possible is 40. The average
score is 39.
The service also introduced a feedback
questionnaire in July 2010 as a means of
gathering qualitative and quantitative
information regarding the perceptions
of service users. A total of 15 service
users responded and rated the service on
a scale of 1 to 10, with 1 being poor and
10 being excellent. The sample size is
small due to it being a specialised service.
Comments from service users were also
requested and have been included.
Diagram 8: PTSD Service Users’ Questionnaire
Question 1
What did you think of the
quality of the reception service
we provide?
Average
Score:
9/10
During your work with us you
may have seen the prescribing
pharmacist. If you saw the
pharmacist, how would you
rate the quality of their work
with you?
Average
Score:
10/10
Did the service meet
your needs?
Question 4
Thinking about the therapist you
saw, how would you rate the
quality of their work with you?
Average
Score:
9/10
• First meeting didn’t know what to expect but
went in like a lamb – came out like a man full
of life
• The therapist was very calming and
professional – excellent at his job
• Your pharmacist was excellent and gave
good advice regarding my medication
Question 5
What did you think about the
quality of the accommodation
in which you were seen?
Average
Score:
8/10
• Rooms were comfortable, very private and
well-spaced apart
• Non-clinical, peaceful and tasteful
• Staff were friendly and helpful
• Very helpful and considerate
• Very friendly and relaxed
Question 3
Question 2
Average
Score:
8/10
• I was introduced to techniques which were
very helpful… I have been able to utilise
these in other aspects of my life successfully
• The interventions and coping strategies I learnt
have stood me in good stead since completion
Question 6
Where could we make
improvements?
• This service needs to grow without
compromising on quality
• Involvement in the workplace – hence clients do
not have to travel to Chorley
• Keep in contact following the referral
Question 7
For you, what were the benefits of attending the service?
• Having a formal diagnosis of severe chronic
PTSD reassured me that my symptoms were
understandable and treatable. Before this
diagnosis I had felt hopeless, despairing and
very frightened. I have been able to cope with
my life much better because of the service
• Putting the trauma which I had been involved
with into a context which I could deal with
• Feel much calmer – nightmares have much
reduced – feelings of panic greatly reduced
• Able to process my trauma in order to regain
doing my own clinical work and move my
personal life forward
Lancashire Care NHS Foundation Trust Annual Report and Accounts 2010 - 2011
33
Survey - The Junction Service
User Experience
The Junction has its own internal young
person’s survey which started in January
2010. The aim of the survey is to ensure
young people using The Junction
have regular opportunities to share
information and questions about their
personal care and service as a whole. The
survey focuses on five stages:
1. Assessment prior to admission
2. Admission
3. Staying at the Junction
4. Planning to leave The Junction
5. Life after The Junction
The Young Person Survey Evaluation
Report is placed on the agenda of team
meetings and viewed by commissioners
and partner agencies via the quarterly
Service Level Agreements. Significant
issues are dealt with immediately. The
outcomes are shown in Diagram 9.
Diagram 9: What young people are
saying about the junction
Staying at the Junction
The young people:
who their key worker and
 Knew
consultant were
 Had copies of their Care Plan (78%)
 Felt that they were being listened to
 Knew how to make a complaint (66%)
what their medication was for
 Knew
and the side effects
how to make suggestions to
 Knew
improve the service

Had attended service development
meetings and felt that they can make
a difference to the service (89%)
the plans to see their family were
 Felt
‘ok’ or ‘good’
Assessment prior to admission
Referral and initial contact:
Admission
of the young people said
 Majority
they were aware of their referral
felt the decision to move to The
 64%
Junction was ‘good’ or ‘alright’
 young people when they first met

Arrangements were ok for 85% of
staff from The Junction
Majority visited before they moved,
shown round by a nurse or key worker
and received a description of the daily
routine

66% were able to talk to staff about
what they needed and felt safe and
welcomed

91% stated they were able to make
their bedroom their own space when
they were ready
young people knew the
 All
arrangements for seeing their families
described the education
 85%
provision as good or alright
Information:
received information about The
 69%
Junction and most of them thought it
was alright
Assessment:
less than 75% were told why they
 Just
were having an assessment by the
Consultant
majority (85%) understood what
 The
decisions were going to be made and
75% felt their views were listened to
during the assessment
but two described the assessment
 All
as ‘alright’ or ‘good’
Assessment prior to Admission
Things to consider:
Staying at the Junction
!
!
The young people:
!
!
!
!
!
!
Were unsure whether being at The
Junction was helping, felt isolated and
misunderstood
Two felt that being at The Junction was not
helping and another felt it was isolating.
Another described feeling misunderstood
46% significantly reported feeling scared or
worried about being assessed
Three young people reported they did not
feel their views were listened to during the
assessment
Admission
Raised issues of friends not being able to
visit due to unexplained risk
!
!
!
!
!
!
Knowledge and preparation time for
review meetings was negligible
Most wanted to know their discharge date
Over half (56%) said they were not
involved in decisions about their care
Two thirds had not met a Participation
Consultant or attended a Crew Session
Less than half of the young people received
a home visit prior to moving
Almost two-thirds reported they were not
involved in planning the move
The time and date of admission was
reported as not ok by 45%
Key workers met half the young people
during admission
Over half reported they had not had their
Care Plan discussed with them
None of the young people describe the
food and mealtimes positively and half
described them as rubbish
Survey - Secure Services
The survey results below identify there have been improvements in some areas and other areas
have reduced. The results are being reviewed by the service and improvements will be identified.
Table 23: LCFT Secure Services satisfaction survey
Criteria
LCFT Internal
Survey 2010
LCFT Internal
Survey 2011
The ward is clean
Always / mostly
97%
73%
24%
I can get regular hot drinks
Always / mostly
81%
92%
11%
The ward feels like a safe place to be a patient in
Always / mostly
69%
64%
5%
My privacy is respected
Always / mostly
80%
80%
0%
I get as much information (written or verbal)
as I want about my treatment
Always / mostly
79%
86%
7%
I am satisfied with how I am involved in my
assessment and care planning
Always / mostly
72%
65%
7%
I know how to make a complaint if I need to
Always / mostly
79%
70%
9%
Indicator
Variance between
2010 and 2011
Source: LCFT Clinical Governance Department
Lancashire Care NHS Foundation Trust Annual Report and Accounts 2010 - 2011
35
The fall in safety on the ward is a key priority for the service. Ward managers are very
aware of the ever changing dynamic of the wards and how this has the potential to make
some service users, at times, feel unsafe. The multi-disciplinary teams continually review
such issues and there are a series of advanced statements and safeguarding care plans in
place to ensure the needs of all service users is prioritised at times of increased incident
and need. Extra support is always provided to ensure safety where this is required.
Diagram 10 LCFT Secure Services satisfaction survey - service user comments
What did the ward do well?





Quiet friendly environment where I
am not influenced by anti-social
behaviours
Now generally getting me out in time
for sessions
Listen to me and the nurses are
available 24/7 if I have a problem
!
!
!
More smoke breaks
I'd let visitors visit more freely
More regular staff (not qualified)
opportunities for getting out in
countryside / walking / less restrictions
They help you as much as they can
There isn’t anything I would change
on the ward
3.3.2 Contributions of stakeholders
The Trust recognises and values the
contribution
that
service
users,
carers and members make to the
effective monitoring, evaluation and
improvement of services. Individual
service users, carers and members of the
public have been specifically invited to
participate in the following areas:
• Trust meetings, working groups, focus
groups and patients’ meetings
• Recruitment panels
• Staff training and development
sessions
• Public relations and promotional
activities
• Service evaluations and designing
service user surveys
A total of 361 service users and 169
carers were involved in these activities
during the year.
6
What would you change
about the ward?
3.3.3 Video booths
In March 2010, the Trust partnered
with the Mental Health Improvement
Programme6 to collect ‘real time’
feedback from patients by using a video
booth to discuss and record their
experience of being an inpatient at
Pendle View, Blackburn. The feedback
from the 15 people who participated in
this pilot, which included service users, a
carer and two patients from the Psychiatric
Intensive Care Unit (PICU), was analysed
and collated into three key themes:
• Workforce issues: these focused on
insights around staff training, time
spent with patients, therapeutic
interventions, medication and
discharge
• Freedom of movement: these
highlighted issues around time off the
ward and exercise, access to activities
and the environment in general
• Communication: these centred on the
quality of engagement between staff
and service users as well as issues to
do with staff attitude to patients
The SHA Video Diary Room Project can be located at http://www.northwest.nhs.uk/document_uploads/
MentalHealthNews_July09/VideoDiaryRoomProject_FinalReport_8b3c6.pdf
Feedback from the Pendle View Video Booth included:
Service users:



had a high level of appreciation for the
quality of care they received
felt they were treated with dignity and
respect
felt staff were committed to treating them
as individuals
After the video booth recordings were
completed staff, senior managers, service
users, governors and non-executive directors
reviewed the footage in two workshops and
discussed appropriate responses to the
emerging themes.
Overall staff felt encouraged by how much
patients valued the care they had received. A
local service improvement programme,
designed to help improve the service user
experience at Pendle View, involves:
• Employing three activity co-ordinators
• Developing a dedicated admissions ward
• Reviewing all administrative processes to
enable staff to spend more therapeutic
time with service users
The current video booth material will form a
benchmark for service users in East Lancashire
and will be evaluated alongside a new set of
recordings in 2011. Quality indicators will
!
!
!
felt staff didn’t have enough time to spend
with them on therapeutic activities
felt staff waited until something went
wrong before spending ‘quality time’ with
them
expressed a general feeling that patient
care centred on the values of the
institution, rather than service users’ needs
“
My thoughts on the video booth diaries
were they were brilliant, it was really
good to see the service users participating,
and most of the feedback was positive
regarding the services.
Trust Governor
“
Service users:
focus on the key themes of therapeutic time,
freedom of movement and the environment
and, in particular, how attitudes and staff
behaviour have changed since the pilot.
Video booths are now being rolled out across
the Trust as an effective way of delivering
improvements in service user experience. They
also form part of the Trust’s Quality Strategy
and provide evidence of improved service
user experience for the mental health
commissioners. Other social reporting techniques
will also be used alongside the video booths in
settings across the area to provide an integrated
programme of service improvements through
the Trust’s Service User Strategy.
Lancashire Care NHS Foundation Trust Annual Report and Accounts 2010 - 2011
37
3.3.4 Patient Complaints
Patient complaints and compliments are important indicators of the quality of care
being provided. Chart 9 and Table 24 identify the numbers for each year and
comparative data on Ombudsman requests.
Chart 9: Number of Compliments or Complaints received
1200
Complaints
Compliments
1000
1017
800
849
600
400
482
235
259
200
243
174
2007/08
2008/09
188
0
2009/10
2010/11
Data Source: LCFT Complaints Department
Table 24:
Ombudsman Requests
2007/08
2008/09
2009/10
2010/11
5
2
13
9
No. of patients who had their
complaint referred to the Ombudsman
Data Source: LCFT Customer Care Department
Thematic Review of Complaints
In February 2011 a thematic review of
complaints from Quarter 3 (October –
December 2010) was undertaken. The
top three categories were:
Care and Treatment
• Level of care and support available
• Access to services and treatment
• Type of care given
• Lack of services and support
Staff related issues including
attitude / behaviour
• Attitude of staff
• Inappropriate actions from staff
Communication
• Communication with service users
• Communication with family
The findings of the review are being
considered through the network
governance groups including the
identification of appropriate actions. The
themes are broadly comparable across all
the networks.
During 2010/11 the role and purpose of
the Complaints Department was reviewed
and changed to a focus of customer care
and service experience. The department
has been renamed the Customer Care
Team and there have been a number of
key developments including:
• The creation of a Patient Story Bank
populated with case studies drawn from
patient experiences of Trust services, many
of which originated in complaints and
compliments
• Setting up a series of Service Improvement
Workshops with frontline staff and teams
where patient stories are shared back in a
way to promote reflective learning and the
creation of locally owned service
improvement plans
• Move to an emphasis on real time
feedback through use of video diaries and
social reporting techniques designed to
address situations as they happen on the
ward and in the field, so staff can work on
these before they become a problem
3.3.5 Age Appropriate Services
The importance of ensuring young people are
not inappropriately admitted to adult wards
has been highlighted nationally. The Trust
monitors the admissions monthly and
established a new young persons’ unit (The
Platform) in April 2010. Chart 10 identifies the
number of admissions to adult wards since
2007/08. .
Chart 10: Young Person Admission to Adult Wards
39
27
21
17
59%
increase on
2007/08
2007/08
2008/09
Data Source: LCFT Information System Datix
44%
increase on
2008/09
2009/10
46%
reduction on
2009/10
40
35
30
25
20
15
10
5
0
2010/11
Chart 10- Due to data validation process the 2008/2009 figure of 28 and 2009/2010 figure of 29 previously
published have both found to be incorrect. The new correct figure of 27 for 2008/2009 and 39 for 2009/2010
have now both been included.
During 2010/11 there was a reduction in the number of admissions to adult wards. This was
due to the introduction of The Platform in April 2010, however, it was anticipated this number
would have been lower based on analysis of previous demand. The following factors should
be noted:
• When a young person is admitted to an adult ward they are still subject to support from
CAMHS and the Outreach Service and an individualised care programme is developed to
support their needs
• There has been a significant increase nationally on the demand for acute inpatient beds
for young people
• Over recent months there has been no bed capacity within the North West in relation to
specialist young people’s inpatient units, this includes both NHS and independent providers
• A number of young people have to be admitted to adult wards as this is an appropriate
admission and is allowed by the guidance, for example when a psychiatric intensive care
unit bed is required
• A clinical pathway has also been subject to review and the Crisis Resolution Home
Treatment Team is taking on the gatekeeping function in a more effective way, trying to
keep the young person out of hospital if this is at all possible
Lancashire Care NHS Foundation Trust Annual Report and Accounts 2010 - 2011
39
3.3.6 Privacy and Dignity Single Sex
Accommodation
The Trust is compliant with the
Government’s requirement to eliminate
mixed sex accommodation, except when
it is in the patient’s overall best interest,
or reflects their personal choice. The
Trust has the necessary facilities,
resources and culture to ensure that
patients who are admitted to inpatient
wards share the room where they sleep,
with members of the same sex, and same
sex toilets and bathrooms will be close to
their bed area.
If the Trust’s care should fall short of the
required standard it will be reported to
the Department of Health. The Trust will
also set up an audit mechanism to make
sure that none of its reports are
misclassified. The Trust will publish the
result of the audit annually. The Trust’s
declaration of compliance is located on
its website:http://www.lancashirecare.nhs.uk/
Privacy-Dignity.php
3.3.7 Peer Support Group
The Peer Support Group was developed
in collaboration with service users in
Central Lancashire Early Intervention
Service (EIS) after several individuals
within West Lancashire stated that they
wanted to meet with other young
people who were also experiencing
mental health problems. The group is
now available every Thursday afternoon
at a community venue to any young
person working with EIS in West
Lancashire.
The group follows the same format each
week, at the request of its attendees,
and feedback is gained weekly. It starts
with a check-up, a psycho-education
session and informal social time. This has
enabled a means of peer support and
this, combined with the availability of
supported learning, has improved the
quality of intervention available in West
Lancashire.
3.4 Performance against Key Mental Health Indicators
Table 25: Performance against Key Mental Health Indicators
Mental Health Indicator
100% enhanced Care Programme Approach
(CPA) patients receiving follow-up contact
within seven days of hospital discharge
2009/10
Threshold
Targets
2009/10
2010/11
2010/11
Performance Threshold Performance Achieved
95%
95%
95%
96.5%
No more
than 7.5%
3%
No more
than 7.5%
4.1%
90%
98%
90%
90.3%
8
8
8
67
Meeting commitment to serve new
psychosis cases by Early Intervention Teams
95%
114.8%
Data completeness: Identifiers
99%
99.04%8
Data completeness: Outcomes
50%
73.8%
Minimising delayed transfers of care
Admissions to inpatient services had access
to Crisis Resolution Home Treatment teams
Maintain level of Crisis Resolution Teams
set in the March 2005 planning round
Data source: CQC Monitor and LCFT IT Systems







Data is governed by Standard National Definitions
The performance of ‘maintain level of Crisis Resolution Teams set in the March 2005
planning round’ have fallen from eight to six as some teams have been
amalgamated due to service changes.
7
The performance of ‘maintain level of Crisis Resolution Teams set in the March 2005 planning round’ have fallen
from 8 to 6 as some teams have been amalgamated due to service changes.
8
Quarter 4 figures: The Trust has achieved compliance for Quarter 4. The Trust however was non-compliant for
Quarters 1-3 and reported as such to Monitor on a quarterly basis. As work was under way throughout the year
to achieve the target at Quarter 4, to report a year end position would not truly reflect the work that has been
undertaken and the Trust’s current position.
As part of the quality strategy the Trust
has introduced initiatives that allow the
measurement and reporting of quality, for
example:
• Patient experience sampling
• Structured site visits
• Outcome measures – such as the Inpatient
Satisfaction Scale
• Care pathways for common conditions
The Trust intends to build on these initiatives
in order to ensure quality improvement is
part of everyday clinical practice. Quality
improvement is defined as the use of clinical
data to improve the outcome of care in terms
of safety, effectiveness, or patient experience.
The quality improvement strategy is being
reviewed and further developed around the
Trust’s care pathways.
The Quality Team will work with clinicians and
interested service users and carers to develop
a quality improvement process for the
pathway. This will involve selecting a critical
step in the pathway and assessing outcome
before and after the step, whilst using an
intermediate metric to provide real-time
improvement data.
3.5.1 Quality Initiatives
There are a number of quality initiatives
within the Trust including:
Lean and the Productives
During 2010, Lean was introduced within
different areas of the Trust with a series of
rapid improvement events aimed at
empowering staff to improve processes
including quality. Lean is the continual
identification and elimination of waste, using
specific Lean tools and techniques developed
by high achieving industries. Within the Trust,
Lean thinking is being used to provide better,
safer healthcare to service users.
In addition the Trust has started to pilot
both the Productive Mental Health Ward
and Productive Community Services within
Secure Services. The focus of the Productive
programme Releasing Time to Care was
developed by the NHS Institute for Innovation
and Improvement after research studies
showed that ward-based nurses spend on
average less than 40% of their time on direct
patient care.
The programme aims to make better use of
nursing time by offering a systematic way of
improving the way teams work together in
delivering safe, quality care to patients. The
programme is introduced gradually in
structured modules. Teams learn simple but
effective techniques that offer dramatic
results in healthcare settings and, importantly,
they lead and control the improvements
themselves.
Equality and Diversity
All engagement work with diverse groups of
staff, service users, carers and communities
supports the delivery of the Trust’s Single
Equality Scheme 2008 -11. During the year
there has been a lot of activity within the Trust
including:
• Development of a Black Minority Ethnic
(BME) Staff Forum – 35 staff attended the
launch in October 2010; the group has met
twice and is working on developing an
action plan
• Development of an LGBT Staff Forum –
launch took place in February 2011 to
celebrate Lesbian, Gay, Bisexual and
Transvestite (LGBT) history month
• Equality and Diversity development
sessions are carried out across the Trust.
Some staff, including those from diverse
groups, have expressed an interest in
supporting the delivery of Equality and
Diversity development sessions within their
own networks. A multi-disciplinary team to
address this will be developed during 2011.
Comments from the session include:
“
“
“
“
“
“
3.5 Quality Management Systems.
Made you think about situations you have
found yourself in and how to deal
with them more appropriately
I’m now more aware of issues and
how to respond
Clarifies implications for clinical practice
Lancashire Care NHS Foundation Trust Annual Report and Accounts 2010 - 2011
41
Currently the Trust is working with other
NHS trusts across Lancashire to carry out
engagement work with all diverse
communities, service users, patients,
carers and staff, ready for setting
Equality Targets for 2011-14.
Examples of outcomes from clinical
services include:
• EIS North Team has worked closely
with Lancashire Police on the
Aquamarine Project which deals with
victims of sexual abuse and has been
awarded a Divisional Commendation
• Boys Own Project: two days per week,
twice a year exploring identity,
gender and homophobic bullying
relating to social care, education and
care homes
• Part time Learning Disability worker
into a school offering counselling,
direct work with families and
children, consultation and training
• Asian Women’s Group in a community
centre in Blackburn. Its members are
all South East Asian women and
consist of ex-service users and existing
clients from EIS in East Lancs. The
group covers such topics as healthy
eating, arts and crafts, needlework,
creative writing, drama workshops,
seminars and education to the
community
• Morecambe CMHT runs a project
called ‘The Mentalisation Programme’
which is specialised treatment for
people suffering from Borderline
Personality Disorder who have long
term mental health problems. At least
30% of the service users in this
programme are from the LGBT
community and are benefitting from
this therapy and are supported by
LGBT clinicians within a LGBT friendly
environment
• Dignity Action Day – service users
were invited to share views on specific
dignity in care issues. All the senior
management team have signed up to
the national Dignity in Care campaign
• Psychologists and staff in East Lancs
and North Lancs work with local
police forces to provide training and
advice on mental health issues in later
life i.e. wandering behaviour, criminal
behaviour and vulnerability
• East Lancs intergenerational project –
working in local schools to raise
awareness of mental illness and
reduce stigma associated with
dementia and ageing. Service users
supported by attending ‘living history’
lessons to talk with students.
• Memory Matters road shows in local
shopping centres and supermarkets to
raise awareness of dementia in the
general population
• World Mental Health Day this year
focused on service user and carer
experiences. The stories were
presented by service users themselves.
These have since been incorporated
into DVDs and other resources to be
used in staff training sessions
• Work around ‘hate crime’ in Secure
Services
Staff and Quality
The Trust recognises that its workforce is
the single most important factor in
providing quality care. Engaging staff
fully and developing the skills, attitudes
and behaviours for the future is thus
recognised as a Trust priority.
Over recent years the Trust has worked
hard to successfully embed the NHS
Constitution. In partnership with staff
and the Council of Governors, it has
developed six values to define its
organisational culture and support the
delivery of high quality care:
• Teamwork
• Compassion
• Integrity
• Respect
• Excellence
• Accountability
These values are the foundation stones
for everything the Trust does and the
behaviours of each and every member of
staff. This has enabled the Trust to
develop an engaging, supportive and
performance focused culture.
Planning and Developing the Workforce
The Trust recognises the importance of
planning and developing its resources to
ensure the right skills are in the right place to
deliver the best care. Over the last 12 months
the Trust has invested heavily in its Human
Resources function to ensure it has the
capacity and capability to support the Trust
moving forward.
It is also strongly committed to organisational
development (OD) and education and
training. In April 2010 the Trust carried out a
strategic review of its current training
provision in order to develop a new, fit for
purpose OD and Learning Team structure. The
shift from a Training and Development Team
to a Learning and OD Team has been made to
provide a planned, holistic approach to
improving organisational performance.
Leadership
The Trust is currently piloting a new leadership
development programme, based upon the
‘appreciative
inquiry’
approach.
This
programme has been designed to develop the
thinking of leaders within the Trust and to
increase their understanding and awareness
of the impact that their behaviour and
language can have on others. It is one of a
range of initiatives aimed at changing the
culture of the organisation by embedding
the values and supporting the transition to
the new organisation and transformation of
services to meet future stakeholders’ needs
and expectations.
The Trust’s management development
strategy will be based around a framework of
Leading me, Leading Others and Leading the
Organisation and will ensure that managers
are equipped with the skills required to
perform their roles more effectively.
A key element underpinning the strategy will
be the development of a coaching culture
which involves developing the manager as
‘coach’ and the provision of mentor support.
Staff Engagement
The NHS Staff Survey provides a robust and
comprehensive evidence base for measuring
how well the NHS Constitution pledges are
being delivered and in turn how well staff are
equipped to deliver quality patient outcomes
and effective care. The Trust recognises the
richness of staff survey data and in 2010/11
issued surveys to each and every employee
instead of taking a sample as in previous years.
Over the last 12 months, the Trust has continued
to hold engagement events involving the senior
leadership team, as a forum where the senior
leadership team can discuss the Trust’s vision for
the future with the executive team and describe
the plans for the next 12 months. Engagement
events are linked into the Trust’s planning cycle.
During 2010/11 the Trust held its second annual
Staff Awards to recognise the contributions of
staff from across the Trust. Awards were given
for the following categories:
• Demonstrate Innovation
• Improve Quality
• Demonstrate Effective Leadership
• Demonstrate Effective Partnership Working
• Demonstrate Effective Public Engagement
• Provide Compassionate Care
• Provide a Wellbeing Focus
• Enhance the Service User Experience
• Enhance the Carer Experience
• Chief Executive’s Award for Overall
Achievement
• Chair’s Award for Unsung Hero
Health and Wellbeing
The Trust is committed to improving the
health of the workforce and has signed up to
the charter for membership of The Mindful
Employer and is about to launch the Open
Your Mind campaign.
In addition a health and wellbeing steering
group has been established which meets on a
monthly basis and looks to share good
practice and develop practical ways to
improve the health and wellbeing of staff.
Using data from the 2009 staff survey the
group has identified initiatives and developed
an action plan to improve mental health and
wellbeing and reduce sickness. The group
are currently drafting a Health and Wellbeing
Strategy which will be launched across the
Trust in spring 2011.
Lancashire Care NHS Foundation Trust Annual Report and Accounts 2010 - 2011
43
4. Annexes
Following submission of a copy of the
draft Quality Account to the LINks, OSCs
and Lead PCT a number of changes have
been made. These changes are intended
to further improve the Quality Account
and are as a result of comments made by
the Council of Governors, external
auditors, members of the Trust Board
and LINks. The key changes are in the
following areas:
• Layout
• Formatting
• Detail of data sources
• Rewording of some sentences
• Additional information included to
provide clearer explanations or
strengthen sections
• Inpatient survey figures were
reconciled and have been updated
• NICE implementation gap analysis
table has been updated
• Keys have been added to the PTSD
clinical outcomes table and low
secure data to make them clearer
• Drug errors table quarter 1 ‘other’
data has been updated (total number
from 15 to 14 and year on year
variance from 4 to 3) and ‘total’ has
been updated (total number from
193 to 192 and the year on year
variance from 25 to 24)
• Staff appraisals diagram has been
updated to include the national
average for 2010
• Admission of Minor chart updated
following review of data checking
processes (2008/09 from 28 to 27 and
2009/10 from 29 to 39)
• Performance against key mental
health indicators have been updated
and data for 2009/10 included
• Quality overview – violent incidents
against staff made more explicit
Statements from Lead PCT, Local
Involvement Networks and Overview
and Scrutiny Committees
Quality Account: Assurance from the
Coordinating Commissioner – NHS
Blackburn with Darwen Care Trust Plus
NHS Blackburn with Darwen is
the organisation responsible for
coordinating the commissioning of
services provided by Lancashire Care
NHS Foundation Trust.
The Care Trust Plus commissions (buys)
services
from
Lancashire
Care
Foundation Trust on behalf of the
people living within Blackburn with
Darwen, as well as coordinating the
commissioning of services on behalf of
other Primary Care Trusts (who are
known as associate commissioners), for
example, people who live within the
areas served by:
• Blackpool PCT
• Central Lancashire PCT
• East Lancashire PCT
• North Lancashire PCT
Throughout the year the commissioners
and Trust have met on a regular basis to
monitor, review and discuss the quality
of services and quality improvements. In
the light of these discussions and in
reviewing information on services
available to commissioners, it is our
belief that the information contained
within the Trust’s quality account gives
a representative view of the quality of
services provided over the last twelve
months.
NHS Blackburn with Darwen can confirm
that Lancashire Care NHS Foundation
Trust achieved completion of all
the
schemes
included
in
the
CQUIN framework and the efforts of
staff in this attainment should be
complimented.
The account also highlights many examples
of programmes and initiatives that have
been used to improve the quality of care
provided to patients, such as participation in
the national audit programmes and
the efforts taken to gain feedback from
patients and their carers. In those areas
where performance has been identified as
requiring strengthening, the commissioning
organisations have seen evidence of action
plans and progress to address these areas.
A welcome addition to the Quality Account
would be inclusion of benchmarking with
comparator Trusts to provide assurance that
the Trust is constantly reviewing its
achievement against similar services within
the North West and beyond.
NHS Blackburn with Darwen as coordinating
commissioner would like to see the priorities
for 2011-12 stretched beyond those set in the
previous year, to indicate aspirations for
continuous improvement building on
achievements demonstrated in 2010-11.
Although there is mention of the
Transforming Community Services process in
relation to the transfer of community health
services in summer 2011, the implications
are not explicit and priorities identified for
2011-12 do not sufficiently reflect areas for
improvement identified by the services being
received by the Trust. NHS Blackburn with
Darwen is confident that priorities identified
for improvement within community health
services will be addressed but further details
accessible to local communities would be
appreciated. We welcome your plans to
publish a summary version of the quality
account to improve accessibility.
NHS Blackburn with Darwen values the
positive relationship with the Trust and looks
forward to seeing the improvements to the
quality of services provided as outlined in this
Quality Account. We feel confident that
Lancashire Care Foundation Trust will
continue to build on its achievements, and
deliver successfully against the priorities to
improve the safety, effectiveness and
experience for patients over the coming year.
Blackburn LINk
BwD LINk welcomes this opportunity to
comment on the Quality Accounts. The layout
was helpful especially in relation to Patient
Experience and would add that the
introduction of video booths by the Trust that
allowed patients to express their opinions was
felt by BwD LINk to be an excellent initiative.
Considering the good work the Trust has done
in relation to carers we do feel it would be
helpful in future to include a section in the
Quality Account that includes opinions and
experiences of carers in relation to Trust
services. The LINk feels that as more emphasis
is placed on community care the importance
of the relatives and friends as partners in
caring should be reflected in the Account.
The major concern of the BwD Link during
2010/11 has been in relation to Respite and
Crisis Care and how services work together.
The LINk found it necessary to refer the issue
of Mental Health supported accommodation
to the health Overview and Scrutiny
committee. While recognising the Trust has
no direct responsibility for supported Housing
in Crisis and Respite Care we would ask that
future Accounts might consider including
the whole patient experience to reflect the
interdependent nature of much of the patient
pathway from provider to provider. We feel
this will be increasingly important as the NHS
moves forward
Blackburn with Darwen LINK
May 2011
Blackpool LINk
Blackpool LINk welcomes the publication of
the Quality Accounts for the second year. We
are pleased to see a huge improvement in the
format of the report.
Please see below our comments on the report:
1. Whilst LCFT has put ‘Standards of Clinical
Supervision’ as a priority, Blackpool LINk is
concerned that supervision has gone down
by 14% and therefore, is not taken seriously
by management or staff.
2. Table 2 National Community Patient Survey
Results
Lancashire Care NHS Foundation Trust Annual Report and Accounts 2010 - 2011
45
a. All patients should have the purpose
of their medication explained to them
and Blackpool LINk is concerned that
LCFT has performed 7% less than
national average
b. All patients should be given (or
offered) a written or printed copy of
their care plan and Blackpool LINk is
concerned that only 52% said ‘yes in
the last year’.
3. Inpatient Surveys (Patient Experience)
– Although LCFT reported that the
response rate was disappointing, it
would be useful for LCFT to state how
many have been distributed.
4. Falls resulting in a fracture (Patient
Safety) – Blackpool LINk is very
concerned that the number of falls
resulting in a fracture has tripled in
the last two years. We are also
concerned that this will increase when
more services are provided out in the
community rather than in-house.
5. Health Care Associated Infections
(Patient Safety) – Blackpool LINk is
very pleased with the work that LCFT
has done to reduce the number of
Health Care Associated Infections.
This is a vast improvement – well done
to all.
6. Talbot Ward Project (Patient Safety) –
This was a good project to identify
problems that were on Talbot Ward. It
would have been interesting to know
what did change. This is a positive
project and LCFT should explain it in
more detail.
7. Blackpool LINk is concerned that the
number of Violent Patient against
Patient Incidents has increased. We are
interested to see how the Trust will
respond to this.
8. Blackpool LINk is pleased to see that
Staff Mandatory training has
continually improved over the last
three years – well done!
9. Blackpool LINk is pleased to see an
increase in Staff Appraisal’s taking
place, but would be interested to see
how the remaining 21% of staff
breaks down.
10. The Junction – Blackpool LINk is
pleased with the layout used to
communicate the views of young
people at ‘The Junction’, but we are
very concerned that 56% of young
people are not involved in decisions
about their care.
11. Table 21 LCFT Secure Services
Satisfaction Survey – Blackpool LINk is
concerned with the reduction in
young people’s views on cleanliness,
not feeling safe as a patients and how
satisfied they are in how they are
involved in their assessment and care
planning.
12. Quality Overview – Blackpool LINk
feels that this is not reflective of the
overall report. Whilst we accept that
there is some improvement, LCFT
should highlight how they will
continue to improve.
Trust Response to Blackpool LINk
There has been additional text included
in the relation to clinical supervision to
provide further explanation. Additional
work is being undertaken to make
improvements in this area which is
why it remains a quality improvement
priority.
The Trust is also concerned about the
survey results on medication and is
working to make improvements. Whilst
the results for patients being given or
offered a written or printed copy of their
care plan is low, the Trust is significantly
higher than the national average.
The Trust uses the number of discharges
to calculate the response rate for the
internal survey rather than how many
have been distributed. The Trust realises
there are some issues with the
methodology and this is being reviewed.
The Trust accepts that the number of
falls resulting in a fracture has increased
but the numbers remain small given
the number of admissions. Falls are
monitored closely and every incident of a
fracture is subject to root cause analysis.
Further detail has been included in the
Quality Account about Talbot ward.
The Trust felt the violent patient against
patient incidents was an important measure
to report on during 2010/11 and has included
this in the Quality Account. The text in the
report has been strengthened to make
reference to how the information is reviewed
and work that is being undertaken to make
improvements.
The Trust regularly monitors performance
against staff appraisals through the network
governance arrangements and will consider
what detail is provided in future reports.
The Trust is concerned about the figure for
young people involved in their care but given
the wider information, the Trust is confident
they are actively involved in their care. Some
of this information is available in the Quality
Account.
The Trust has included additional text to
outline the work that is being undertaken to
address service users concerns in secure
services.
The Trust will consider how the quality
overview is presented in future reports.
Lancashire LINk
Our overall comment is that we found the
statistical reporting difficult to make sense of
throughout most of the report. It would be
useful to have actual numbers and not just
percentages as this gives the public a better
idea of the overall picture or emphasis that is
needed.
We found there was a lot of information
about services that may be doing well (such as
The Junction, the Platform or the Traumatic
Stress Service) and almost no information on
the services which LINk has been concerned
about (the Community Mental Health Teams,
and crisis support in particular).
Given the strict word limit, we have chosen to
respond to the following issues.
2.2.1 – There is a downward trend for clinical
supervision of staff and this is worrying given
our observations later on in this response. We
would be interested to find out why 1 in 4
staff are not receiving supervision. Presumably
the figures following the first standard
refer to those supervisions that actually
took place – so caseload management and
acknowledging good practice has improved
but only for those receiving supervision. In
total, the figures may not have improved.
2.2.2 – It is stated that the Trust has performed
well above average for the indicators listed in
Table 2. However, according to the CQC
website9 the Trust performed ‘about the same’
on almost all of the criteria. Additionally,
Table 2 shows that less people have a number
they can call out of hours this year than last
year and less people rate the care received in
the last 12 months as excellent, very good or
good. If we break down the figures from the
CQC, we see that for those who had used a
crisis number, almost 1 in 2 said they did not
get the help they needed the last time they
called this number10. This is worrying and
leads us to believe that crisis services are not
adequate. LINk officers have also been told
this numerous times over the last year at
various meetings. The Trust’s score in the
survey is at the bottom of the range of
expected results as stated by the CQC, so
clearly this needs to be an area of urgent
priority especially as more service users are
increasingly dependent on the crisis service
following the closure of inpatient units by the
Trust.
2.2.5 – We’re wondering why the period
stated in Table 7 is from 2008-2011?
Furthermore, there is no explanation of the
scores – unless you’re a clinician it is not
possible to assess whether these scores are
good, bad or average.
2.3.2 – In relation to actions being undertaken
to raise awareness and promote SDS, we’d like
to comment that our community engagement
9
http://healthdirectory.cqc.org.uk/findcareservices/informationabouthealthcareservices/summaryinformation/searchfororganisation.cfm?faArea1=
customWidgets.patientsurveys_show_1&cit_id=RW5&zone=MAIN
10
http://healthdirectory.cqc.org.uk/findcareservices/informationabouthealthcareservices/summaryinformation/searchfororganisation.cfm?faArea1=
customWidgets.patientsurveys_show_2&cit_id=RW5&subset=450090&zone=MAIN&view_mode=2
Lancashire Care NHS Foundation Trust Annual Report and Accounts 2010 - 2011
47
in the North Locality has shown that SDS
is still a mystery to staff and patients, and
there is a lot of anxiety about the future
of service provision. We have written to
PCT commissioners and LCC reporting
this issue and are expecting to meet with
them shortly. People with mental health
problems have told us that their care
coordinators have not heard of SDS, or
believe it is not available for mental
health clients. Only yesterday we had a
report of a CPN completing his first
assessment who was unsure how to do
this and had to be supported by a social
worker and a mental health worker who
were present.
3.1.2 - The statistics provided are for a 6month period and we are not clear why
this is the case.
3.1.3 - We are seriously concerned about
the level of increase in violent patient
against patient incidents and are further
concerned by the lack of alarm shown in
the Quality Accounts. There is no
commentary on what is being done to
remedy this situation – the number of
violent incidents per occupied bed day
has DOUBLED since the previous
reporting year. Studying the Trust’s
Board papers shows that the rate of
violent incidents has been constant
throughout the year and we would have
expected some kind of immediate and
urgent plan to be put in place with
this regard. The high rate of incidents
against patients is even more disturbing
given the unacceptably high number
of children (21 in total) still being placed
on adult wards despite the change
in regulations from 1st April 2010. We
would like some reassurance that
the Board is taking these matters
seriously and ensuring an action plan
is
developed,
implemented
and
monitored.
Furthermore, the figures for violent
incidents against staff are for 2009/2010
and for some reason are quoted per
1000 staff (as a rate rather than an actual
figure as was the case for violence
against patients). How many staff does
this rate relate to? In table 2 3.5.2. we
are told that the figures for 2010/2011
are ‘not applicable’ yet the trend is
noted as ‘improved’ despite Board
papers stating that the overall trend
shows a steady increase.
3.1.4 - The report does not make clear
what category of issues come under SUIs
and an explanation of this would have
been very useful. We are not given any
information about the actual numbers,
rather just told about how long it took
to report them. We would have liked
more information about these, especially
as SUIs include children on adult wards.
We are even more concerned about
these figures given that the quarterly SUI
reports have been withheld from the
public for the last two quarters.
We would like to have seen some
information in relation to dementia
services and work which the Trust is
doing in relation to carers. We believe
that even though there may be top-level
commitment to improving work with
carers this is not being translated down
to frontline staff. A LINk member has
mentioned that ward staff in Burnley
were not aware of the Trust’s carers’
strategy until she talked to them about
it. Furthermore, we would appreciate
some monitoring information in next
year’s QA in relation to numbers of
completed carers’ assessments.
Glossary
CPN – Community Psychiatric Nurse
CQC – Care Quality Commission
LCC – Lancashire County Council
PCT – Primary Care Trust
SDS – Self Directed Support
SUI – Serious Untoward Incident
Trust Response to Lancashire LINk
The use of numbers and the statistical
reporting will be considered in the
2011/12 Quality Account. The Trust has
tried to provide a balanced picture and
will consider your comments about
inclusion of additional services in future
reports. Improved services around CMHTs and
the work around the crisis pathway is a
priority for the Trust.
An additional 100 staff completed the clinical
supervision audit and the Trust is confident
based on the results that more inpatient staff
are receiving supervision. The Trust is
disappointed with some of the community
staff results; however, the focus on supervision
has been on formal one-to-one discussions.
What the data has not included is regular
forums in community teams where peer
support and supervision are undertaken, for
example, complex care panels. Work is being
undertaken to review the definitions and
review the audit tool. It is not possible to draw
clear conclusions from the findings such as
one in four staff are not receiving supervision.
The performance of crisis resolution home
treatment teams is a priority for the Trust and
their performance is monitored closely, for
example, the executive team review access to
the teams on a weekly basis. A recent survey
of service users has demonstrated some
positive results and further work is being
undertaken on the crisis care pathway as
documented in the report.
The community national survey indicators are
selected for inclusion in the Quality Account
as they are key indicators. All the survey
results are reviewed, including getting help
when needed and actions are being taken to
address any areas of concern. The indicators
to be included in the Quality Account 2011/12
will be reviewed to ensure those most
relevant to the Trust are included.
The data for PTSD is from 2008-2011 as this is
the way it has been collected. In each section
of the table there is an explanation of the
findings and a key has been added to explain
some of the terms used.
The Trust is aware that SDS is a challenge
which was confirmed by the audit results. This
has led to the key recommendation which is
included in the report and this is a priority for
the adult network.
Drug errors is a new indicator and has been
included for the first time.
The Trust felt the violent patient against
patient incidents was an important measure
to report on during 2010/11 and has included
this in the Quality Account. The text in the
report has been strengthened to make
reference to how the information is reviewed
and work that is being undertaken to make
improvements. During the year the Trust
Board has raised concerns about the number
of young people being admitted to adult
wards and this has been reviewed in some
detail including a root cause analysis of each
individual case. A work programme has been
undertaken to improve the situation and
recent data suggest there has been a
significant decrease.
The information on violent incidents against
staff is data the Trust has to provide on an
annual basis. This has to be provided in a
certain format and at a set time. The Trust is
currently submitting the 2010/11 data and
these results will be published in November
2011. Further information has been included
in the report. The Department of Health
guidance requires the Trust to use nationally
benchmarked data which is why this is
included in the Quality Account. The Trust
does, however, report violent incidents
against staff on a quarterly basis in the quality
Board report. The Trust will consider using this
data in future reports.
The Quality Account has been updated to
include the categories for SUIs and these
relate to patient safety. The indicators used
are those included within the quality schedule
of the Trust’s contract with commissioners.
The SUI quarterly report is available in the
public domain. There was a problem with the
link to one of the SUI quarterly reports and
the other report was missed off, however,
they are both now available.
The Trust will consider the type of information
that can be included in relation to dementia
services. The staff awards are included in the
report and a number of these recognised
the good practice in dementia care.
Lancashire Care NHS Foundation Trust Annual Report and Accounts 2010 - 2011
49
The Quality Account does include a
section on carers (3.2.6) and there is
comparable data on completion of
carers’ assessments for the last two years.
The Trust would be interested to hear
your views about further information
which may be useful.
Blackburn OSC
I can confirm that unfortunately we are
not in a position to review or comment
on the draft Quality Account as part of
our current work for Health Overview
and Scrutiny. Whilst this may have been
part of the work programme previously
for this Committee, the authority has
recently undergone a series of
efficiencies and merged its Health
Overview and Scrutiny Committee with
that of Children's Services Overview and
Scrutiny Committee; resulting in a new
Children and Health Overview and
Scrutiny Committee. The Committee
does not meet until the second week in
June, when it will be advised to prioritise
firstly on work we are mandated to
undertake, whilst directing its work
programme for the next three months
towards the performance and delivery of
internal portfolio and departmental
efficiency reviews.
John Addison
Scrutiny Officer
Blackburn with Darwen Borough Council
Blackpool OSC
Following our telephone conversation, I
would just like to confirm the situation
regarding
our
Health
Scrutiny
Committee and the Quality Account
submitted by Lancashire Care NHS
Foundation Trust for 2010/11.
As you may be aware, due to the local
Council election that was held on 5th
May, there was a cessation of all formal
Council meetings, including the Health
Committee, from the end of March until
after the election.
Following the election, we have retained
a separate Health Committee that will
be meeting for the first time on 16th
June. However, given that the
Committee will be comprised of a
complete new membership base, it is not
considered viable for it to comment on
the Quality Account for this year in a
meaningful way.
Steve Sienkiewicz
Democratic Services Team Leader
(Overview and Scrutiny),
Blackpool Council
Lancashire OSC
The Trust has engaged with the
Lancashire Health Scrutiny Committee
on a periodic basis over the past twelve
months. This engagement has largely
related to the ongoing mental health
inpatient
service
reconfiguration
consultation. The Committee will
continue to have an overview of the
proposals as they develop and
subsequent transitional plans until their
natural conclusion.
The Committee intends to also
undertake further discussions with the
Trust with regard their performance in
the delivery of the provider services
being transferred from Central and East
Lancashire PCTs.
Annex:
Statement of directors’ responsibilities
in respect of the Quality Account
The directors are required under the
Health Act 2009 and the National Health
Service (Quality Accounts) Regulations
2010 to prepare Quality Accounts for
each financial year.
Monitor has issued guidance to NHS
foundation trust boards on the form and
content of annual Quality Accounts
(which incorporate the above legal
requirements) and on the arrangements
that foundation trust boards should put
in place to support the data quality for
the preparation of the Quality Account.
In preparing the Quality Account, directors are
required to take steps to satisfy themselves
that:
• The content of the Quality Account meets
the requirements set out in the NHS
Foundation Trust Annual Reporting
Manual;
• The content of the Quality Account is not
inconsistent with internal and external
sources of information including:
• Board minutes and papers for the period
April 2010 to June 2011
• Papers relating to Quality reported to the
Board over the period April 2010 to June
2011
• Feedback from the commissioners dated
23/05/2011
• Feedback from governors dated
27/04/2011
• Feedback from LINks dated 16/05/2011
• The Trust’s complaints report published
under regulation 18 of the Local Authority
Social Services and NHS Complaints
Regulations 2009 dated 28/04/2011
• The Head of Internal Audit’s annual
opinion over the Trust’s control
environment dated 19/05/2011
• The 2010 national patient survey
• The 2010 national staff survey
• Care Quality Commission quality and risk
profiles dated April 2011
• The Quality Account presents a balanced
picture of the NHS Foundation Trust’s
performance over the period covered;
• The performance information reported in
the Quality Account is reliable and accurate;
• There are proper internal controls over the
collection and reporting of the measures of
performance included in the Quality
Account and these controls are subject to
review to confirm that they are working
effectively in practice;
• The data underpinning the measures of
performance reported in the Quality
Account is robust and reliable, conforms
to specified data quality standards and
prescribed definitions, is subject to
appropriate scrutiny and review; and the
Quality Account has been prepared in
accordance with Monitor’s annual reporting
guidance (which incorporates the Quality
Accounts regulations) (published at
http://www.monitor-nhsft.gov.uk/
annualreportingmanual)
as well as the standards to support data
quality for the preparation of the Quality
Account (available at http://www.monitornhsft.gov.uk/annualreportingmanual).
The directors confirm to the best of their
knowledge and belief they have complied
with the above requirements in preparing the
Quality Account.
By order of the Board
Professor Heather Tierney-Moore
Chief Executive
June 3rd 2011
Stephen Jones
Chairman
June 3rd 2011
Lancashire Care NHS Foundation Trust Annual Report and Accounts 2010 - 2011
51
INDEPENDENT AUDITOR’S REPORT TO THE COUNCIL OF GOVERNORS OF
LANCASHIRE CARE NHS FOUNDATION TRUST ON THE ANNUAL QUALITY ACCOUNT
We have been engaged by the Council of Governors of Lancashire Care NHS
Foundation Trust to perform an independent assurance engagement in respect of
the content of Lancashire Care NHS Foundation Trust’s Quality Account for the year
ended 31 March 2011 (the “Quality Account”).
Scope and subject matter
We read the Quality Account and considered whether it addresses the content
requirements of the NHS Foundation Trust Annual Reporting Manual, and
considered the implications for our report if we become aware of any material
omissions.
Respective responsibilities of the Directors and auditors
The Directors are responsible for the content and preparation of the Quality
Accountin accordance with the criteria set out in the NHS Foundation Trust Annual
Reporting Manual 2010/11 issued by the Independent Regulator of NHS Foundation
Trusts (“Monitor”).
Our responsibility is to form a conclusion, based on limited assurance procedures,
on whether anything has come to our attention that causes us to believe that the
content of the Quality Account is not in accordance with the NHS Foundation Trust
Annual Reporting Manual or is inconsistent with the documents.
We read the other information contained in the Quality Account and considered
whether it is materially inconsistent with:
• Board minutes for the period April 2010 to May 2011;
• Papers relating to quality reported to the Board over the period April 2010 to
May 2011;
• Feedback from the commissioners dated 23rd May 2011;
• Feedback from the Council of Governors dated 27th April 2011;
• Feedback from LINks dated 16th May 2011;
• The Trust’s complaints report published under regulation 18 of the Local Authority
• Social Services and NHS Complaints Regulations 2009, dated 28th April 2011;
• The 2010 national patient survey;
• The 2010 national staff survey;
• The Head of Internal Audit’s annual opinion over the trust’s control environment
dated 19th May 2011; and
• CQC quality and risk profile dated April 2011.
We considered the implications for our report if we became aware of any apparent
misstatements or material inconsistencies with those documents (collectively, the
“documents”). Our responsibilities do not extend to any other information.
This report, including the conclusion, has been prepared solely for the Council of
Governors of Lancashire Care NHS Foundation Trust as a body, to assist the Council
of Governors in reporting Lancashire Care NHS Foundation Trust’s quality agenda,
performance and activities. We permit the disclosure of this report within the Annual
Report for the year ended 31 March 2011, to enable the Council of Governors to
demonstrate they have discharged their governance responsibilities by commissioning an
independent assurance report in connection with the Quality Account. To the fullest extent
permitted by law, we do not accept or assume responsibility to anyone other than the Council
of Governors as a body and Lancashire Care NHS Foundation Trust for our work or this report
save where terms are expressly agreed and with our prior consent in writing.
Assurance work performed
We conducted this limited assurance engagement in accordance with International Standard
on Assurance Engagements 3000 (Revised) – „Assurance Engagements other than Audits or
Reviews of Historical Financial Information‟ issued by the International Auditing and Assurance
Standards Board (“ISAE 3000”). Our limited assurance procedures included:
• Making enquiries of management;
• Comparing the content requirements of the NHS Foundation Trust Annual Reporting Manual
to the categories reported in the Quality Account; and
• Reading the documents.
A limited assurance engagement is less in scope than a reasonable assurance engagement. The
nature, timing and extent of procedures for gathering sufficient appropriate evidence are
deliberately limited relative to a reasonable assurance engagement.
Limitations
It is important to read the Quality Account in the context of the criteria set out in the NHS
Foundation Trust Annual Reporting Manual.
Conclusion
Based on the results of our procedures, nothing has come to our attention that causes us to
believe that, for the year ended 31 March 2011, the content of the Quality Account is not in
accordance with the NHS Foundation Trust Annual Reporting Manual.
Tim Cutler (Senior Statutory Auditor)
for and on behalf of KPMG LLP, Statutory Auditor
Chartered Accountants
St James' Square
Manchester
M2 6DS
3rd June 2011
Lancashire Care NHS Foundation Trust Annual Report and Accounts 2010 - 2011
53
Lancashire Care NHS Foundation Trust,
Sceptre Point,
Sceptre Way,
Walton Summit,
Bamber Bridge,
Preston PR5 6AW
Tel: 01772 695300
e-mail: lct.enquiries@lancashirecare.nhs.uk
www.lancashirecare.nhs.uk
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