Quality Accounts
2011/12
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1. Quality Narrative
Statement from the Chief Executive
I am delighted to welcome you to our third dedicated Quality Account which describes the quality and standard
of the care and services we provide. The aim of this document is to illustrate how important quality is to our
organisation and how it underpins all of our work. It outlines our quality achievements during 2011/12 and sets
our out objectives to further enhance the quality of our services for the benefit of service users during 2012/13.
In compiling this report we have liaised closely with our Board, our clinicians, service users and carers and NHS
Commissioners and other key stakeholders.
Alpha Hospitals was established in 2002 to meet the growing need for small specialist units providing care for
patients with enduring mental illness. It is the group’s aspiration to provide hospitals where staff can feel pride
in their work and patients can receive a holistic approach to treatment providing the best care possible. It is our
objective to provide a culture and an environment where staff feel they belong, are happy in their jobs and
patients feel their contribution is valued in the development of services. We believe that to provide a
professional service, it is paramount to preserve the integrity and commitment of the team. We must value each
other and put the patients first in everything we do.
Our Mission is to deliver the highest standard of patient care which is clinically effective in a manner which
respects people’s dignity, privacy and individuality in a safe, homely setting.
The primary aim of Alpha Hospitals is to provide specialist psychiatric services that meet the needs of the local
community. The company works toward partnership arrangements with the NHS through the development of
good working relationships, an informed understanding of the local needs and a unique integrated approach to
the commissioning of services.
Alpha Hospitals is committed to the continued development of an organisational culture which allows the
accommodation of an underlying approach of continuous quality improvement. Our comprehensive quality
framework makes explicit to all care staff the organisation’s expectations and vision regarding clinical standards
and lines of accountability. Lead clinicians and senior managers are encouraged to show a clear commitment to
care quality improvement through the inclusion of clinical governance as a key strategic and operational priority
within the hospital structure and operations. All staff members are involved in measurement of performance
and its analysis thereby leading to continuous performance improvement. This means that service-wide as well
as team and individual specific quality improvement initiatives are promoted, supporting a culture of learning
from experience and innovation in care delivery.
We strive for the highest quality and to ensure this we make continuous improvements within an environment
of openness, transparency, innovation, safety and reliability. To facilitate this, our services are delivered based
on the outcomes of robust internal and external audit processes. We regard highly the views of the people who
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use our services and we constantly monitor and review practice and actively encourage external influence
through service user / carer groups and peer review.
We would like to thank our staff, service users and carers, NHS Commissioners and other key stakeholders for
their continued support over the past year in helping us strive for excellence. We look forward to working with
them in partnership during the forthcoming year to further improve the quality and effectiveness of our services
which we recognise as essential in the challenging climate faced by the NHS.
We are looking forward to the challenges of Payment by Results and adjusting our documentation and practice
to support the Shared Pathway. We will provide cost effective services efficiently with lower lengths of stay
along each step of the care pathway.
We would welcome your feedback on the Quality Account and if you would like to let us know your views please
contact the Group Clinical Nurse Director on 0161-762-7247.
As the Chief Executive of Alpha Hospitals I can confirm that, to the best of my knowledge, the information
contained in this document is accurate.
This Quality Account was approved by the Board on 4 June 2012.
Patricia Hodgkinson
Chief Executive Officer
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2. Quality Performance
Priorities for Quality Improvement 2012/13
Following consultation with key stakeholders, Alpha Hospitals’ top four priorities for quality improvement in 2012/13
are:
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Service User Involvement/Recovery Planning
Clinical Effectiveness
Care Programme Approach (CPA)
Physical Wellbeing
These priorities reflect improvement goals identified through Alpha Hospitals’ own Clinical Governance
arrangements and they also complement the priorities identified by NHS Commissioners via Commissioning for
Quality and Innovation measures included in the 2012/2013 NHS standard mental health contract. They are also in
keeping with the national and regional secure services Quality, Innovation, Productivity, Prevention (QIPP)
programme, the Government strategy ‘No Health without Mental Health’ and other key national priorities for
mental health services specifically in relation to patient safety, personalisation, measurable outcomes, choice,
service innovation and tackling stigma and discrimination.
These priorities have been identified and this report developed with and for key stakeholders including lead
clinicians and managers within our own organisation who work within each of our specialist service streams as
follows:
Medium Secure Male Mental Illness/Personality Disorder
Low Secure Male Mental Illness/Personality Disorder
Medium Secure Male Personality Disorder
Low Secure Male Deaf Mental Disorder
Low Secure Female Personality Disorder
Low Secure Female Personality Disorder/Mental Illness
Medium Secure Female Personality Disorder
Medium Secure Female Personality Disorder/Mental Illness
Low Secure Male Mental Disorder
Locked Rehabilitation for Females
Locked Rehabilitation for Males
Low Secure – PICU Service for Female Adolescents
Low Secure – PICU Service for Male Adolescents
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Service Users and Carers were involved in the consultation together with a range of interested parties including our
own staff and NHS Commissioners.
Each of the priorities for improvement is described in more detail below.
Priority 1 – Service User Involvement/Recovery Planning
Our goal is to implement a Recovery and Outcomes based approach to the Care Pathway which demonstrates
Recovery orientated practice in identifying, planning and achieving joint goals and Outcomes with Service Users
and which gives Service Users more choice and opportunities to drive their own Outcomes.
The goal is supported by our Shared Pathway Strategy the purpose of which is to provide a strategic framework for
the implementation of the Shared Pathway across all of our services. Our Shared Pathway Strategy was developed
through our participation as a Share Pathway Pilot Site during 2011/12 and is, accordingly, informed by our
experience of implementing the Shared Pathway in practice.
The strategy is aimed at identifying a clear process for how the Shared Pathway will be linked to MDTs, CPAs and
Care Plans and how it will provide Service Users with the opportunity to work more collaboratively to achieve a
Shared Understanding. This will involve identification of key individuals, including staff and Service User Leads within
the organisation to receive and develop training and involvement of Service Users in joint training with staff on a
continuous basis to raise awareness of the Shared Pathway.
The Shared Pathway Strategy is underpinned by the following Commissioning for Quality and Innovation (CQUIN)
standard:
Shared Pathway Recovery and Outcomes
Priority 2 – Clinical Effectiveness
Our goal is to identify a number of standard milestones which aim to ensure that the Pathway is efficient, reduces
delays and improves patient experience. We will work collaboratively with Service Users to achieve key
milestones with the aim of reducing lengths of stay.
All patients will have an Outcomes plan which will demonstrate a collaborative/Shared Understanding of Outcomes
which agrees to move them through/out of secure services. This will be achieved by working through the four
pathway steps outlined in the Shared Pathway documentation evidencing recovery orientated practice.
We will aim to set service wide targets on reducing average lengths of stay which we will negotiate and agree with
NHS Commissioners. We will carry out awareness raising and training for all MDT’s on which of the key milestones
are priorities for each service, and how the targets may be achieved. We aim to ensure by the end of the year that all
key milestones are introduced and implemented and targets for average lengths of stay target are met.
Our strategy for optimising Clinical Effectiveness is underpinned by the following Commissioning for Quality and
Innovation (CQUIN) standard:
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The Secure Pathway/Implementing a Standard Pathway
Priority 3 - CPA
Our CPA goal is to put people who use services at the heart of what we do. This will be achieved through
empowering patients and carers to be equal partners with professionals in the CPA process through the
implementation of CPA standards which have been defined by service users.
This goal is supported by the following CQUIN standards:
Service User Defined CPA Standards
Shared Pathway Recovery and Outcomes
An implementation plan is in place to ensure the Shared Pathway is lined directly to CPA, MDT’s and Care Plans.
Service Users and Carers will be involved in all aspects of the CPA process and their involvement will be
benchmarked against the Service User nationally defined CPA standards across all services.
Priority 4 – Physical Wellbeing
Our goal is ensure more people with mental health problems have good physical health. We will achieve this
through continuing our commitment to establish parity between the quality of physical health services which can
be accessed by the general public and the physical health services we provide. This includes Health Promotion
and establishing healthy lifestyles and choices which can be continued in the community.
Our dedicated Nurse Practitioner will continue to lead on a physical healthcare and health promotion strategy
jointly with medical staff and senior nurses. The physical healthcare and health promotion group will continue to
meet on a regular basis to review the physical healthcare and health promotion needs of our patients including
relevant aspects of the General Medical Services Quality and Outcomes Framework.
Statement Relating to Quality of NHS Services Provided
Information required under the National Health Service (Quality Accounts) Regulations 2010
During the year ended 31 March 2012 Alpha Hospitals provided thirteen types of services on behalf of the NHS
comprising gender specific medium and low secure and locked rehabilitation mental health services.
We have reviewed all the data available to us on the quality of care in all thirteen of these NHS services.
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The income generated by the NHS services reviewed in the year ended 31 March 2012 represents 100 per cent of
the total income generated from the provision of NHS services by Alpha Hospitals for the year ended 31 March 2012.
Participation in Clinical Audits and Confidential Enquiries
During the year ended 31 March 2012 four national clinical audits covered NHS services that Alpha Hospitals
provides. Alpha Hospitals did not participate in the National Clinical Audit programme during 2011/12. However, we
undertake a programme of local audit of clinical performance which is reported to the Clinical Governance
Committee on each hospital site.
We have a dedicated clinical audit department with dedicated staff who coordinate the clinical audit programme for
each hospital. The clinical audit programme is designed to meet the audit requirements of government initiatives
and demonstrates the achievement of group objectives, standardised approaches to care and treatment, outcome
measures, and self- regulation of patient centred care and clinical practice.
A clinical audit committee is established and includes members of the multidisciplinary team who are involved in
carrying out audits within their own clinical speciality. We will introduce, wherever possible in practice, audits which
can be carried out by Qualified Nurses whilst engaged in clinical practice for example, use of seclusion, physical
health monitoring, the management of violence and aggression and rapid tranquilisation.
The national confidential enquiries that Alpha Hospitals was eligible to participate in during year ended 31 March
2012 are as follows:
National Confidential Enquiry into Suicide
We report to The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness to identify
individuals on the data sheets for whom we hold medical records to ensure all cases of patient suicide and homicide
are included in the research undertaken by this group.
We are involved in the following quality improvement programmes which were underway year ended 31 March
2012; The Quality Network for In-Patient Child and Adolescent Mental Health Services (QNIC) and Quality Network
for Forensic Mental Health Services (QNFMHS). During the coming year we plan to participate in the Prescribing
Observatory for Mental Health (POMH-UK).
The reports of 92 local clinical audits were reviewed by Alpha Hospitals in the year ended 31 March 2012 and we
identified the following key actions to improve the quality of healthcare provided:
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Ensure service users are given a full explanation of why they are admitted to a secure hospital and
ensure their Named Nurse is present on their first day of admission and they discuss their role in the
Service User’s care and treatment.
Provide de-briefs for Service Users following incidents on the ward to ensure they feel safe.
Continue to provide family and friends forums to allow the opportunity for carers to be involved in
service planning and provision.
Extend the range of healthy options on the patient menu and in the patient shops.
Further develop the provision of religious and spiritual services and associated facilities for patients.
Enhance the patient community meeting process by increasing attendance by different disciplines and
enhancing response times.
Development of a Safer Community framework and supporting policy and procedure to prevent and
reduce bullying.
Provision of additional ward facilities to enhance the internal care pathway.
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Increase educational provision for patients and enhance links with local education establishments.
Implement the Star Wards programme in male services.
Participation in Research
During the year ended 31 March 2012 no patients receiving NHS services provided or sub-contracted by Alpha
Hospitals were recruited during that period to participate in research approved by a research ethic committee.
A core group of professionals with an interest in research and development attends regular Research Governance
meetings and reports to the Clinical Governance Committee in relation to developments in social, psychological
practice, research and clinical guidelines.
We are committed to improving the quality of care we offer and in contributing to wider healthcare quality
improvement which is demonstrated through our involvement in clinical networks and research programmes which
include:
Development of the Shared Pathway and patient portfolio.
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Participation as a Shared Pathway pilot site.
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Research opportunities regarding clinical Outcome measures in forensic mental health settings.
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Accessibility of recovery tools for Deaf patients.
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Analysis of serious deliberate self-harm in secure female patient population.
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Participate as a pilot site for the introduction of SAPROF (Structured Assessment of Protective Factors
for Violence Risk).
Goals agreed with Commissioners
A proportion of Alpha Hospitals’ income in the year ended 31 March 2012 was conditional on achieving quality
improvement and innovation goals agreed between Alpha Hospitals and any person or body they entered into a
contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality
and Innovation payment framework. Further details of the agreed goals for the year ended 31 March 2012 and for
the following 12 month period are available on request from the Group Clinical Nurse Director, based at Alpha
Hospitals Bury, Bolton Road, Bury, Lancashire, BL8 2BS.
Regulatory Reports
Alpha Hospitals is required to register with the Care Quality Commission and is currently registered for:
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Treatment of disease, disorder or injury
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Assessment or medical treatment of persons detained under the Mental Health Act 1983
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Diagnostic and Screening Procedures
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Nursing Care
Alpha Hospitals’ registration is not subject to any outstanding conditions of registration.
The Care Quality Commission has not taken enforcement action against Alpha Hospitals during the year ended 31
March 2012.
Alpha Hospitals has not participated in any special reviews or investigations by the Care Quality Commission during
the reporting period.
Alpha Hospitals is subject to periodic reviews by the Care Quality Commission and the last review for which a report
is available was based on an inspection in April 2012 at Alpha Hospital Bury. The CQC’s assessment of Alpha Hospital
Bury following that inspection was that it was meeting all the essential standards of quality and safety reviewed.
Data Quality
As an independent sector provider Alpha Hospitals did not submit records during the year ended 31 March 2012 to
the Secondary Uses Service for inclusion in the Hospital Episode Statistics which are included in the latest published
data.
Records Management assessed using the Information Governance Toolkit was level 2. We have a comprehensive and
systematic approach to the management of data quality held in patient records which is overseen by our
Information Governance Committee. Our Information Management Strategy was reviewed and approved by the
Board providing assurance that the organisation has commitment and support to on-going improvement of data
quality at the highest level. Alpha Hospitals’ score for the year ended 31 March 2012 for Information Quality and
Records Management was 66%.
We recognise that good quality information underpins the effective delivery of patient care and is essential if
improvements in quality of care and value for money are to be made. We ensure that our Information Governance
Strategy guides and informs our record-keeping to support our delivery of care and treatment and that the accuracy,
completeness and validity of those records is monitored on an on-going basis by audit to continually improve data
quality.
We have commenced an electronic patient records implementation plan and are working with RiO to fully
implement new systems during 2012/13. Expected benefits of the project include processing efficiencies, improved
accuracy and accessibility of records and enhanced external reporting capabilities.
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Review of Quality Performance 2011/12
The following summary outlines our achievements during 2011/12:
Priority 1 –Involvement
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Development of activity programmes based on interest questionnaires and individual patient choice.
Involvement of Service Users and staff in the Safer Community Committee (aimed at reducing bullying) so
that direct and indirect bullying behaviours can be challenged and reduced.
De-briefing sessions held for Service Users following incidents on the ward.
Training for Service Users on how to manage interpersonal problems through the development of ‘living
together ‘groups in service areas.
Development of the Relational Security Strategy across service areas using evidence based practice (See
Think Act).
Continued work with Advocacy services to enhance Service User/Carer involvement in service provision.
Continued development of Recovery Strategies to ensure that Service Users are fully involved in their vision
of their shared pathway.
Development of a working party to contribute to the Shared Pathway as a pilot site.
Joint planning of policy and procedures with Service Users/Carers regarding extending internal care
pathways within services.
Enhanced community meetings which are attended on a regular basis by the MDT and all actions raised are
addressed within one week wherever possible or a progress report is provided.
Daily de-brief sessions for Service Users and staff at the end of each shift.
DBT skills training for all ward staff on female services to enhance the therapeutic milieu.
Introduction of Senior Support Workers on the wards who are provided with additional specialist training to
enable them to support and coach junior staff working with service users on the ward.
Mainstreaming of the Recovery agenda and introduction of the Shared Pathway
Priority 2 – CPA
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HONOS Secure, HONOSCA and HCR20 utilised
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25 hours structured week evaluated leading to further innovation in delivery of meaningful activity.
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Clear specifications for each patient group were further developed to include specific assessments using the
right tools for the best mental health practice in each service. We achieved this in conjunction with the
development of the Shared Pathway and Patient Portfolio. In adult services we use HoNOS-secure, HCR-20,
SAPROF, START, MOHOST and CAN-FOR and in Adolescent services we use HONOSCA, STAR, 3 DI, MANCAS,
SDQ, SAQ and MOHOST. Patients were provided with information to assist their understanding of the
assessment tools used.
Patients were encouraged to write their own reports for their CPA meetings with support from staff.
We built on the structured day for patients striking a balance between therapy and recreation and achieved
a minimum of 25 hours meaningful activity to promote recovery and improve clinical outcomes. We focused
on preparation for patients to achieve wider outcomes when they are discharged from secure care, for
example gaining employment.
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The therapeutic group programme was enhanced to include groups with measurable outcomes; these
included amongst others, arson, violence reduction, emotional regulation, Dialectical Behavioural Therapy
and Schema Focussed Therapy.
We implemented a Recovery Action Plan based on the Sainsbury Centre framework for organisational
change to demonstrate Alpha Hospitals’ engagement in delivering Recovery orientated services and
commitment to build on existing good areas of practice.
All Service Users were supported by staff to develop a Recovery action plan to ensure they had the
necessary opportunities to explore and discuss issues relevant to their own individualised care needs.
Alpha Hospitals worked to meet the needs of Carers, families and friends of relatives and results have shown
that we attained high standards in this area indicating that Alpha Hospitals communicates well, giving carers
information that they can understand and that they are treated with respect.
Priority 3 – Recovery Planning
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All patients were offered the opportunity of completing a Recovery plan.
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Staff training was delivered on the use of approved Recovery tools.
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Information fairs on Involvement, Choice and Responsibility were held on all services during 2011-2012 for
Services Users and staff. These workshops brought together MDTs and Service Users to discuss and identify
priority areas for changes to be made to embed the Shared Pathway. These ideas and suggestions were
jointly developed into a work plan for each service to underpin the work required to implement the Shared
Pathway in 2012/2013.
Service Users and MDTs were consulted on what service changes needed to be put in place to make the
service more Recovery and Outcome focussed.
Service Users and MDTs were consulted on what collaborative working needed to occur with Service Users
to reach a Shared Understanding, increasing transparency and placing as much responsibility for meeting
outcomes into the hands of the Service Users.
All patients were supported to complete a Recovery plan with support from care staff and with the
involvement of Carers.
Recovery workshops and Recovery groups were organised for each service regularly and key areas for
development were identified. A joint patient/staff report was produced and progress monitored and
evaluated as part of a joint work plan.
We continued to provide Service User defined activity plans which promoted a balanced and structured day
linking with individual Recovery plans and the Shared Pathway. We assessed activity plans using the agreed
national definition of Meaningful Activity and recorded and evaluated them using the agreed benchmarking
tool.
Activity staff are now in place on all wards across the hospital. They have regular and open dialogue with
patients to try and generate ideas and interests in a range of activities.
Through a range of daily morning meetings, community meetings and diary management group sessions all
patients on all services are now offered a range of opportunities to be involved in determining their own
weekly planned activity and therapy timetable in negotiation with activity staff, their OTs and their clinical
team. Personal activity timetables are reviewed regularly in ward round and in CPA meetings on all services.
All service users are provided with a diary to enable them to plan and record individual session timetables
All wards have display spaces where weekly timetables of activities are displayed. There is also information
on display about new groups due to start, themed events and activities coming up, competition activity
posters and celebration events.
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All community meetings across the hospital are chaired by Service Users with the support of staff. MDT
members attend community meetings and all actions are completed within one week wherever possible or
an update is provided.
All wards have an activity budget which is managed by activities staff and decisions about how to spend this
budget are made in consultation with patients, activities staff and OT’s jointly.
Information about patients’ interests and the meaningful activity that is being provided as part of an overall
treatment package is regularly discussed and reviewed. This review process happens between the patient,
the activities staff, the ward staff, the OT and the MDT, using all systems and forums including morning
meetings, diary management groups, community meetings, ward rounds and CPA reviews.
Priority 4 – Physical Wellbeing
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Establishment of ward based healthy eating groups.
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Training for all care staff regarding health promotion and how to help patients to make healthy choices
regarding their lifestyle.
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Introduction of an in practice audit tool for physical health monitoring with training in its use for all qualified
nurses.
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Increasing physical exercise and weight management.
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We employ a dedicated Nurse Practitioner who is dual trained as RMN/RGN and is a Nurse Prescriber who
works full time in managing and providing physical healthcare to a high standard. The Nurse Practitioner has
undergone further training in the past 12 months to further enhance her skills.
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The Physical Health Group and Health Promotion Group have continued to meet on a regular basis
throughout the year to review the physical healthcare and health promotion needs of our patients including
application of some relevant aspects of the General Medical Services Quality and Outcomes Framework.
Delivery of health education to patients with different needs and problems including dietary modification,
exercise, weight management, diabetic control and techniques of using Spacer/inhalers etc.
Patients on admission are assessed by qualified gym instructors and exercise care plan were devised based
on individual patient needs which support patients to continue to have regular access to the Gym and
walking groups.
Specialist support is given to MDTs to develop Physical Health Care / Health Promotion management plans
for all patients.
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Priority 5 Improving outcomes
Service specific assessment algorithms were used during 2011/12 which set out a structured approach to the
assessment of patients with a focus on a number of areas which are fundamental to a patient’s journey in secure
care.
We demonstrated our commitment to the national and regional QIPP schemes through engagement in the
development of the Shared Pathway and Patient Portfolio work streams.
We gained a better understanding of current lengths of stay for the patients in our services and developed strategies
to reduce them including:
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Identification of a predicted length of stay in the first few months of admission.
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More robust and active transition plans between services i.e. if admitted from another hospital or between
different levels of security.
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Extension of the care pathway ranging from medium secure to low secure to locked rehabilitation for male
and female patient populations.
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Full engagement in My Shared Pathway Pilot Scheme.
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Strong emphasis on relational security and implementation of See Think Act and compliance with relational
security standards issued by the QNFMHS.
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Experienced and established MDTs within each service who are career matched to specialist services e.g.
Adolescent, Deaf, Female and Personality Disorder.
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Offence related groups which are Outcome based and have a defined completion date.
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DBT service for females which is a specialist treatment aimed at reducing self-harm which involves staff at all
levels.
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Priority 2 - CPA
3. Quality Information
Review of Quality Performance
A number of metrics have been chosen to summarise our performance against key quality indicators of
effectiveness, safety and patient experience. These were chosen in consultation with our staff, clinicians, patients
and carers, NHS Commissioners and other key stakeholders.
Safety Indicators
Ensuring patient safety is of paramount importance to us in the delivery of our services. We have robust systems in
place to ensure we are aware of and adhere to new Service Users’ safety pronouncements and guidance. All safety
notices are processed in line with national guidance and feedback is gained from the clinical areas as directed. A
patient safety report is discussed at Clinical Governance Committee each month and actions taken are cascaded via
the meeting minutes.
There have been no breaches of Nationally Specified Events during year ended 31 March 2012. We report serious
incidents which have taken place on a quarterly basis and describe the actions we have taken. This information is
shared across the group and with the NHS. This demonstrates our commitment to learning from experience and
improving practice. We review all incidents and accidents on an individual basis and service basis in the following
forums: MDT Partnership Forums, Health and Safety meetings and Clinical Governance. We use the information
available to measure reduction of risk in individual patients and safety on the wards and we have identified trends
through analysis of data and produce action plans to improve practice.
Indicator
Target
Result
Report serious and untoward
At least 95% reports
Met
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incidents to NHS Secure
Commissioners within one
working day
Achieve compliance with
requirements set out in the
Best Practice Guidance:
specification for adult medium
secure services and National
Minimum Standards for
General Adult Services in Low
Secure Psychiatric Intensive
Care Units (PICU) or for
Adolescents and Low Secure
Environments including draft
low secure guidance
At least 90% compliance
Met
Compliance with infection
prevention and control
guidance
At least 90% compliance
Met
Compliance with Standards for
Medium Secure Forensic
Services – QNFMHS
At least 90%
Achieved 96%
Compliance with NPSA safety
alerts.
100% compliance
Met
Effectiveness Indicators
An effective service can be defined as one that puts people who use services at the heart of what it does using ‘No
decision about me without me’ as the governing principle. This section describes some of the indicators we have in
place to measure effectiveness of our services in providing the right service, to the right person at the right time.
Indicator
Target
Result
All patients will have the
opportunity to complete a
recovery plan using an
approved recovery tool
All services
Met
Physical health checks for all
patients on admission and
annually including adhering to
best practice for chronic
disease management
All patients
Met
Robust and comparable data on All patients
ethnicity of service users
Met
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collated and reported
Implementation of service user
defined CPA standards
All patients
Met
Patient Experience Indicators
We are committed to seeking patient and carer feedback and input to service delivery to support continual
improvement in the patient experience ensuring care is personalised to reflect individual needs, access to
information and support to exercise choice and receive care and treatment in accordance with clinical guidance and
which can be measured.
Indicator
Target
Result
Ensure all patients on CPA have
a named care co-ordinator to
support the patients (eventual)
discharge
90%
Met
Undertake an annual patient
satisfaction survey and ensure
actions are taken following the
feedback to further enhance
the patient experience
All services
Met
Undertake regular surveys of
the ward atmosphere taking
into account how safe patients
feel, how engaged in treatment
they feel and the level of
support they have from care
staff and other patients they
live with
All services
Met
All patients have a CPA within 3
months of admission
All services
Met
All patients have an initial care
plan within 24 hours of
admission
All services
Met
All patients have a detailed care
plan within 3 months of
admission
All services
Met
All patients are offered copy of
their care plan
All services
Met
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Complaints are responded to
within 2 days and are resolved
within 25 days or an agreed
extended period
All services
Met
Other Achievements
In the year ended March 31st 2012 we were successful in meeting our strategic aims and had the following
achievements:
We were successful in terms of NHS contract compliance and achieved quality and innovation targets and had our
work on recovery and Service User involvement recognised nationally by the NHS. We were also selected to be a
pilot site for the Shared Pathway initiative and successfully completed the pilot and are now implementing the
initiative across all of our services.
We continue to receive regular inspections from the Mental Health Act arm of CQC. We have had a number of
inspections so far this year including visits to our adolescent services. The inspection results were excellent and the
quality of our MHA documentation was again commended.
In December 2011 we were visited by the MHA arm of CQC and our usual inspector was accompanied by the lead for
our area. They presented on their inspection findings for the previous year and praised us highly for the quality of
our services and our adherence to the Mental Health Act.
In December 2011 we were also subject to a peer review by members of the Medium Secure Quality Network who
inspected our medium secure services over two days. We were delighted to receive a score of 95% compliance, an
increase from our previous year’s score of 94%.
Our Specialist PD trainer, Professor Livesley, a world renowned academic expert in PD, recently visited to provide the
second module of training to our Support Worker staff in the treatment of PD as part of an Alpha Diploma. Our staff
valued the training enormously and are looking forward to the third instalment later this year in October.
We continue to achieve great success in our education department with an unprecedented number of patients
achieving formal qualifications ranging from City & Guilds to University degrees. We are fortunate to have excellent
qualified teachers and the commitment and dedication of the education department is commended by families, NHS
Commissioners and CQC inspectors alike.
Our Education department has increased the number of patients who are accessing education and patients achieved
significant success at examinations with over 100 certificates being awarded to patients.
We continue to lead the way in our Management of Aggression and Potential Aggression (MAPA) practice and have
recently been awarded Trusted Partner Status with our training accreditation organisation, Positive Options.
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We carried out a major refurbishment of a 31 bedded building on our site in Bury and successfully launched
adolescent mental health services in September 2011. We also expanded our site in Sheffield with the opening on
schedule of a new 15 bedded extension which enabled us to extend our service offering to include locked
rehabilitation services for men.
A large number of our patients were supported in submitting artwork to the Koestler Awards and patients were
awarded 67 certificates for artwork, craft and writing.
All of our male service wards worked towards achieving Star Wards awards which they plan to complete shortly.
Our Therapies department has reviewed individual and group programmes to include further offence related
therapy groups, functional skills groups and recreational groups.
Our Eco-Therapy department has expanded its activities with patients and growing of produce and keeping livestock
has been of particular interest to patients.
Nurse Therapy together with other members of the clinical teams have introduced a full DBT programme and skills
groups.
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