Quality Account
2011/12
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Contents
Table, 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 2011/12 Priorities and
Statements of Assurance from the Board
Priorities for Improvement
Performance against 2011/12 Priorities
Priority 1: Standards of Clinical Supervision (Patient Safety)
Priority 2: Performance of Community Mental Health Teams
Priority 3: Standards on 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)
5
7
9
10
12
17
20
23
23
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 (& Clinical Coding)
24
24
24
26
26
27
29
3.
PART 3: Review of Quality Performance
Patient Safety
Improved Safety Culture
Drug Errors
Violent Incidents
Serious Untoward Incidents (SUIs)
Mandatory Training
Staff Appraisal
Pressure Ulcers
31
31
31
32
34
39
39
40
40
3.1
3.1.1
3.1.2
3.1.3
3.1.4
3.1.5
3.1.6
3.1.7
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
3.2.4 Advancing Quality
3.2.5 Carer’s Assessments
3.2.6 Accredited Services
42
42
46
47
3.3
Patient Experience
3.3.1 Service User Experience
3.3.2 Crisis Patient Reported Outcome Measures (PROMS) / Patient Reported Experience
54
55
55
3.2
3.2.1
3.2.2
3.2.3
3.3.3
3.3.4
3.3.5
3.3.6
3.3.7
3.3.8
3.3.9
Measures (PREMS)
Dementia
Other Examples
Surveys - The Junction Service User Experience
Contributions of stakeholders
Patient Complaints
Age Appropriate Services
Privacy and Dignity Single Sex Accommodation
3.4
Performance Against Key Mental Health Indicators
50
53
54
56
57
57
62
64
65
65
66
3.5
Quality Management Systems
3.5.1 Quality Initiatives
66
67
4.
71
Annexes
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
Table 26
Table 27
Table 28
Table 29
Table 30
Table 31
Table 32
Table 33
Table 34
Table 35
Table 36
Table 37
Table 38
Table 39
Quality Priorities for 2012/15
Quality Overview with comparison against previous year’s data
Clinical Supervision
National Community Patient Survey Results
National Inpatient Survey Results
Adult and Older Adult Inpatient Surveys
Longridge Inpatient Survey
Safety Thermometer for Longridge Ward
Guidelines published 2011/12
Outcome from POMH-UK Assessment of the side effects of Depot Antipsychotics
Outcome from POMH-UK Monitoring of Patients Prescribed Lithium
Outcome from POMH-UK Use of antipsychotic medicines in people with learning disabilities
Outcome from POMH-UK Prescribing antipsychotics for people with dementia
Participation in Clinical Audits
National Confidential Enquiries
CQC Review of Compliance – Balmoral Ward, Parkwood Hospital January 2012
Data Quality
Clinical Coding
NPSA Categories
Administration errors
NHS Outcomes Framework – Safe Patient environment
National Patient Safety Agency data (Mental Health only)
Indicators for Quality Improvement
National Community Indicators - Immunisation
National Community Indicators - Prevalence of Breastfeeding
WHAM Audit data (Blackburn with Darwen Data only)
Royal College of Psychiatrists Peer Review of Guild Lodge
QNIC Accreditation Report for The Junction
QNIC Report for The Platform
Advancing Quality Indicators
Advancing Quality and NICE Quality Standards
New Advancing Quality Indicators for 2012/13
PEAT Assessment Scores
Carer’s Assessment Audit
NHS Outcomes Framework- Patient Experience
Crisis Patient Reported Outcome Measures and Patient Reported Experience Measures
Secure Services Service User Satisfaction Survey
Ombudsman Requests
Performance against Key Mental Health Indicators
6
8
9
10
12
13
14
16
17
18
18
18
19
25
25
27
29
29
33
33
38
38
42
43
44
45
47
48
48
50
50
51
53
53
54
55
61
64
66
Diagram 1
Diagram 2
Diagram 3
Diagram 4
Diagram 5
Diagram 6
Diagram 7
Diagram 8
SUIs reported within 2 working days
SUIs reviews completed (45 days)
Staff Mandatory Training
Staff Appraisals
What young people and parents said in the QNIC Report
What young people are saying about The Junction
What young people are saying about The Platform
Patient comments taken from Ormskirk Hospital video diary
39
39
39
40
49
58
60
63
Chart 1
Chart 2
Chart 3
Chart 4
Chart 5
Chart 6
Chart 7
Chart 8
Chart 9
Chart 10
Chart 11
Chart 12
Chart 13
Chart 14
Chart 15
Chart 16
Chart 17
Chart 18
Chart 19
Chart 20
Chart 21
Chart 22
Chart 23
Falls resulting in a fracture
Number of patients colonised with MRSA
Number of patients C.difficile Toxin Positive
Longridge Community Hospital Patient Expected Outcomes of Stay
PTSD Clinical Outcomes
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 Pharmacy Interventions from April to September 2010
Number of Pharmacy Interventions from April to September 2011
Number of Violent Patient Against Patient Incidents
Number of Occupied Bed Days per Violent Patient Against Patient Incident
Violent Incidents Against Staff (rate per 1,000 Staff)
Year on Year Comparison of Assaults on Staff by Patients
Severity of Reported Incidents of Assaults on Staff by Patients
Percentage of staff experiencing physical violence from patients, relatives or the public in last 12 months
Perceptions of effective action from employer towards violence and harassment
Categories of Pressure Ulcers by Provider by Quarter during 2011/12
Setting of Acquired Pressure Ulcer- Category 3
Setting of Acquired Pressure Ulcer- Category 4
Advancing Quality : Dementia Outcomes
Advancing Quality : Psychosis Outcomes
Number of Compliments and Complaints Received
Young Person Admission to Adult Wards
14
15
15
20
21
31
31
32
32
34
34
35
36
36
37
37
40
41
41
51
52
64
65
3
Quality Account
Part 1: Statement on Quality from the Chief Executive
This year has seen Lancashire Care NHS Foundation Trust develop as a health and wellbeing
organisation. In June 2011 the provider arms of the Primary Care Trust in Blackburn with Darwen,
Central and East Lancashire joined the Trust. We now provide a range of community and mental
health services and we have made a number of changes that will improve the lives of people in
Lancashire.
Delivering high quality services to the local community remains our core purpose and, driven by a
clear set of standards, we strive to make improvements every year. This report provides an account
of how our services have performed over the last 12 months and we have included many examples
of excellent services. We have met all our key national targets and performance has improved in
a number of areas. There are some areas however where further work needs to be undertaken.
We know we have areas where improvement is needed and we are working hard to address these,
and this is reflected in our priorities. The report describes the plans we have in place to make the
changes necessary to achieve the improvements. We are particularly keen to ensure that high
standards are consistently achieved and where we can demonstrate excellence, that this is used as
an exemplar, to promote wider improvements across the whole organisation.
The Council of Governors and the Trust Board have approved this Quality Account which covers
the full range of the Trust’s services. To the best of our knowledge the information contained in
this account is accurate.
Professor Heather Tierney-Moore
Chief Executive
4
Part 2: Priorities for Improvement, Performance against 2011/12 Priorities and
Statements of Assurance from the Board
2.1 Priorities for Improvement
Quality is about protecting people from harm (safety), giving them treatments that work
(effectiveness), and making sure that they have a good experience of care (patient experience).
Quality is part of our Trust value of excellence. The Trust’s approach to quality is based on the three
domains of quality (patient safety, effectiveness and patient experience), using national and local
metrics to identify performance and where required, a range of improvement techniques. The Trust
aims to ensure minimum high standards are achieved and our goal is to achieve upper quartile
performance in all areas. Focused management attention, clinical leadership, performance review
and audit are the mechanisms for achieving this.
The diagram below illustrates the main components of quality:
Quality
Safety
Effectiveness
Patient Experience
National Requirements
Compliance Framework
Benchmarking
Priorities for Improvement
Focus on Outcomes
Views of Stakeholders
Quality Strategy
Quality Metrics
The Trust has reviewed its quality strategy
focusing on what has worked well and
analysing what has been successful for other
trusts. The ideas have been discussed with
service users, governors and staff and the new
strategy explains how it will be easier for
everyone who works for the Trust to provide
better quality care.
The Quality Improvement Strategy is based on
four simple actions:
■ Action one: collect useful information on
quality (that is: safety, effectiveness, and the
patient experience) across all parts of the
organisation
■ Action two: share this information quickly
with the people who are best placed to
improve care
■ Action three: empower these people to get
things done
■ Action four: keep making sure that the
process is working
5
The strategy details how the Trust will get
better at these four actions. A detailed
implementation plan will be produced by July
2012. This will list the tasks that need to be
completed and set timescales using an
Enterprise Assurance Management (EAM)
approach. EAM has been introduced in the Trust
to ensure there is a robust process for managing
the risks to the achievement of our strategic
aims and priorities, and a mechanism by which
the Board can gain confidence that the
associated risks have effective systems of control
in place. The use of EAM to underpin the
Quality Strategy will ensure that quality
becomes embedded in the objectives of the
organisation and that any risks to the delivery
of the strategy will be clearly understood.
Through the identification of controls and
assurances, the progress of delivery will be clear
and where gaps exist, further work will be
undertaken to address these. Using this
approach the Trust can ensure that areas of
highest risk will become the focus of delivery,
the tasks within the strategy are systematically
prioritised and there are clear accountabilities
against all activities. This will be overseen by an
implementation group which will be set up,
with service user representation, to supervise
the plan and progress will be reported to the
Trust Board on a quarterly basis.
Following the changes to the Trust in June 2011
and the updating of the quality strategy, a
review of the existing quality priorities was
undertaken. This identified the need for new
priorities which better reflect the services the
Trust now provides including a focus on health
and wellbeing. A framework was developed to
support the identification, development and
measurement of the Trust’s new quality
priorities. The framework ensures that the
identification of priorities involved a wide
range of stakeholders including service users,
carers, members, staff, network directors,
director and deputy directors of nursing, and
professional leads. The priorities were identified
in line with both national (Harm Free Care,
National Institute for Health and Clinical
Excellence, and Quality, Innovation Productivity
and Prevention) and local (Commissioning for
Quality and Innovation) quality improvement
targets. The priorities and the rationale for
inclusion are listed in Table 1.
Table 1: Quality Priorities for 2012/15
Priority
Rationale
Domain
Target Year
1
Target Year
2
Target Year
3
Quality Priority 1
Set up systems
to collate data.
Establish
baseline with
pilot teams.
Monthly
submissions to
Safety Express
across all
eligible services95% harm free
care.
As above
As above
As above
As above
As above
As above
As above
As above
As above
As above
As above
As above
As above
As above
Establish
baseline and
report against
the baseline.
Implement
incremental
change to move
towards
compliance with
the NICE
Guidelines.
Compliant with
the NICE
Guidelines.
Establish
baseline and
reporting.
Agree targets
for year 2 and 3
at the end of
year 1.
To be
determined
by the end of
year 1.
To be
determined
by the end of
year 1.
Compliance with the
Harm Free Care
national priority
Harm Free Care / Safety
Express quality initiative.
Commissioning for Quality
and Innovation (CQUIN).
Quality Strategy.
Reduction in the
number of pressure
ulcers developed in
our care
As above
Reduction in the
number of falls
Reduction in the
number of catheter
acquired infections
Safety
Stretch target
to improve
harm free care –
97%
Quality Priority 2
Increase in service user
involvement
CQUIN. Quality Strategy.
Productive Care.
National Institute for Health
and Clinical Excellence
(NICE) Clinical Guideline 136
– Service user experience in
adult mental health and 138
– Patient experience in adult
NHS services.
Patient
Experience
Quality Priority 3
Reducing time on non
value added activity
Linked to Department of
Health Quality, Innovation,
Productivity and Prevention
(QIPP) target.
Effectiveness
6
Progress against these priorities will be
reported regularly to the Trust Board and will
be included in the 2012/13 quality account. A
simple ranking of elements will be used, which
will enable clear identification of where new
mechanisms are needed to make improvements
and where existing approaches are working
well. These will replace the existing priorities
which are still key areas for the Trust and will
be reported internally during 2012/13 in a
number of ways including through the clinical
audit priority programme, quality report and
Director of Nursing governance report.
To ensure high standards throughout the
organisation the Trust has revised the quality
strategy and this is also supported by
developing a more sophisticated approach to
obtaining the views of service users. The focus
of this work will be the development of plans
and goals right through to team level which will
be monitored through a balanced scorecard
approach. Each team and network will be clear
about its priorities and these will be closely
monitored by a formal performance process
through the quarterly Chief Executive’s review
and other similar mechanisms. Risks to
achievement will be managed through the
Enterprise Assurance Management Framework
and where success is challenged then effective
controls will be put in place to minimise the
opportunity for underachievement.
2.2 Performance
against 2011/12
Priorities
The priorities for improvement for 2011/12
were defined in the Quality Strategy which was
approved by the Board in February 2009. The
Strategy was a three year strategy and progress
against these priorities was reported in the
2010/11 Quality Account. The priorities were 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
7
■
■
■
Priority 5 - Developing care pathways
Priority 6 - Clinical risk assessment
Priority 7 - Therapeutic activity
The Trust was 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
Engagement with stakeholders
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.
A stakeholder map has also been developed.
The Trust has implemented a programme of
quality reviews and the assessment teams have
included
governors
and
non-executive
directors. Feedback from service users and staff
using questionnaires and interviews has also
been included. A service user consultant is a
member of the quality strategy group and is
commissioned to undertake quality projects
including a summary of the 2010/11 Quality
Account. The service user consultant and a nonexecutive director have reviewed the draft
2011/12 Quality Account in detail. The
Standards and Assurance Committee (SAC) is a
sub-committee of the Council of Governors
(CoG) and during 2011/12 they have had a key
role in reviewing evidence against the quality
priorities and providing assurance back to the
CoG. The committee has also reviewed this
quality account on behalf of the CoG. A quality
summary of this quality account is being led and
produced by a service user consultant and will
be available from the Trust in summer 2012.
Information Systems
The Trust delivers services primarily through
three service networks: Adult Community and
Specialist Services; Adult Mental Health;
Children and Families. 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 system of key
information in place, accessible to all staff
through the intranet. These systems cover both
national and local indicators. During 2011/12
the Trust has appointed clinical directors to each
network. They are practising clinicians and part
of their role will be to enhance quality in their
area of responsibility.
During 2011/12, the Trust has been successful in
improving the data quality systems to ensure
data is reliable and any necessary 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.
Throughout the report, where applicable, the
Trust measures its performance against national
and local standards.
Table 2 provides an overview of the quality
performance compared with data from
previous years. Further detailed information is
included throughout the report.
Table 2: Quality Overview with comparison against previous year’s data
Quality Measures Reported
2007/08
2008/09
2009/10
2010/11
2011/12
Service users with colonised MRSA
43
28
21
17
15
Service users with C.difficile Toxin Positive
17
9
8
4
0
SUI reported in 2 days
-
-
71%
72%
81%
SUI completed in 45 days
-
-
68%
84%
80%
Falls resulting in fracture
10
4
11
13
12
61%
67%
63%
79%
78%
Staff received Mandatory Training
-
-
53%
67%
74%
Complaints referred to Ombudsman
5
2
13
9
16
Young People admitted to adult units
17
27
39
21
9
Improving Safety Culture (lower score better)
28%
32%
27%
26%
27%
Violent incidents against staff
157
146
80
218
Issued November
2012
Staff with up-to-date appraisal
Trend
(2010/11)
8
2.2.1 Priority 1: Standards of Clinical Supervision (Patient Safety)
Clinical supervision
The measurement of clinical supervision has been by way of a clinical audit to identify practice
against the standards listed in Table 3. The results represent a sample of community and inpatient
staff, including staff from new services. The response increased by 81 staff in the 2011/12 audit.
Table 3:
Clinical Supervision
Community Staff
2010/
11
2011/
12
All staff have a right to
regular formal supervision
85%
71%
78%
Supervision will take place
in line with professional
codes of conduct
86%
88%
86%
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
Identifying and
acknowledging good
practice during managerial
supervision
Community staff supervision started 2009
2009/
10
Standard
2008/
09
Inpatient staff
Variance
between
2010/11 &
2011/12
Variance
between
2010/11 &
2011/12
2008/
09
2009/
10
2010/
11
2011/
12
7%
81%
85%
75%
78%
3%
73%
15%
82%
89%
87%
73%
14%
77%
81%
4%
95%
88%
75%
80%
5%
80%
75%
77%
2%
86%
76%
73%
78%
5%
47%
55%
46%
9%
76%
60%
60%
59%
1%
81%
98%
68%
30%
64%
77%
94%
73%
21%
79%
95%
70%
25%
75%
79%
95%
77%
18%
Data Source: LCFT Clinical Governance
Clinical Supervision remains a priority for the
Trust. Throughout 2011/12, staff have been
encouraged to attend clinical supervision
training provided by the Higher Education
Institutions and other organisations. A number
of the results show a decrease from last year’s
audit. A reason for this could be that there are
four different policies in place and each has
different standards. For example ‘Supervision
will take place in line with professional codes of
conduct’ is not included in the Blackburn with
Darwen policy so could explain why that result
has decreased. The Trust is confident that
9
management supervision is embedded within
the organisation and keen that excellence is
promoted through the use of effective systems
of clinical supervision. This is why it remains a
priority for the Trust. Training has been made
available and work undertaken to ensure that
protected time is made available to support
this process. A new supervision policy will be
introduced during 2012 and this includes more
explicit standards and definitions which will
allow the Trust to monitor progress more
effectively. This will be a clinical audit priority
for 2012/13.
2.2.2 Priority 2: Performance of Community Mental Health Teams (which are now called
Complex Care and Treatment Teams in Adult Mental Health Services) and Community Teams
(Patient Experience)
Community Patient Surveys (Patient Experience)
The 2011 Community Mental Health Service Users’ Survey was undertaken by the Care Quality
Commission (CQC). National Surveys help the Trust compare themselves against national data on
an annual basis.
The Trust performance compared to last year has seen an improvement in the majority of
indicators. The greatest increase is in the percentage of people having a care review in 12 months,
which saw an eight percentage point increase on last year’s figures. There was one indicator that
saw a one percentage point decrease on last year and that was in the offer of a printed copy of
their care plan. The improvements reflect the work that has been undertaken since the previous
report.
Table 4: National Community Patient Survey Results
National
Survey
Results
(LCFT)
2008
National
Survey
Results
(LCFT)
2009
National
Survey
Results
(LCFT)
2010
National
Survey
Results
(LCFT)
2011
National
Average (All
MH/LD Trusts)
2011
Yes definitely
61%
66%
61%
66%
68%
2%
Do you have a number of someone
from your local NHS MH service that
you can phone out of hours?
Yes
51%
70%
63%
70%
51%
19%
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%
77%
56%
21%
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%
80%
79%
1%
Have you been given (or offered) a
written or printed copy of your care
plan?
Yes in the
last year
52%
51%
42%
9%
Yes definitely
& Yes to some
extent
97%
98%
98%
0%
Indicator
Were the purposes of medication
explained to you?
Did this person (Health and Social Care
Workers) treat you with respect and
dignity?
Criteria
Data Source: CQC National Community Survey Results
Variance
between LCFT
and National
Average 2011
Data governed by Standard National Definitions
When comparing the 2011 results with the national average, it can be seen that the Trust has
scored well above the national average with regard to two indicators. The Trust has improved its
performance ‘against the purposes of the medication explained’ although this is still two
percentage points below the average. Additional work is underway to continue to make
improvements in this area including the development of guidance on care plans and clear
standards that incorporate requirements about medication.
Performance of Community Teams
In June 2011 the Trust took on responsibility for the provision of wider community health services.
This has seen the number of staff in the Trust increase from 3,613 to 6,725. There have been a
number of initiatives within community teams to enhance patient experience and some examples
are included which demonstrate quality practice across a range of services.
10
Continence Team (Patient Experience)
The continence team have developed a
leaflet about teenage pelvic floor health, using
a group of teenage girls to obtain help and
guidance. This work won two Nursing Times
awards in 2011 (Child and Teenage Health
Award and the Continence Award). In addition,
a member of the continence team has also been
shortlisted for the development of the Urinary
Catheter Assessment and Monitoring (UCAM)
tool. This will act as a personalised record of all
aspects of catheter care that the patient needs
to be taught to enable them to self-manage
their condition.
Discharge Planning Team
(Effectiveness)
The Discharge Planning team in Central
Lancashire has been nominated for the
Partnership Working award. This team are key
enablers in ensuring that discharges are safe
and that delayed transfers to Community
Services are minimised. This supports Lancashire
Teaching Hospitals Foundation Trust in
maximising its bed capacity and is an everyday
example of partnership working at its best.
11
‘Breathable’: Pulmonary rehabilitation
programme Blackburn with Darwen
(Patient Experience)
The programme is for people living with long
term respiratory problems particularly Chronic
Obstructive Pulmonary Disease (COPD) and aims
to provide confidence, knowledge and ability
to self-manage their long term condition. The
service has been recognised as an example of
best practice and is in the North West
Advancing Quality Alliance (AQuA), Improving
Outcomes Pack (IOP).
There have been a number of service
developments over the last year including
initiatives to improve uptake and participation.
An intervention has been developed, in
partnership with the community matron service
which enables GP services to focus on those
eligible for pulmonary rehabilitation within a
set risk category, from their COPD register. This
targets those patients at very high or high risk
of hospital admission. The service, which is now
direct and seamless, contributes to avoiding
admissions and supporting discharges.
2.2.3 Priority 3: Standards on Inpatient Units Inpatient Surveys (Patient Experience)
National Mental Health Inpatient Survey
The National Inpatient Survey findings in Table 5 compare the results for the Trust over the last
three years and with the national average for this year. The Trust has scored better than the
national average with four indicators, matched the national average on one and was one
percentage point below the average in one indicator. Work is continuing on inpatient units to
make improvements in these areas.
Responding to the views of service users is crucial in improving the patient experience and a new
approach will be implemented during 2012/13 which will include use of the Patient Opinion facility.
Patient Opinion is an independent social enterprise who run an award winning national website
(www.patientopinion.org.uk) on which service users, carers and relatives share their experiences
of health services and the NHS services involved are able to respond and where appropriate,
demonstrate improvements. During 2012, Patient Opinion will be working closely with the Trust
to develop new ways of receiving and responding to feedback from service users and carers. This
will provide immediate feedback and allow the Trust to respond more quickly.
Table 5: National Inpatient Survey Results
Criteria
National
Survey
Results
(LCFT)
2009
National
Survey
Results
(LCFT)
2010
National
Survey
Results
(LCFT)
2011
National Average
(All Mental
Health/Learning
Disability Trusts)
2011
During your most recent stay, did
you feel safe?
Yes always and
Yes sometimes
83%
88%
84%
84%
0%
In your opinion, how clean was
the hospital room or ward that
you were in?
Very clean and
Fairly clean
87%
90%a
90%
84%
6%
Were you given enough privacy
when discussing your condition
or treatment with the hospital
staff?
Yes always and
Yes sometimes
81%
83%b
86%
87%
1%
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%
70%c
74%
73%
1%
Yes
37%
45%
46%
39%
7%
Excellent,
Very good
and Good
67%
73%d
71%
70%
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
Variance
between LCFT
and National
Average
(2011)
Data governed by Standard National Definitions
a-d
2010 report which was received from the CQC was an interim report and as such did not show the true 2010 end position for
LCFT. This error was noticed when reviewing the 2011 report which contained the 2010 figures. Indicators that have changed
are as follows:
abcd-
Cleanliness original
Privacy original
Care and treatment original
Rate of care original
2010 = 91%
2010 = 85%
2010 = 71%
2010 = 72%
revised 2010 = 90%
revised 2010 = 83%
revised 2010 = 70%
revised 2010 = 73%
12
Mental Health Inpatient Internal Survey
The internal survey commenced in May 2009 as a questionnaire given to all older inpatients and
adult inpatients on discharge. It consists of ten 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 main challenge is to increase the response rate as it has been
disappointing. Many service users are reluctant to complete the survey on discharge. The Trust is
looking at ways of improving this and particularly ways of collecting more ‘real time’ data.
Table 6: Adult & Older Adult Inpatient Surveys
Indicators
Criteria
2009/10
2010/11
2011/12
Variance between
2010/11 & 2011/12
Was the ward clean?
‘always’ and ‘mostly’
94%
95%
94%
1%
Could I get a hot drink when I wanted?
‘always’ and ‘mostly’
76%
85%
91%
6%
The ward felt a safe place to be in
‘always’ and ‘mostly’
82%
80%
81%
1%
I got as much information as I wanted about
my treatment
‘good’ and ‘satisfactory’
74%
84%
84%
0%
I knew how to make a complaint if I needed to
‘good’ and ‘satisfactory’
68%
81%
82%
1%
I was satisfied with how I was involved in
planning my hospital care
‘good’ and ‘satisfactory’
80%
82%
88%
6%
‘always’ and ‘mostly’
80%
80%
85%
5%
I was satisfied with how I was involved in
planning my discharge
‘good’ and ‘satisfactory’
81%
81%
88%
7%
I experienced discrimination on the ward
‘never’
89%
83%
87%
4%
7
7
0
My privacy was respected
Would you recommend us to a friend
Scored out of 10
Data Source: LCFT Clinical Governance
The annual results are being reviewed and the Trust has seen an overall improvement on last year.
The largest improvement seen on 2010/11 was a seven percentage point increase in involvement
on planning discharge. There was one indicator that saw a one percentage point decrease on last
year and that was in regard to ward cleanliness.
Longridge Inpatient Survey
In April 2010 the use of a Patient Experience Questionnaire (PEQ) was introduced onto the ward
at Longridge Community Hospital (LCH).
13
Table 7: Longridge Inpatient Survey
Criteria
November 2011
Were you given enough privacy whilst on the ward?
Yes
100%
Do you feel there is a sufficient range of beverages available during the day and at mealtimes?
Yes
100%
In your opinion, was the hospital room or ward that you were in sufficiently clean?
Yes
100%
Were you given the opportunity to discuss your condition or treatment?
Yes
100%
Were you involved as much as you wanted to be in decisions about your care and treatment?
Yes
99%
Were you given the opportunity to discuss your condition or treatment?
Yes
99%
Were you made aware of how to complain or report any concerns during your stay on the ward?
Yes
88%
Were you told when you were going to be discharged?
Yes
99%
Indicators
Source: Longridge ward
Overall the results were positive and the main area for improvement related to awareness of how
to complain or report any concerns (88%). To address this area the patient information leaflet has
been updated.
Chart 1:
Falls resulting in a fracture
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.
Falls resulting in a fracture have
slightly decreased during 2011/12. 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 Trust is
committed to reducing falls which is
demonstrated by its involvement in
the Safety Express programme which
is a national scheme to promote
improvements in specific areas, with
falls being one example
14
12
13
12
10
11
8
10
6
4
4
60%
reduction
on
2007/08
2007/08
2008/09
175%
increase on
2008/09
2009/10
18%
increase on
2009/10
2010/11
Data Source: LCFT Internal Information System (Datix)
Data is governed by Standard National Definitions
8%
reduction
on 2010/11
2
Number of falls resulting in a fracture
Falls resulting in a fracture
(Patient Safety)
0
2011/12
Financial Year
14
Health Care Associated Infections
(Patient Safety)
Chart 2:
Number of patients colonised with MRSA
The information below identifies two different
health care associated infections, which are of
importance to the Trust.
50
45
In June 2011 the Trust took on responsibility for
community services in Blackburn with Darwen,
Central Lancashire and East Lancashire. There is
no specific target for these services but
information is submitted to commissioners on a
monthly basis. Regular meetings occur between
commissioners and the infection control lead,
and the Trust participates in root cause analysis
of any incidents of MRSA bacteraemia or
C.difficile. There have not been any infections
identified that were acquired in the community.
To support the reductions in infections,
antibiotic prescribing is closely monitored by the
non-medical prescribing lead for community
services. There have not been any outbreaks at
Longridge Community Hospital during 2011/12.
35
30
28
25
20
21
15
17
35%
reduction
on
2007/08
2007/08
2008/09
25%
reduction
on
2008/09
2009/10
15
19%
reduction
on
2009/10
2010/11
10
12%
reduction
on
20010/11
Data Source: LCFT Infection Prevention & Control Dept.
Data is governed by Standard National Definitions
Financial Year
Chart 3:
Number of Patients C.difficile Toxin Positive
18
16
17
14
12
10
9
8
Never Events (Patient Safety)
The ‘never events’ applicable to the Trust
include:
■
■
■
■
15
Wrong site surgery
Suicide using non-collapsible rails
Wrong implant/prosthesis
Escape of a transfered prisoner
0
2011/12
8
The Department of Health extended the list of
‘never events’, and have introduced financial
measures to penalise service providers when
these events do occur. ‘Never events’ are
defined as ‘serious, largely preventable patient
safety incidents that should not occur if
the avoidable preventable measures have
been implemented by health care providers’
(National Patient Safety Agency 2010/11).
5
6
47%
reduction
on
2007/08
2007/08
2008/09
11%
reduction
on
2008/09
2009/10
0
4
100%
reduction
on 2010/11
2
4
50%
reduction
on 2009/10
2010/11
Number of reported cases
It can be seen in Charts 2 and 3 that over the last
five 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 and rates will be continually
monitored during 2012/13.
Number of reported cases
40
43
0
2011/12
Data Source: LCFT Infection Prevention & Control Dept.
Data is governed by Standard National Definitions
Financial Year
■
■
■
■
Retained foreign object post surgery
Falls from unrestricted windows
Wrongly prepared high-risk injectable
medication
■ Entrapment in bedrails
■ Opiod overdose of opiod-naive patient
■ Maladministration of potassium-containing
solutions
■ Misplaced naso-gastric or oro-gastric tubes
■ Wrong route administration of oral/enteral
treatment
■ Failure to monitor and respond to oxygen
saturation
■ Maladministration of insulin
■ Wrong gas administered
■ Overdose of midazolam during conscious
sedation
■ Air embolism
■ Misidentification of patients
Inappropriate administration of daily oral
methotrexate
■ Severe scalding of patients
The Trust did not have any ‘never events’.
Harm Free Care (Patient Safety)
Over the last year Longridge Community
Hospital has participated in the national ‘Safety
Express’ pilot programme to reduce harm from
pressure ulcers, falls, Urinary Tract Infections
(UTI), and Venous Thromboembolism (VTE).
Harm free care data has been collected on a
monthly basis and submitted via a host
organisation: Lancashire Teaching Hospitals
Trust (LTHT). The aim of Safety Express is to
have 95% harm free care by December 2012.
Table 8: Safety Thermometer for Longridge Ward
Apr11
May11
Jun11
Jul11
Aug11
Sep11
Oct11
Nov11
Dec11
Jan12
Number of
patients harm free
85%
85%
73%
100%
83%
100%
83%
86%
77%
93%
Number of patients
not harm free
15%
Feb12
Mar12
100%
No data
submitted1
15%
27%
0%
17%
0%
17%
14%
23%
7%
0
0
Of those not harm free, which of the four conditions were present
Pressure Ulcers
1
2
2
0
3
0
0
0
3
Falls
0
0
0
0
0
0
0
0
0
0
UTI
0
2
1
0
1
0
0
1
1
0
VTE
1
1
1
0
0
0
1
1
0
0
Source: LCFT Internal Systems
No data
submitted
0
0
0
Data governed by Standard National Definitions
The programme will be rolled out across Lancashire during 2012/13 and will be included in
Commissioning for Quality and Innovation (CQUIN). The Trust will submit data independently as
an organisation from April 2012. This will enable the Trust to effectively monitor harm free care
across the services it provides and ensure the data is used to develop services, and improve the
quality of care provided.
There was an administration error in February 2012 and the data did not get submitted. To address
this, the data will now be submitted from a central department.
1
Data was not submitted in February 2012 due to an administration error
16
2.2.4 Priority 4: Ensuring National Institute for
Health and Clinical Excellence (NICE)
compliance (Patient Safety)
The importance of ensuring the Trust has a
robust system in place to review and implement
relevant NICE guidance was identified in the
Quality Strategy as a key priority for the Trust.
A baseline assessment is completed against
each Clinical Guideline, and where a service
identifies they are partially or not compliant
with a guideline, a systematic approach to
implementation is taken across the Trust.
During 2011/12 the focus of the work has been
to integrate the NICE systems across the Trust
and embed the process. There has been a
significant increase in the number of NICE
guidelines applicable to the community
services, and work is underway to complete the
appropriate baseline assessments. Work is also
progressing in relation to NICE quality
standards although there are challenges given
the volume of standards now applicable to the
Trust.
Table 9 below outlines the guidelines published
during 2011/12 that are relevant to the Trust.
The CG138 guideline and guidelines in quarter
4 are being reviewed, and baseline assessments
completed, to determine their level of
compliance.
Table 9: Guidelines published 2011/12
Publication
Date
Guidelines/Quality Standards
Quarter 1
2011/12
CG123 Common Mental Health Disorders
PH35 Preventing type 2 diabetes
✓
✓
Quarter 2
2011/12
CG124 Hip Fracture
CG127 Management of Hypertension
CG128 Autistic Spectrum Disorders in Children and Young People
✓
✓
✓
Quarter 3
2011/12
CG134 Anaphylaxis
CG133 Longer term Management of Self Harm
CG136 Service User Experience in Adult Mental Health
✓
✓
!
Quarter 4
2011/12
CG137 Epilepsy
CG138 Patient Experience in Adult NHS Services
CG139 Infection
!
!
!
Key:
✓ Compliance Determined
Source: LCFT NICE Guidance Lead
✓ None Compliant
Level of
Compliance
! Compliance being determined
Data governed by Standard National Definitions
A number of NICE clinical guidelines recommend the use of Cognitive Behavioural Therapy (CBT).
In January 2012, the Trust’s Lead for Psychological Therapies and the NICE Guidelines
Implementation Lead organised a half day event attended by a wide range of staff from across
the Trust to identify how the provision of CBT could be increased. This event generated very
practical positive ideas, for example the development of an intranet page with resources for CBT
that staff can access and share, which has been taken forward.
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. Tables 10-13 identifies four
of the audits which the Trust has participated in, and the results compared to the national position
for key standards.
17
Table 10: Outcome from POMH-UK Assessment of the side effects of Depot Antipsychotics
Re-Audit
2010
Re- Audit
May 2011
Documented evidence of side
effect monitoring
58%
99%
98%
1%
82%
16%
Evidence of physical assessment of
side effects
6%
79%
56%
23%
22%
34%
Documentation regarding
measurement of weight/ BMI/
waist circumference
20%
86%
89%
3%
53%
36%
Standard
Data Source: POMH-UK
Re-Audit
Variance
National
Average
2012
Re-Audit/
National
Average
Variance
Baseline
Audit
Oct 2008
Data is governed by Standard National Definitions
Table 11: Outcome from POMH-UK Monitoring of Patients Prescribed Lithium
Re-Audit
Sept 2010
Re-Audit
Sept 2011
Serum Lithium level
(3 monthly)
25%
19%
61%
42%
48%
13%
Renal Function
(creatinine) (6 monthly)
38%
17%
89%
72%
70%
2%
Thyroid Function
(6 monthly)
36%
30%
81%
51%
61%
20%
Standard
Data Source: POMH-UK
Re-Audit
Variance
National
Average
2012
Re-Audit/
National
Average
Variance
Baseline
Audit
Jan 2009
Data is governed by Standard National Definitions
Table 12:
Outcome from POMH-UK Use of antipsychotic medicines in people with learning disabilities
Re-Audit
Jan 2011
National
Average
2012
Prescribed an antipsychotic less than 12 months:
indication for treatment with antipsychotic
medication is documented in the clinical records
100%
93%
7%
Prescribed an antipsychotic more than 12 months:
the continuing need for antipsychotic medication
should be reviewed at least once a year
100%
97%
3%
66%
56%
10%
Documented evidence of weight monitoring
55%
28%
27%
Blood Pressure Test result recorded
8%
27%
19%
Blood Glucose Test result recorded
74%
42%
32%
Lipid Profile Test result recorded
74%
41%
33%
Standard
Documented evidence of EPS monitoring
Data Source: POMH-UK
Baseline
Audit
Aug 2009
In house
audit
Re-Audit / National
Average Variance
Data is governed by Standard National Definitions
The ‘Blood Pressure Test result recorded’ relates to the outcome of the test being recorded in the notes
and not that the test had not been carried out. Approximately 80% had a references to the blood pressure
being taken in the notes and there were only 2% of patients who did not have a test carried out.
18
Table 13 Outcome from POMH-UK - Prescribing antipsychotics for people with dementia
National
Average
2012
The clinical indications (target symptoms) for antipsychotic
treatment should be clearly documented in the clinical records
100%
97%
3%
Before prescribing antipsychotic medication for Behavioural and
Psychological Symptoms of Dementia (BPSD) likely factors that
may generate, aggravate or improve such behaviours should
be considered
100%
80%
20%
The potential risks and benefits of antipsychotic medication
should be considered and documented by the clinical team,
prior to initiation
75%
43%
32%
The potential risks and benefits of antipsychotic medication should
be discussed with the patient and/or carer(s), prior to initiation
100%
49%
51%
100%
76%
75%
46%
25%
30%
Standard
Medication should be regularly reviewed, and the outcome of the
review should be documented in the clinical records. The
medication review should take account of:
■ Therapeutic response
■ Possible adverse effects
Data Source: POMH-UK
The
audits
demonstrated
significant
improvements in a number of areas, with only
one area of practice falling below the national
average in the ‘Use of Antipsychotic Medicines
in People with Learning Disabilities’ re-audit.
The reason for the fall in performance for the
depot antipsychotics side effects monitoring
was that additional teams were included in this
audit, which have not been included in the
previous audits. This resulted in a fall as
compared to previous Trust results although it
still shows that the Trust overall is better than
the national average. The individual teams are
now being targeted to bring their practice in
line with the other teams across the Trust.
Medicines Management Strategy
(Patient Safety)
A medicines management strategy has been
developed which includes onsite medicines
management by teams, the review of
medication errors, provision of training, and
developing processes to disseminate and
integrate
learning.
Two
Medicines
19
Re-Audit /
National
Average
Variance
Baseline
Audit
Mar 2011
Data is governed by Standard National Definitions
Management Nurses are in post and promote
an open learning culture in relation to the
reporting and review of medication errors. They
have developed a procedure for the
management of medication errors by nurses
which focuses on individual reflection and
learning, together with a review of factors
contributing to medication errors when
required. Feedback from incident reports and
reflective practice accounts (currently over 100)
are used to identify common themes for the
types of medication errors made and their
causes. This qualitative information is
invaluable when developing responses to risk
from medication errors. The Strategy was
presented as a poster at the Mental Health and
Medication
Safety
2011
International
Conference Adelaide, SA Australia and the
Patient Safety Congress 2011 in Birmingham.
The Medicines Management Nurses also work
closely with ward and community team
managers to address difficulties being faced
in clinical work, either by providing support
with the review of individual errors or via
the introduction of ‘Medicines Safety
Walkrounds’. The ‘Walkrounds’ enable teams to
promote their good practice initiatives but also
draw attention to areas of concern such as
environmental constraints. All inpatient mental
health units across the Trust have had a
‘Walkround’, and a programme is in place to
complete the same in mental health community
services.
2.2.5 Priority 5:
Developing Care Pathways (Effectiveness)
During 2011/12 a number of groups were
established to review and update the mental
health care pathways against NICE guidance.
The groups include clinicians and they have also
been looking at developing outcome measures.
A piece of work is in progress to map the
community care pathways and this will form a
key part of the new quality strategy. A
significant amount of work has been
undertaken to allocate patients to a care
pathway as part of the Trust wide project on
Payment by Results (PbR). Data has now been
produced on the number of patients on each
care pathway by PbR cluster. Work will be
undertaken during 2012/13 to further analyse
the data and identify ways to use the data for
quality improvement.
A number of examples of measures are
reported below and the service user experience
data has been included in Part 3.
Longridge Patient Reported
Outcome Measures (PROMS)
(Patient Experience)
At Longridge Community Hospital, a PROM was
introduced on the ward in June 2011, which
asks patients what they hope will be the
outcome of their stay at Longridge Community
Hospital. Chart 4 shows the results of the
patient expected outcomes.
Chart 4: Longridge Community Hospital Patient Expected Outcomes from Stay
45
40
35
39
30
25
20
22
15
18
16
10
12
5
8
4
0
To go home
Improved
mobility
To improve Independance
generally or
be better
Fitter
4
Symptom
free
Don’t
know
To be
cared for
2
Put on
weight
Data Source: Longridge Community Hospital
The rate was 96.15%, with 100 patients from 104 achieving their hoped for outcome. Of the four
patients who did not achieve their hoped for outcomes, one patient in the ‘improved mobility’
category was admitted to a care home as an interim measure and three patients in the ‘to go
home’ category were admitted to care homes as they required more care than could be provided
at home.
20
Included below are some comments taken from the PROMS forms and there were no negative
comments.
Care... highest standards in every respect
Been happy here
Very glad to be walking
Care/treatment…superbly performed by the excellent staff at LCH
Staff very helpful in all ways
Nurse, food, care and treatment grand
The Lancashire Traumatic Stress Service (LTSS) (Effectiveness)
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 chart 5 and a 15 point
reduction in scores on the Clinician’s Administrated Post Traumatic Stress Disorder Scale (CAPS) is
considered to be a clinically significant improvement.
80
70
Chart 5: PTSD Clinical Outcomes
A comparison of average Pre and
Post CAPS Scores for Completed
Treatment Cases
71
73
60
50
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.
40
36
20
10
Average
Initial
CAPS
Average
Final
CAPS
April 2008 to February 2011
21
30
Average
Initial
CAPS
0
Average
Final
CAPS
April 2008 to February 2012
A comparison of average Pre and Post BDI and BAI Scores for Completed
Treatment Cases
45
40
35
36
34
30
25
28
27
20
15
19
17
15
10
14
5
0
Average
Pre BDI
Average
Post BDI
Average
Pre BAI
Average
Post BAI
Average
Pre BDI
Average
Post BDI
April 2008 to February 2011
Average
Pre BAI
Average
Post BAI
April 2008 to February 2012
This graph illustrates changes in symptoms of depression (Beck Depression Inventory-BDI) 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.
A comparison of average Initial and final PHQ-9, GAD-7 and WSAS Scores for all
Completed Treatment Cases
30
24
24
22
18
17
12
15
14
16
13
10
6
9
8
13
8
0
Average
Initial
PHQ-9
Average
Final
PHQ-9
Average
Initial
GAD-7
Average
Final
GAD-7
Average Average
Initial
Final
WSAS
WSAS
April 2008 to February 2011
Average
Initial
PHQ-9
Average
Final
PHQ-9
Average
Initial
GAD-7
Average
Final
GAD-7
Average Average
Initial
Final
WSAS
WSAS
April 2008 to February 2012
This graph shows changes in the scores on 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 we assess.
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.
Source: LCFT Lancashire Traumatic Stress Service (LTSS)
Data governed by Standard National Definitions
22
Definitions of
abbreviations
CAPS
Clinician’s Administrated PTSD Scale
BAI
Beck Anxiety Inventory
BDI
Beck Depression Inventory
PHQ9
Patient Health Questionnaire
GAD7
Generalised Anxiety Disorder
WSAS
Work and Social Adjustment Scale
DSM IV
Diagnostic and Statistical Manual of Mental Disorders
(Fourth Edition)
The results demonstrate that the Trust
maintained or improved the outcomes for
patients who attended the service.
Psychological Therapies Governance
Committee - Frameworks for the Use
of Assessment Tools
A framework approach was taken to clarify the
governance arrangements for the use of
psychological tools that are part of common or
core assessment pathways within clinical areas
or networks.
They may be defined as
questionnaires or scales and/or psychometric
tests that are used in assessing a service user’s
psychological presentation and/or cognitive or
intellectual functioning. Where a psychological
tool is in use by a range of different professions
and/or staff groups then suitable arrangements
need to be in place to ensure the appropriate
and effective use of the psychological tool.
Networks and clinical areas were asked to
provide assurance against a number of
indicators in relation to their use of
psychological tools as described above. This has
now been completed for all the areas where
these tools are in use. This includes Early
Intervention Services, Older Adult Mental
Health, Children’s Psychological Services, Secure
Services and Improving Access to Psychological
Therapies (IAPT).
2.2.6 Priority 6:
Clinical Risk Assessment (Patient Safety)
During 2011/12 a clinical risk policy has been
developed including clear standards for
23
practice. The policy has been approved and will
align with the Payment by Results (PbR)
clustering tool. As part of the clinical systems
board, a subgroup was established to review
the clinical risk processes. A model was
developed and is now awaiting inclusion in the
clinical system. When the clinical system has
been designed this will be rolled out and an
audit of the standards will be carried out.
Reducing the risk of suicide remains an
important clinical priority and mental health
services have continued to roll out key training
during 2011/12.
2.2.7 Priority 7:
Therapeutic Activity (Effectiveness)
A Trust group was set up to identify and review
therapeutic activity across the Trust. The
membership includes professional leads from
each of the networks and the Trust Lead for
occupational therapy. A template of activity
was developed and agreed by the group for
completion on each of the mental health wards.
The data that has been received has undergone
a thematic review. There were four areas within
the audit that looked at wards’ activities from
routine, familiar tasks to more therapeutic
focused activities. Therapeutic activities are
about replicating normal life on many of the
wards; however challenges of environment,
client group and staff group mean that the
availability of the activities across the Trust is
not consistent. What is evident however, from
the brief analysis that has taken place are clear
activities that are age appropriate and
individualised to needs. Examples include
exercises ranging from football, swimming and
running in Child and Adolescent Mental Health
services (CAMHS), to bean bag targets, skittles
and tea dances in the Older Adult wards.
Examples of activities by theme are as follows:
■
Exercise
Running, swimming, gym, climbing, Tai Chi
and dancing
■ Activities of Daily Living (ADL)
Laundry, shopping, food and drink
preparation and budgeting
■ Games
Puzzles, jigsaws, dominoes, snooker and
quizzes
■ Entertainment
DVD nights, karaoke and film evening
■ Relaxation
Reading material, spiritual requirements,
anxiety management groups and pamper
sessions
■ Community (off Trust property)
Walks in local parks and gardens, trips to
museums, cinemas and access to libraries
■ Arts and crafts
Drawing, gardening, creative writing,
pottery, woodwork, metalwork, art sessions
and drama
■ Education/re-training/voluntary work
Adult courses on literacy, numeracy and IT.
Volunteer work within the community e.g.
market stalls
■ Internet and Communications
Internet, games consoles and phones
■ Directed Therapies
Social skills, anxiety and anger management,
goal setting and Cognitive Behavioural
Therapy
More detailed analysis of the data is to be
undertaken to find similarities and differences
between activities on wards and provide
benchmarking so that improvements can be
monitored over the next year.
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 projects and initiatives aimed at
improving quality such as recruitment of
service users to clinical research trials
2.3.1 Review of Services
During 2011/12 the Trust provided two NHS
services (mental health and community). The
Trust has reviewed all the data available to
them on the quality of care in all (two) of these
NHS services. The income generated by the NHS
services reviewed in 2011/12 represents 100% of
the total income generated from the provision
of NHS services by the Trust for 2011/12.
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. This work is
supported by the quality governance
framework which has been reviewed by the
Board during 2011/12.
2.3.2 Participation in Clinical Audits
During 2011/12, two National Clinical Audits
and one National Confidential Enquiry covered
NHS services that the Trust provides.
During 2011/12, 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 Clinical Audits and National
Confidential Enquiries that the Trust was
eligible to participate in during 2011/12 are
included in Table 14 and Table 15.
24
The National Clinical Audits and National Confidential Enquiries that the Trust participated in
during 2011/12 are listed in Table 14 and Table 15.
The National Clinical Audits and National Confidential Enquiries that the Trust participated in, and
for which data collection was completed during 2011/12, are listed in Table 14 and Table 15
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 14: Participation in Clinical Audits
Participation
% Cases
Submitted
Assessment of the side effects of Depot Antipsychotics
Yes
100%
Monitoring of Patients Prescribed Lithium
Yes
100%
Prescribing antipsychotics for people with dementia
Baseline Audit
Yes
100%
2. National Audit Schizophrenia
Yes
100%
Participation
% Cases
Submitted
Suicide
Yes
85%
Homicide
Yes
100%
National Clinical Audits
1. Prescribing Observatory for Mental Health – UK (POMH-UK)
Table 15 National Confidential Enquiries
1. National Confidential Enquiries - Suicide and Homicide by People
with Mental Illness (National Confidential Inquiry (NCI)/National
Confidential Inquiry Suicide and Homicide (NCISH))
Source: LCFT Clinical Governance Department
Data is governed by Standard National Definitions
The reason for the lower response rate for the suicide enquiry is that a number of questionnaires
were only sent out in early 2012 and are still going through the normal reminder process. They
are not expected to be returned by the end of March 2012.
The reports of two national clinical audits (psychological therapies and POMH-UK) were reviewed
by the Trust in 2011/12 and a number of actions are being implemented to improve the quality of
healthcare provided including:
■ Implementation of the ‘access times initiative’ across the adult mental health
■ Workshops on improving access to Cognitive Behavioural Therapy (CBT)
network
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 Account. The reports of 23 local clinical audits were reviewed by the Trust
in 2011/12 and the Trust intends to take the following action to improve the quality of healthcare
provided:
■ Development
of an electronic safeguarding assessment for young people as service users. This
will ensure that the recording and updating of vulnerability, risk and safeguarding history is
clearly identifiable
25
■ All
managers to be reminded of the need to
hold a Section 117 register
■ A reminder to all staff that written
information on the Mental Health Act must
be given to the patient’s nearest relatives
unless the patient states otherwise
2.3.3 Participation in Clinical Research
The number of patients receiving NHS services
provided or sub-contracted by the Trust in
2011/12, that were recruited during that period
to participate in research approved by a
research ethics committee was 4001, compared
to 382 recruited in 2010/11. In 2011/12 the Trust
took on a number of new services and this has
led to a dramatic increase in recruitment,
predominantly due to one Dental Study which
has recruited 3258 participants.
The
recruitment from mental health services was
655, which meant the Trust still increased its
recruitment significantly when compared like
for like to the previous year. It has also
exceeded its Cumbria and Lancashire
Comprehensive Local Research Network
(C&LCLRN) target for mental health services of
450 (including non-patient recruits), set prior to
the new services joining the Trust.
Participation in clinical research demonstrates
the Trust’s commitment to improving the
quality of care and contributing to wider health
improvement. Clinical staff stay abreast of the
latest possible treatment possibilities and active
participation in research leads to successful
patient outcomes.
In 2011/12 the Trust:
■ Was actively involved in conducting a total
of 97 research projects, compared to 85 in
2010/11. A total of 66 were UK Clinical
Research Network (UKCRN) portfolio studies,
20 were student projects and the remaining
11 were Trust funded pilot studies. The Trust
has seen an increase from 43 UKCRN
portfolio studies in 2010/11 to 66 in 2011/12
■ Worked closely with C&LCLRN to continue
effective use of the National Institute for
Health Research (NIHR) Central System for
Permissions (CSP) and improved NHS
Research and Development (R&D) permission
times. The Trust has a very impressive four
day median approval time, compared to
twenty days in 2010/11; which is the quickest
median approval time in the C&LCLRN for
two years running
■ Worked
closely with the C&LCLRN , Mental
Health Research Network (MHRN), and the
Dementias and Neurodegenerative Diseases
Network (DeNDRoN) to lead and host an
increased number of portfolio and NIHR
funded projects
■ Continued to host the North West Hub of
the MHRN
■ Continued to significantly increase its activity
in portfolio commercial clinical drug trials
■ Led on one NIHR programme grant, and
three NIHR Research for Patient Benefit
Grants; is a key applicant on an awarded
Programme Grant; and a Trust Senior Nurse
has commenced a three year NIHR Clinical
Doctoral Research Fellowship
■ Submitted eight NIHR and Research Council
grant applications, compared to four in
2010/11. The 2011/12 submissions included a
submission by a Senior Psychologist to the
NIHR Clinical Doctoral Research Fellowship
■ Research studies led by the Trust, or in which
the Trust was actively involved, have
produced 47 publications over the last three
years, compared to 114 reported in the
2010/11 Quality Account
■ Research and Development Department
(R&D) has worked closely with the new
services that transferred into the Trust on
1 June 2011 to increase the portfolio
research activity within those services, and
increase recruitment to studies. The goal for
next year is to continue this increased
portfolio activity and recruitment, and to
submit a Trust led research grant application
from these services
■ The Trust was invited to speak at the
National Advances in Medical Science
Conference and delivered a Masterclass in
how it had become a successful research
organisation, particularly as the Trust is not a
University Hospital Trust. The Trust was
applauded for its four day median
permission time and successful integration of
R&D management; academic researchers and
operational services to ensure proportionate,
quick, and effective governance; and
continued success in obtaining research
grants
2.3.4 Commissioning for Quality and
Innovation (CQUIN)
A proportion of the Trust’s income in 2011/12
was conditional upon achieving quality
improvement and innovation goals agreed
26
between the Trust and the commissioning
Primary Care Trusts/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 of
income for 2011/12 is £3.82 million and is
conditional
upon
achieving
quality
improvement and innovation. The Trust
achieved the indicators in 2010/11 and
successfully received the payment of £2.63
million.
The Trust works to a number of different
targets, including nationally mandated ones
such as the national performance indicators
reported in the quality schedule of the contract,
and locally driven indicators identified through
the contract such as CQUIN. The CQUIN
indicators 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 Trust has put in place
simple, practical steps to monitor and improve
quality through CQUIN for both community and
mental health services, and continues to work
with commissioners including the new Clinical
Commissioning Groups (CCG), to agree goals
that reflect measured improvements in the
performance of quality.
The North West Specialised Commissioning
Group had a separate set of CQUIN criteria for
the Secure Services and Children and
Adolescent Mental Health service (CAMHS).
Further details of the agreed goals for 2011/12
and for 2012/13 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’.
The CQC has not taken enforcement action
against the Trust during 2011/12 and the Trust
has not participated in any special reviews or
investigations by the CQC during the reporting
period.
In December 2011 the CQC carried out a review
of compliance at Balmoral ward, Parkwood
Unit, Blackpool Victoria Hospital. The outcome
of this review was that the ward was not
meeting one or more essential standards and
improvements were needed. The review was
carried out due to concerns with four outcomes
which are detailed in Table 16.
Table 16: CQC Review of Compliance – Balmoral Ward, Parkwood Hospital January 2012
Outcome
Outcome 1 – Respecting and involving people who use services
Outcome 4 – Care and welfare of people who use services
Outcome 10 – Safety and suitability of premises
Outcome 14 – Supporting workers
Source: Care Quality Commission (2012)
27
Concern
Moderate concerns
Major concerns
Moderate concerns
Major concerns
Data is governed by Standard National Definitions
This situation has challenged the Trust to
consider why it arose and what can be learned
in order to make sure it does not happen again.
The Trust has made significant improvements in
the areas where problems were identified.
The compliance issues related specifically to the
situation on Balmoral ward when it was
reviewed in December 2011, however the Trust
response has been to consider the issues both
for the Parkwood unit and other inpatient units
managed by the Trust. The following action has
been taken:
1. A detailed action plan was submitted to the
CQC in relation to achieving compliance on
Balmoral ward. The implementation of this
plan was managed by a team of senior
managers and clinicians within the adult
network under the direction of the Network
Director. It was monitored on a weekly basis
by a task force composed of Executive
Directors, senior managers and clinicians.
This task group was chaired by the Chief
Executive. Excellent progress was made in
implementing the plan and the CQC visited
the unit again in April 2012. There are no
longer any major or moderate concerns.
There is one minor concern that is currently
being addressed.
2. Following receipt of the CQC report all
inpatient areas in Lancashire Care NHS
Foundation Trust (the exceptions are those
services in secure services which have
recently been subject to a Royal College
Accreditation) have been subject to an
internal assessment. The methodology
underpinning the assessment has been
based on that which is utilised by CQC
assessors when undertaking a Mental
Health Act or responsive review. These
assessments have provided assurances to the
Executive Management Team that a similar
situation as that experienced in Balmoral
ward is not experienced elsewhere in
inpatient areas managed by the Trust.
A review of all CQC Mental Health Act
reports received during the last two years
has also been undertaken in order to ensure
that appropriate action has been taken in
response to any concerns that have been
previously raised. Each network has
provided assurances that this work has
been completed.
3. In order to ensure future compliance with
the essential standards of safety and quality
the Trust has taken the following action:
1. The assurances provided to the
Governance Committee are under review
and a new process of reporting will be
introduced from the April 2012 meeting.
This will include details of actions taken
and improvements made in relation to
issues that may be raised in specific
reports e.g. reports relating to serious
untoward incidents, patient feedback
and incident management
2. An Enterprise Assurance Management
system is being applied across the
organisation and each network through
its Network Governance Group will
undertake a risk analysis against each
standard of quality and safety, and these
will form the basis of reporting
arrangements to the Governance
Committee
The Trust is now confident it is compliant with
the essential standards and this was confirmed
by the CQC following a visit to the Trust in April
2012.
The CQC produce a Quality and 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. The profile is updated
regularly by the CQC and the Trust reviews the
profile to identify any areas for improvement.
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.
28
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:
■ Continuing
work on data and service quality
through the use of Informatics, with
information being shared more openly and
frequently through tools such as the GP
Portal which will allow GPs access to clinical
and performance level information for their
patients at Practice level
■ The introduction of balanced scorecards
(visual quality, performance and finance
data) and benchmarking reports to highlight
variances within the Trust, while complex
information is being analysed in different
ways
NHS Number and General Medicine
Practice (GMP) Code Validity
The Trust submitted records during 2011/12 to
the Secondary Uses Service (SUS) for inclusion in
the Hospital Episode Statistics which are
included in the latest published data. The
percentage of records in the published data
which included the patient’s valid NHS number
and the patient’s valid General Practice
Registration Code are included in Table 17.
Table 17: Data Quality
Record Type
Patients Valid NHS Number
Area
Trust Compliance
Admitted Patient Care
100%
Outpatient Care
100%
Admitted Patient Care
100%
Outpatient Care
100%
Patients Valid General Practitioner Registration Code
Source: SUS Data Quality Dashboard
Data is governed by Standard National Definitions
Information Governance Toolkit Attainment Levels
The Trust Information Governance Assessment Report score overall score for 2011/12 was 78% and
was graded green. The Trust achieved attainment level two or above on all requirements.
Clinical Coding Accuracy
The Trust was not subject to the Payment by Results clinical coding audit during 2011/12 by the
Audit Commission because it was a Health and Wellbeing Trust. The Trust, however, participated
in the Connecting for Health Clinical Coding Audit in February 2012. 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 Children and Adolescent Mental Health
services (CAMHs).
Table 18 Clinical Coding
Coding Field
% Incorrect 2011
% Incorrect 2012
Primary Diagnoses Incorrect
25%
8%
17%
Secondary Diagnoses Incorrect
83%
7%
76%
Primary Procedures Incorrect
0%
0%
0%
Secondary Procedures Incorrect
0%
13%
13%
Data Source: Connecting for Health Clinical Coding Audit
29
Data is governed by Standard National Definitions
Re-audit variance
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. Table 18 shows that the overall
accuracy of clinical coding is excellent which
meets level three in the standards defined in
the
Information
Governance
Toolkit
requirement. The Trust continues in its efforts
to improve the depth and quality of the data it
collects. This year has seen positive rewards for
focusing on the recording of more than one
medical condition. The improvement is
significant in the accuracy of relevant nonmental health secondary conditions being
recorded. The percentage of incorrect
secondary procedures (13%) was due to
capacity issues within clinical coding and the
Trust is aiming to recruit a clinical coder to
address this issue.
There are further improvements the Trust can
make and these include a training programme
for 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
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 the indicators reflect the new
services in the Trust, and new indicators have
been included that relate only to community
services. Internal discussions through the Trust’s
governance system, and events held with staff,
service users, members 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.
There were two indicators included in the
2010/11 account which have not been included
in this quality account:
■ Low secure self-assessment toolkit – the
assessment is not taking place until summer
2012
■ Drug errors – comparison of drug errors is
not available for 2011/12 as data is reported
differently. New data has been included
although it is not comparable with previous
years
During 2012/13 further work around the quality
indicators in line with the new quality strategy,
and the introduction of the quality section in
the balanced scorecard will be undertaken. This
work will include key stakeholders and be
reported regularly throughout 2012/13 and in
the annual quality account to ensure
improvements to the quality of care continue.
The indicators include:
Patient Safety
■ Improved safety culture
■ Drug and medication errors
■ Violence against staff and service users
■ Mandated and National Quality Indicators
■ Serious Untoward Incidents
■ Mandatory training
■ Staff appraisal
■ Pressure ulcers
Effectiveness
■ National Quality Indicators
■ Wound healing assessment
■ Peer reviews
■ Advancing Quality
■ PEAT
■ Carers Assessment
■ Accredited Services
tool
Patient Experience
■ Mandated Quality Indicators
■ Service User Experience
■ Patient complaints
■ Age appropriate services
■ Single sex accommodation
30
3.1 Patient Safety
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 Table 22.
Percentage of staff witnessing potentially harmful errors, near misses or incidents in last month
(the lower the score the better)
Chart 6: Percentage of staff witnessing potentially
harmful errors, near misses or incidents in the previous month
100%
80%
60%
40%
20%
28%
32%
27%
26%
27%
27%
2009
2010
2011
National Average 2011
0%
2007
2008
Source: CQC National NHS Staff Surveys
Data is governed by Standard National Definitions
Chart 6 shows that 27% 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
matches the National Average.
Percentage of staff reporting errors, near misses or incidents witnessed in the last month (the
higher the score the better)
Chart 7: Percentage of staff that Reported a Near Miss Witnesses in the Previous Month
100%
80%
96%
99%
97%
93%
97%
88%
60%
40%
20%
0%
2007
Source: CQC National NHS Staff Surveys
31
2008
2009
2010
2011
National Average 2011
Data is governed by Standard National Definitions
Chart 7 shows that in 2011 93% 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 is below the national
average when compared with trusts of a similar type and has decreased on the 2010 score.
Communication has been provided to staff in relation to reporting requirements.
3.1.2 Drug Errors
The Trust has invested in the number of pharmacists it employs over the last 12 months, with
pharmacists attached to wards and community teams. The pharmacy team record details of their
interventions through a specific data collection form on the Datix (risk management) system. The
data is presented according to intervention category for April to September 2010 and April to
September 2011. Direct comparisons across years are not possible due to the changes in the way
pharmacy interventions are recorded in 2011. A large part of the pharmacy activity is recorded as
a clinical intervention and this is consistently the largest reporting category each year. Some
interventions e.g. blank allergy sections and incomplete medication administration boxes on
prescription charts are now recorded on a tally chart; this has led to more consistent reporting.
Between April to September 2011, 7000 interventions were recorded on this system.
Number of Pharmacy Interventions
Chart 8: Number of Pharmacy Interventions from April to September 2010
2000
1800
1600
1400
1200
1000
800
600
400
200
0
1830
1210
140
100
210
Administration
Clinical
Clozapine
440
NPSA
Prescribing
Storage of
Medication
Source: LCFT Information System DATIX
Number of Pharmacy Interventions
Chart 9: Number of Pharmacy Interventions from April to September 2011
2000
1800
1600
1400
1200
1000
800
600
400
200
0
900
660
60
Administration
235
Clinical
Clozapine
390
NPSA
50
Prescribing
Storage of
Medication
Source: LCFT Information System DATIX
32
The Datix system allows for closer interrogation of the data according to need. In May 2011,
pharmacy intervention data for medicine reconciliation (the process where medication prescribed
on admission is checked against what the patient was taking before admission) was presented as
a poster at the Patient Safety Conference. Between August 2010 and January 2011 an unintended
discrepancy was found in 14% of admissions, lower than the national figure of between 30-70%.
Details of the discrepancies can be found in Table 19.
Table 19: NPSA Categories
Number of
incidents
Issue (NPSA category)
Omitted medicine
277
Wrong dose or strength
43
Medication prescribed but not taken/patient poorly compliant pre-admission
36
Wrong frequency
30
Wrong drug
12
Wrong formulation
10
Allergy details incorrect
3
Prescribed at wrong time
2
Medication details incorrectly recorded in the patient record
2
Total
415
Source: LCFT Internal systems
Medication Errors
In September 2010 a new Trust procedure for the management of nursing administration errors
and near misses was introduced by the medicine management nurses. The procedure encourages
open reporting, individual and organisational learning, and improves patient safety. Key elements
of the process are individual reflection and objective review of the environment by the service
manager. This enables thematic analysis and reviews of the impact of Trust policies and
environment. The number of reported errors could increase due to open reporting but will enable
the Trust to develop effective error capture strategies to improve patient safety.
Table 20: Administration errors
Type of incident
Missed dose
37
Unauthorised
33
Unsigned chart
32
Wrong dose
24
Wrong time
17
Controlled drugs
15
Wrong drug
13
Other
5
Wrong patient
3
Recording error
Total
Source: Medicine Management Nurse Error Database
33
Number of incidents (April – September 2011)
2
181
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. The charts below identify the annual data.
Number of Violent Patient Against Patient Incidents
900
800
700
771
Violence Incidents
Chart 10: Number of Violent Patient Against
Patient Incidents
600
500
523
494
400
423
300
2%
reduction
on
2007/08
2007/08
19%
reduction
on
2008/09
2008/09 2009/10
Chart 11: Number of Occupied Bed Days per
Violent Patient Against Patient Incidents
200
82%
increase
on
2009/10
2010/11
36%
reduction
on
20010/11
600
100
500
546
0
2011/12
470
400
454
396
300
257
4%
reduction
on
2007/08
2007/08
20%
increase
on
2008/09
2008/09 2009/10
53%
reduction
on
2009/10
2010/11
Number of OBDs per violent incident
533
200
54%
increase
on
20010/11
100
0
2011/12
The ‘number of violent patient against patient incidents’ has decreased since 2010/11 (Chart 10).
As a result of the inpatient reconfiguration programme, the Trust has closed a number of wards.
This has led to a fall in the number of Occupied Bed Days (OBD) and as such the number of OBD
per incident has risen (Chart 11). This shows that the frequency of incidents has reduced. The Trust
reviews the data in detail on a quarterly basis and identifies trends and hotspots. There are some
specific issues 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.
34
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 12. The violent incidents against
staff (rate per 1,000) for 2010/11 have increased significantly although this is almost exactly on
the average. The data for 2011/12 will be submitted in May 2012 and the results will be published
in November 2012.
Chart 12: Violent Incidents Against Staff (rate per 1,000 Staff)
Violent Incidents per 1,000 Staff
250
200
150
218
216
184
157
146
100
50
15%
reduction
on
2006/07
7%
reduction
on
2007/08
2007/08
2008/09
80
45% reduction
on 2008/09
173%
increase
on
2009/10
0
2006/07
Data Source: NHS Security Management Service
2009/10
2010/11
2010/11
National Average
Data is governed by Standard National Definitions
The Board receives data on violent assaults against staff by patients and this data has been
included in Chart 13 as a year on year comparison by quarter. Overall it shows there has been an
increase on the previous year, except for quarter 2 which saw a 1% decline. The severity of these
incidents predominantly (96.9%) fall into the ‘None - No injury or adverse/outcome’ category
(Chart 14).
35
Chart 13: Year on Year Comparison of Assaults on Staff by Patients
300
250
256
227
200
228
224
192
183
150
256
238
100
50
1%
decrease
on 10-11
5%
increase
on 10-11
12%
increase
on 10-11
8%
increase
on 10-11
0
10-11
11-12
10-11
11-12
Q1
10-11
11-12
Q2
10-11
11-12
Q3
Q4
Source: LCFT Information System DATIX
Chart 14: Severity of Reported Incidents on Staff by Patients
160
Number of Reported Incidents
140
120
100
80
60
40
20
109
82
10
0
149
66
3
1
149
88
9
0
137
68
4
0
0
Q1
Q2
Q3
Q4
2011 - 2012
Source: LCFT Information System DATIX
Data is governed by Standard National Definitions
None -
No Injury or adverse/outcome. No treatment/intervention required
Low -
Short Term Injury/First aid given
Moderate -
Semi-Permanent injury/damage. Moderate increase in treatment. Medical
treatment required e.g. X-ray/Broken bones
Severe -
Permanent injury. Loss of body part. Mis-diagnosis, poor progress. Injury to
individual not life threatening but actually jeopardises the wellbeing of the
patient
36
The levels of violence and aggression are a major concern for the Trust and the approach to
reducing the levels and measuring the impact is focused on:
■ Detailed analysis of the data
■ Clear identification of the problem
■ Improving the physical safety of clinical environments
■ Ensuring the policy and procedural framework reflects
■ Providing appropriate education and training
■ Reviewing staffing levels on a regular basis
best practice
The staff survey asks a number of questions about physical violence and the results of two
questions have been included in Chart 15 and Chart 16.
Percentage of staff experiencing physical violence from patients, relatives or the public in last 12
months (the lower the better)
100%
Chart 15: Percentage of staff experiencing
physical violence from patients, relatives or
the public in last 12 months
80%
Chart 15 shows that over the last four years the
percentage of staff that have experienced
physical violence from patients, relatives or the
public in last 12 months has fallen to where it
has reached a 2011 position that is 2% below
the National Average.
60%
40%
20%
19%
2008
2009
20%
19%
10%
2010
2011
Source: CQC National NHS Staff Surveys
Data is governed by Standard National
Definitions
12%
0%
National
Average
2011
5
Effective
Action
4
3.64
3.59
3.58
3.71
3.56
3
2
1
Ineffective
Action
2008
2009
2010
2011
Source: CQC National NHS Staff Surveys
Data is governed by Standard National Definitions
37
0
National
Average
2011
Chart 16: Perceptions of effective action from
employer towards violence and harassment
Chart 16 shows that staff perception of effective
action towards violence and harassment is that
the Trust has taken effective action towards the
incidents experienced and as such the Trust
exceeds the National Average.
Mandated and National Quality Indicators
The Department of Health, and Monitor, have proposed to introduce mandatory reporting of a
small, core set of quality indicators for the 2012/13 quality accounts. A number of these are
relevant to the Trust and have been included in this quality account. They are:
■ Perceptions
of staff who would recommend the provider to friends or family needing care
(Table 35)
of patient safety incidents and percentage resulting in severe harm or death (Table 21)
■ Rate
Table 21: NHS Outcomes Framework – Safe Patient environment
Indicator
LCFT 2011
April 11 to
September 11
National
Average
Rate of patient
safety incidents
38.53 per 1,000
bed days
21.1 per 1,000
bed days
17.43 per
1,000
bed days
Percentage resulting
in severe harm
0.3% (12 cases)
0.4%
0.1%
Percentage resulting
in death
0.1% (4 cases)
0.4%
0.3%
NHS Outcomes
Framework domain
Domain 5: Treating
and caring for
people in a safe
environment and
protecting them
from avoidable harm
Data Source: http://www.nrls.npsa.nhs.uk/resources/?entryid45=132789
LCFT v National
Average Variance
Data is governed by Standard National Definitions
The four reported deaths were due to three suicides and a death by substance misuse.
In addition to the mandated Quality Indicators, the Indicators for quality improvement have also
been included.
Table 22 shows that the Trust is reporting patient safety incidents two days quicker than the
national average. The NPSA states that “organisations that report more incidents usually have a
better and more effective safety culture. Organisations cannot learn if they don’t know what the
problem is”.
Table 22: National Patient Safety Agency data (Mental Health only)
NRLS-1: Consistent reporting of patient safety events
reported to the Reporting and Learning System (RLS)
NRLS-2: Timely reporting of patient safety events reported
to the Reporting and Learning System (RLS) (50% of cases)
Data Source: National Patient Safety Agency
LCFT 2011
April 11 to September 11
National Patient
Safety Agency
All reporting is carried out on a
monthly basis
Not comparable
34 days
36 days
Data governed by Standard National Definitions
38
3.1.4 Serious Untoward Incidents (SUIs)
The metrics used for SUIs are reported in
Diagram 1 and Diagram 2. 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, pressure ulcers 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 1:
SUIs reported within 2 working days
2009 / 2010
Target
71%
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 3:
Staff Mandatory Training
2011/2012
Target
2008/2009 29%
2009/2010
2010/2011
2011/2012
53%
67%
75%
74.3%
Source: LCFT Internal Data Source: (Training Dept)
2010 / 2011
72%
2011 / 2012
90%
81%
Source: LCFT Internal Data Source (DATIX)
Data is governed by Standard National Definitions
Diagram 2:
SUIs reviews completed within 45 days
2009 / 2010
2010 / 2011
2011 / 2012
Target
68%
84%
90%
80%
Source: LCFT Internal Data Source (DATIX)
Data is governed by Standard National Definitions
The target for the number of SUIs reported
within two working days and SUI reviews to be
completed within 45 working days were not
met. A programme of work is being undertaken
to integrate reporting systems, standardise
practice and deliver training. This indicator will
continue to be monitored during 2012/13.
39
The percentage of people who were compliant
for a twelve month period ending 31 March
2012 was 74.3%. The results have improved
since last year, however, it remains an area of
concern for the Trust. There have been a
number of improvements made to the process
and in April 2012 a new Mandatory Training
Programme was launched which is flexible and
meet the needs of individual teams. The
training is not delivered using a workbook or
an ‘all in one day’ session. Following extensive
consultation, it has been agreed that the
new programme will link with the objectives
of the North West Core Skills Framework.
This will allow training from other
organisations/providers to be recognised if it
matches the objectives, which will prevent
repetition.
Training will be supported by e-learning
programmes using Training Tracker. This is a
simple platform that can be accessed from
anywhere that has internet access or via the
National Learning Management System. To
supplement e-learning a variety of dates are
available so staff can choose the day that suits
their requirements. In addition, single sessions
will be available for all the face to face subjects.
The Trust is also considering the way that data
is collected to support evidence of mandatory
training. Analysis suggests that currently there
is under-reporting.
development and organisation development, as
well as revalidation. The Medical Director, who
is the Responsible officer, provides evidence
which complies with General Medical Council
regulations and a statement that satisfactory
progress is being made towards achievement of
the four domains and twelve attributes
specified in the guidance. The doctor should
also demonstrate participation in the appraisal
process in a meaningful way. The appraiser will
also have to make a clear statement after each
appraisal that there are no concerns about
patient safety.
3.1.6 Staff Appraisal
Staff appraisal is measured through the
National Staff Survey.
Diagram 4:
Staff Appraisals
2007
61%
2011/2012
Target
2008
67%
2009
63%
75%
2010
79%
2011
78%
Source: CQC National NHS Staff Survey
Data is governed by Standard National Definitions
The 2011 staff survey shows 78% of staff had an
appraisal in the last twelve months which is a
slight decrease on last year but exceeds the 75%
target set by commissioners.
The new electronic Personal Development Review
(PDR) system was launched in early February
2012. Improvements and further developments
to the system are still on-going to ensure it is Lean
and user-friendly. PDR data will be updated
automatically which will provide more robust
reporting. PDR Awareness sessions have been
delivered across the Trust for managers and staff
and details have been advertised widely.
The medical staff have a separate process of
medical appraisal which is about professional
3.1.7 Pressure Ulcers
Work has been undertaken to ensure a single,
robust system and standardised approach is in
place to report pressure ulcers within the Trust,
as there were very different reporting
mechanisms in the previous organisations. All
Grade 4 pressure ulcers were recorded in
2011/12, including those not acquired in the
Trust’s care. This will change in 2012/13, with
only those acquired in the Trust’s care being
reported, and this will be reflected in next year’s
Quality Account. Pressure ulcers will also be
reported in 2012/13 as part of Harm Free Care.
Charts 17 to 19, detail the number of pressure
ulcers reported. Changes to reporting definitions
in September 2011 led to a substantial increase
in the reporting of pressure ulceration across all
categories in Quarter 3. There have also been
significant developments with the Wound
Healing Assessment and Monitoring (WHAM)
Tool which facilitates a single assessment process
and incorporates the Pressure Ulcer Score for
Healing (PUSH) Tool. Additional information
regarding this tool can be found in the clinical
effectiveness section of this report.
Number of reported cases
Chart 17: Categories of Pressure Ulcers by
Provider by Quarter during 2011/12
Category 3 Pressure Ulcer
Category 4 Pressure Ulcer
60
50
48
40
40
30
20
26
20
10
0
16
12
10
4
Q1
Source: LCFT Information System DATIX
Q2
Q3
Q4
2011 - 2012
40
Care home
Patient’s home
Community
Hospital
Chart 18: Setting of Aquired Pressure Ulcer - Category 3
35
Number of reported cases
30
25
20
31
15
27
10
14
5
5
0
2
11
6
3
3
Q1
Q2
4
3
5
4
Q3
Q4
2011 - 2012
Quarter/Year by Area
Source: LCFT Information System DATIX
Care home
Patient’s home
Community
Hospital
Not stated
Chart 19: Setting of Aquired Pressure Ulcer - Category 4
18
Number of reported cases
16
14
12
10
16
8
6
4
9
2
0
1
2
Q1
2
2
1
Q2
Q3
2011 - 2012
Source: LCFT Information System DATIX
41
6
5
4
6
2
2
Q4
Quarter/Year by Area
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
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 23: Indicators for Quality Improvement (Mental Health)
Indicators for Quality
Improvement
Description of Indicator
MH06: The proportion of those
service users on Care Programme
Approach (CPA) discharged from
inpatient care who are followed
up within 7 days
2009/10
2010/11
2011/12
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
95%
97%
96.5%
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
N/A2
85%
86%
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
N/A
16%
16%
Indicators definitions available from Information Centre website www.ic.nhs.uk/services/measuring-for-quality-improvement
Data source: LCFT Internal Information System (eCPA) Data is governed by Standard National Definitions
Almost all childhood immunisations in Blackburn with Darwen, East Lancashire and Central
Lancashire are undertaken within GP practices. The role of the 0-19 health visitor teams is to
support and encourage parents of children that have not completed their immunisation schedules
to attend the practice. Only a small minority of children are vaccinated by health visitors. The
national target for childhood immunisation is 95%.
2
The Trust Commenced reporting against the National Indicators during 2010/11. No comparitive data is available from previous years.
42
Figures for ‘Proportion of children who complete MMR immunisation (1st and 2nd dose) by their
5th Birthday’ show the greatest of variance against the target across the three areas. Reasons that
have been identified by the areas that result in the low figures are nationally recognised. Due to
the child’s age engagement with the teams is lost and personal data is not up to date, resulting in
high DNA (Did Not Attend) rates for immunisation clinics. There is a national drive to improve data
and take-up rates.
Table 24: National Community Indicators - Immunisation
PCT
East
Lancashire
Blackburn
with Darwen
Central
Lancashire
Q1
2011/12
Q2
2011/12
Q3
2011/12
Q4
2011/12
2011/12
(National
Target)
WCC 2.09 Proportion of
children who complete
MMR immunisation by
2nd Birthday
90.3%
93%
92.5%
93.1%
92.2%
(95%)
2.8%
WCC 2.10 Proportion of
children who complete
MMR immunisation (1st
and 2nd dose) by their
5th Birthday
87.9%
88.5%
88.8%
87.1%
87.8%
(95%)
7.2%
WCC 2.11 Proportion of
children who complete
DTP immunisation by
their 5th Birthday
89.6%
91.3%
90.2%
97.0%
96.8%
(96%)
0.8%
WCC 2.09 Proportion of
children who complete
MMR immunisation by
2nd Birthday
92.8%
92.4%
92.6%
91.3%
91.8%
(95%)
3.2%
WCC 2.10 Proportion of
children who complete
MMR immunisation (1st
and 2nd dose) by their
5th Birthday
87.9%
88.5%
86%
87.1%
86.9%
(95%)
8.1%
WCC 2.11 Proportion of
children who complete
DTP immunisation by
their 5th Birthday
90%
91.2%
87.1%
95.3%
95.8%
(96%)
0.2%
WCC 2.09 Proportion of
children who complete
MMR immunisation by
2nd Birthday
93.3%
93.0%
94.2%
95.7%
93.8%
(95%)
1.2%
WCC 2.10 Proportion of
children who complete
MMR immunisation (1st
and 2nd dose) by their
5th Birthday
87.6%
87.3%
87.5%
89.9%
88.1%
(95%)
6.9%
WCC 2.11 Proportion of
children who complete
DTP immunisation by
their 5th Birthday
96.8%
96.2%
97.6%
97.4%
97.8%
(96%)
1.8%
National Indicator
Source: LCFT Internal Systems
43
Variance on
National Target
Data is governed by Standard National Definitions
Immunisation uptake over the past three years
has significantly improved and further work is
being undertaken to ensure national targets
are met.
The national targets for breast feeding are:
■ Coverage
of breastfeeding data submitted
by GPs at 6-8 weeks. The national target is
95% and commissioners are currently
working with GPs to improve coverage.
■ Prevalence of breastfeeding at 6-8 weeks
(shown in table 25). This target is set locally
for PCTs and the Strategic Health Authority
(SHA). Data is submitted nationally on a
quarterly basis and is monitored by the SHA
and Department of Health.
East Lancashire has data collection and
reporting issues which prevent accurate
reporting of their data. Reporting from health
visitors at 4-6 weeks show rates between 3640%, this is in line with the PCT target. When
the data is submitted Nationally alongside GP
data at 6-8 weeks, the data shows a 16.5% fall
on PCT targets. Work is on-going to establish
better data collection and reporting practices.
Table 25 : National Community Indicators: Prevalence of Breastfeeding
Q1
2011/12
Q2
2011/12
Q3
2011/12
Q4
2011/12
2011/12
PCT target
2011/12
Blackburn with
Darwen
37.9%
34.4%
36.8%
29.63%
34.7%
35.1%
0.4%
East Lancashire
23.4%
22.6%
23.1%
22.8%
23.0%
39.5%
16.5%
Central Lancashire
33.5%
34.0%
33.2%
32.1%
33.2%
33%
0.2%
PCT
Source: LCFT Internal Systems
Blackburn with Darwen (BwD), East Lancashire
and Central Lancashire each has their own
initiatives to increase the number of mothers
breastfeeding by antenatal and postnatal
settings delivered by the infant feeding teams.
These include the Baby Friendly Initiative (BFI)
Project which is a worldwide programme of the
World Health Organization and UNICEF. It also
works to implement the Seven Point Plan for
Sustaining Breastfeeding in the Community and
works with the health-care system to ensure a
high standard of care in relation to infant
feeding for pregnant women and mothers and
babies. Support is provided for health-care
facilities that are seeking to implement best
practice and an assessment and accreditation
process recognises those that have achieved the
required standard. This has been achieved in
BwD, with the other areas working towards full
accreditation.
Variance
Data governed by Standard National Definitions
Wound Healing Assessment and
Monitoring (WHAM) Tool
The WHAM tool was developed within
Blackburn with Darwen to facilitate a single
assessment process and support personalised
care plans. The agreed documentation
incorporates a locally adapted version of the
PUSH Tool (Pressure Ulcer Score for Healing) to
provide accurate measuring of all types of
wounds. The use of the WHAM tool has:
■ Prompted
greater collaboration between
multi-disciplinary team members and earlier
intervention and treatment through joint
care planning
■ Improved record keeping as a result of
changes to documentation and structured
training
■ Demonstrated patient benefits of quicker
healing rates through the ability to measure
44
and monitor outcomes including collation of
wound healing rates
■ Shaped holistic assessment, supported
clinical judgement, encouraged regular
evaluation, and initiated consistent, safe
regulated practice, with training resources
targeted in areas of need
■ Prompted appropriate referrals to specialist
services within the community and reduced
hospital admissions and improved patients’
health and social care
■ Enabled access to the ‘Healthy Legs Service’
in a social care setting with staff continuity
to monitor and reduce the recurrence of
wound breakdown through patient
education and self-management advice. This
setting also provides patient, social and peer
support
The tool is now used across the Trust by all
health professionals caring for adult patients
with wounds. Improvements have been
demonstrated through repeat audits and the
tool was a national finalist in the 2011 GP
Awards.
Table 26: WHAM Audit data (Blackburn with Darwen Data only)
Year on year
variance
Nov 2010
Nov 2011
Is the date of wound onset documented?
60%
90%
30%
Is a treatment plan in place?
55%
100%
45%
Is the type of wound defined?
90%
95%
5%
Are the wounds measured within the 14 day criteria?
52%
87%
35%
Is the wound(s) photographed within the 14 day criteria?
15%
72%
57%
Are there treatment plans in place for individual wounds?
47%
90%
43%
Is there a clear rationale for re-evaluation of treatment?
73%
100%
27%
Is there evidence of nutritional status being assessed?
65%
90%
25%
Is there evidence of pain being assessed?
37%
100%
63%
Is the dressing selection compliant with Trust wound care
formulary?
77%
93%
16%
Source: LCFT Internal Systems
Dialectical Behaviour Therapy (DBT)
As part of the Trust’s coordinated response to
Personality Disorder, the Personality Disorder
Managed
Clinical
Network
(PDMCN)
successfully applied for ‘Innovate Now’ funding
to pay for training to enable the establishment
of full DBT Programmes across the Trust. The
aim was to develop DBT within local integrated
teams. A DBT team of eight people is now
established in each of the three localities, with
the DBT programme being implemented across
the adult network within the local community.
The programme requires service users to attend
weekly skills training groups; weekly individual
DBT therapy; and to have access to out-of-hours
45
telephone coaching with their therapist. All
therapists attend a supervision group to
monitor adherence to the model and support
effective treatment.
DBT is currently being evaluated as part of
the Innovate Now bid and the Trust is awaiting
the results. So far, anecdotal evidence
would support the idea that is has significantly
reduced self-harming behaviour, crisis team
contacts and A&E presentations. Care
co-ordinators also report a reduction in planned
and unplanned contacts. Service users have
reported finding the programme challenging
but also report significant benefits.
The skills taught help control the mess in your head. If you can
use the skills you can control the mess. It’s really hard but DBT
is worth it for the element of control and the improvement it
has had on my life. It’s got me away from A&E.
I don’t think about doing myself in every day now. I use the
skills to focus on the moment. I understand more what’s up
with us. I used to get frustrated, hitting out at everyone,
blaming them. I’m taking more responsibility. I don’t think
everyone is against me anymore.
In November 2011, the Trust was invited by DBTUK to present at the National Conference.
Delegates were impressed by how quickly the
programme has been implemented and how it
is embedded within local mainstream services.
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 155 standards, the Secure Service partly
met ten standards, fully met 144 and did not
meet one standard. All standards related to
services for women were fully met with the
exception of one. This was regarding a specific
policy for the individualised management of
women who self-harm. To address this, the
service initiated training in January and
February 2012 for staff regarding gender issues
and the care of women in particular.
Actions being taken to address the physical
security findings of the Safety and Security
section include:
■A
re-design of records that are being kept
for inspections of the perimeter fence
■ A plan to revise the height of the fence and
roof line by a further 2.5 metres
■ An action plan to address the outstanding
standards
The governance review area saw a decrease on
the previous year’s outcome. The decrease was
not due to a fall in performance but was a
result of subjective opinion. The peer review is
conducted by several members whose views on
standards of quality can differ year on year.
These perspectives are taken and reviewed
and, where possible, specific actions plans are
undertaken to strengthen areas that were
judged to be weak.
46
Table27:RoyalCollegeofPsychiatristsPeerReviewofGuildLodge
Criteria
met by
Trust 2010
Criteria
met by
Trust 2011
Criteria
met by
Trust 2012
1. Physical Security
91%
100%
78%
22%
2. Procedural Security
92%
100%
100%
0%
3. Relational Security
83%
97%
97%
0%
4. Serious Untoward Incidents
100%
100%
100%
0%
5. Safeguarding Children
Visiting Policy
100%
100%
100%
0%
Clinical and Cost Effectiveness
92%
80%
100%
20%
Governance
93%
100%
87%
13%
Patient Focus
69%
89%
100%
11%
Accessible and Responsive Care
100%
50%
89%
39%
Environment and Amenities
85%
89%
82%
7%
Public Health
83%
100%
100%
0%
Review Area
Percentage
Point
Variance
Safety and Security
Data source: Royal College of Psychiatrists
3.2.3 Peer Review by Quality Network for
Inpatient CAMHS (QNIC) and Qualitative Data
QNIC Report - The Junction
The Junction is an established eight bedded
unit which covers the Tier 3 CAMHS teams
within Lancashire and South Cumbria,
providing a comprehensive inpatient service
across this large geographical area. The
development of The Junction has introduced a
valuable service for young people and their
families experiencing mental health difficulties.
The Junction has undertaken an accreditation
process in February 2012, which involved a
detailed self-review, a detailed peer review and
47
Data is governed by Standard National Definitions
a decision about accreditation category and
feedback. This process replaces the Peer Review
of previous years.
During the self-review
phase, teams measure their performance
against the QNIC service standards:
■ Type
1 – failure to meet these standards
would result in a significant threat to patient
safety, rights or dignity and / or would
breach the law (100% compliance required)
■ Type 2 – standards that an accredited ward
would be expected to meet (80%
compliance required)
■ Type 3 – standards that an excellent ward
should meet or standards that are not the
direct responsibility of the ward
Table 28: QNIC Accreditation Report for The Junction
Section
Type 1(100%)
Type 2 (80%)
Type 3
Environment and Facilities
85%
91%
100%
Staffing and Training
94%
91%
50%
Access, Admission and Discharge
100%
83%
50%
Care and Treatment
76%
79%
60%
Information, Consent and
Confidentiality
85%
80%
Young People’s Rights and
Safeguarding Children
84%
100%
100%
Clinical Governance
100%
93%
83%
Source: Quality Network for Inpatient CAMHS(QNIC)
100%
Data governed by Standard National Definitions
These are initial findings which are subject to
external validation in the coming months.
Further evidence has been submitted by the
service to demonstrate 100% compliance with
Type 1 and over 80% compliance with Type 2
standards. If this evidence is validated then The
Junction will achieve a QNIC accreditation.
The Platform, which 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, also completed the new QNIC’s
accreditation process in March 2012. The results
therefore are not comparable with previous
‘self-assessments’.
Table 29: QNIC Report for The Platform
Section
Type 1(100%)
Type 2 (80%)
Type 3
Environment and Facilities
96%
85%
86%
Staffing and Training
94%
82%
63%
Access, Admission and Discharge
100%
94%
100%
Care and Treatment
86%
79%
20%
Information, Consent and
Confidentiality
95%
85%
100%
Young People’s Rights and
Safeguarding Children
97%
100%
100%
Clinical Governance
94%
71%
50%
Source: Quality Network for Inpatient CAMHS(QNIC)
Data governed by Standard National Definitions
The data requires external validation and this will be achieved by July.
48
Diagram 5 identifies a range of positive and negative comments from the young people and their
parents collected as part of the reviews.
Diagram 5: What Young People and Parents said in the QNIC Report
Staffing & Training:

!
The staff are really friendly and nice
I would like to be able to get on with
college work
Information, Consent & Confidentiality:



!
Staff are working on a ‘leaving pack’
Written information is easy to
understand and if you don’t they’ll read
it to you and explain
Staff ask before they pass information
on to other people and explain who
they pass it on to
I didn’t know about my diagnosis but I
saw it written on my care plan
Young People’s Rights &
Safeguarding Children:

We have access to an advocate who is
very supportive
Environment & Facilities:




!
!
It looks more like a house than a ward
Everyone’s friendly
Everybody has their own room
I feel safe on the unit
We need more outdoor recreational
space than there is
We don’t get out except on leave and
even then there aren’t many places to go
Source: QNIC
49
Access, Admission & Discharge:

Staff are really friendly and helpful,
they’re there for you.

There’s a sense of staff wanting to help
us instead of ‘it’s just a job’
!
I was lied to on admission – I got told was
coming for a talk or just a few days
!
I would have liked more information
when I was first admitted
Care & Treatment:





!
!
!
!
!
!
!
!
We get the opportunity to change
activities
We get takeaways on Saturdays
We’re involved in CPA review meeting
Whenever your key worker is working
they try and see you
I know there are Halal meals
Some of the sessions and activities are a
bit young - there should be ones we all
find interesting or that will be useful
Most staff have leave at weekends
I would like more to do in the evenings
It would be good if there was a set time
each week to see my key worker
No school is provided at the unit
The food is shocking and disgusting,
there’s not enough variety.
I don’t get therapy – I need it
They should talk more about what the
next step are and what support will be
in place
3.2.4 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 a complete picture
As part of CQUIN, the Trust is participating in AQ in Mental Health and this includes reporting on
the indicators listed below (five in Dementia and three in Early Intervention Services).
Table 30: 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 seven days of hospital admission
Assessment for depression and anxiety within 14 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 Coordination
Antipsychotic medication review within six weeks of antipsychotic medication
being prescribed
Data Source: Advancing Quality Data Dictionaries
The mental health CQUIN for 2011/12 included
stretch targets for Advancing Quality. For
Dementia the percentage pass rate must exceed
75%, and 85% for First Episode Psychosis, for
patients’ outcomes submitted from October
2011 to March 2012. Charts 20 and 21 show the
monthly percentage pass rates since reporting
commenced. This data was validated by the
Audit Commission in March 2012 although its
Data governed by Standard National Definitions
findings have yet to be published. The data
included is the Trust’s internal data and only
when the Audit Commission have validated all
the data and the data is reported publicly, can
it be benchmarked with other participating
North West Mental Health Trusts.
The Dementia indicators are also applicable to
the NICE Quality Standards as shown Table 31.
Table 31: Advancing Quality and NICE Quality Standards
NICE Quality Standards
Indicator Detail
Compliant
Possibility of complying
with guidance
Assessment of functional capacity before discharge from hospital
Standard 4
Standard 1, Standard 6
Assessment of cognitive ability within 14 days of hospital admission
Standard 4
Standard 1
Assessment of physical health within 14 days of hospital admission
Standard 4
Standard 7
Assessment for depression and anxiety within seven days of hospital
admission
Standard 4
Standard 1, Standard 6
and Standard 7
Tailored care plan for carers upon discharge from hospital
Standard 4
Standard 1, Standard 7
Data Source: Advancing Quality Data Dictionaries
Data governed by Standard National Definitions
50
New indicators (listed in Table 32) are being considered for April 2012 and they will be recorded
but not used in any performance data until they have been deemed robust enough to be included
in CQUIN targets.
Table 32: New Advancing Quality Indicators for 2012/13
AQ Indicators
Indicator Detail
Initial assessment of pain completed within seven days of admission to hospital
Assessment of nutritional needs within three days of admission to hospital
Dementia Indicators
Discharge care plan review within 14 days following inpatient hospital stay
Duration of Untreated Psychosis Assessment
Early Intervention Service
(EIS)
There is an offer of psychological interventions made to the service user in the
first six months of acceptance into the Early Intervention Service
Data Source: Advancing Quality Data Dictionaries
Data governed by Standard National Definitions
Advancing Quality: Dementia Outcomes
Chart 20: Advancing Quality - Dementia Percentage Pass Rate
100%
90%
80%
%
70%
%
60%
50%
84%
40%
30%
55%
53%
Jan-11
Feb-11
60%
52%
20%
59%
56%
58%
May-11
Jun-11
Jul-11
63%
70%
78%
90%
87%
Dec-11
Jan-12
10%
0%
Mar-11
Apr-11
Data Source: LCFT Internal Information System
51
Aug-11
Sep-11
Oct-11
Nov-11
Data is governed by Standard National Definitions
Advancing Quality: Psychosis Outcomes
Chart 21: Advancing Quality - Psychosis Percentage Pass Rate
100%
90%
80%
%
70%
60%
50%
40%
84%
87%
93%
89%
92%
79%
86%
91%
94%
Aug-11
Sep-11
Oct-11
87%
91%
90%
Nov-11
Dec-11
Jan-12
74%
30%
20%
10%
0%
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Data Source: LCFT Internal Information System
Jul-11
Data is governed by Standard National Definitions
PEAT Assessment
The 2011 Patient Environment Action Teams
(PEAT) report published by the National Patient
Safety Agency shows greater numbers of
hospitals are treating their patients in cleaner,
better maintained environments. The PEAT
programme assesses all hospitals and inpatient
units with ten or more beds. The PEAT teams
consist of nurses, matrons, doctors, catering
staff, domestic service managers as well as
groups of patients, their representatives and
members of the public. They look at levels of
cleanliness, some aspects of infection control
(such as hand hygiene), the quality of the
environment (such as decoration, maintenance
and lighting) as well as the standard of food
offered to patients.
The Trust has gone out to tender for its facilities
management suppliers to centralise and ensure
improved services are provided. This is one of
the key drivers behind Trust plans to improve
inpatient accommodation and provide facilities
that are suitable for delivering modern mental
health care.
NHS trusts are each given scores from one
(unacceptable) to five (excellent) for standards
of environment, food and dignity and privacy
within buildings.
Overall, the Trust scored well. Comparing the
results from the 2010 and 2011 PEAT
assessments, eight out of 12 inpatient sites have
improved over the previous year. These results
highlight an area for improvement which the
Trust is already aware of and is acting upon.
52
Table 33: PEAT Assessment Scores
Weighted
Environment Score
Food Score
Privacy & Dignity
Score
4 Good
4 Good
4 Good
BURNLEY GENERAL MENTAL HEALTH
3 Acceptable
3 Acceptable
4 Good
CHORLEY GENERAL MENTAL HEALTH
5 Excellent
5 Excellent
5 Excellent
4 Good
5 Excellent
4 Good
5 Excellent
5 Excellent
4 Good
ORMSKIRK AND DISTRICT GENERAL HOSPITAL
4 Good
5 Excellent
4 Good
LONGRIDGE COMMUNITY HOSPITAL
4 Good
5 Excellent
5 Excellent
LYTHAM HOSPITAL
4 Good
5 Excellent
4 Good
3 Acceptable
3 Acceptable
3 Acceptable
RIDGE LEA HOSPITAL
4 Good
5 Excellent
5 Excellent
ALTHAM MEADOWS
4 Good
5 Excellent
5 Excellent
OAKLANDS
4 Good
5 Excellent
5 Excellent
Site Name
QUEENS PARK HOSPITAL (BLACKBURN HOSPITAL)
GUILD PARK LODGE WHITTINGHAM PRESTON
RIBBLETON HOSPITAL PRESTON
VICTORIA HOSPITAL, BLACKPOOL (PARKWOOD)
Source: www.ic.nhs.uk/statistics-and-data-collections/facilities/patient-environment-action-team-peat
Data governed by Standard National Definitions
3.2.5 Carer’s 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. There
were a number of new standards included in the audit and Table 34 shows the three standards
which have been audited over the last two years.
Table 34: Carer’s Assessment Audit
Questions
Individual Health and Social care assessments must identify if
there is a carer involved in the service user’s care.
67%
Where carers are offered an assessment there is evidence that
this has been completed on the healthcare record.
64%
Carer’s assessments conclude with a clear plan to address
the identified carer’s needs which will be located in the
healthcare record.
70%
Source: LCFT Information Systems & Clinical Governance Department
53
2010/11
2011/12
90%
(n= 244)
77%
(n=130)
62%
(n=130)
Variance on
2010/11 and
2011/12
23%
13%
8%
Although there has been improvement, there is
still work to be undertaken to maintain and
improve these figures. The Trust launched
the Carer’s Strategy in 2010. To ensure the
strategy is implemented across mental health
services each network within the Trust has
nominated a lead and developed an action plan
that identifies priorities, development work and
training initiatives. A range of standards has
now been introduced to support the strategy:
■ Individual
Health and Social Care
assessments must identify if there is a carer
involved in the service user’s care
■ The issue of confidentiality and information
sharing with the carer is discussed with the
service user as part of the initial assessment,
CPA reviews and admission to hospital
■ Carers are provided with the care
coordinator’s name and contact details to
enable them to communicate effectively
with staff. A record that this information has
been shared will be evidenced in the
healthcare record
■ Carers are provided with specific and general
information appropriate to their needs if
required. This information will be recorded
in the healthcare record identifying the
range of information available to carers
■ Where carers are identified they are offered
a carer’s assessment and the outcome of this
discussion is recorded in the healthcare
record
■ Where carers are provided with an
assessment there is evidence that this has
been completed on the healthcare record
■ Carer’s assessments conclude with a clear
plan to address the identified carer’s needs
which will be located in the healthcare
record
It has long been recognised that confidentiality
issues are sometimes considered a barrier when
staff are thinking about sharing information.
The Trust has now invested in an online
learning resource provided by the national
charity RETHINK. This provides support for staff
in managing issues of confidentiality and
information sharing with family/friend carers
supporting people with mental health
problems.
3.2.6 Accredited Services
A number of Trust services including
Electroconvulsive Therapy, Psychiatric Liaison
teams and Memory Assessment continue to
maintain their external accredited status. In
addition, a number of new services including
Talkwize (sexual health team in Lancashire)
have recently been awarded accreditation.
3.3 Patient
Experience
This section includes information from service
users on the quality of their experience and
identifies areas for improvement.
Mandated Quality Indicators
The data in Table 35 relates to the proposed
nationally
mandated
quality
indicator
concerned with ensuring that people have a
positive experience of care. The data shows the
Trust is above the national average and has
improved compared to the previous year’s
results, in relation to the percentage of staff
who would recommend the provider to friends
or family needing care. The scores range from
1 to 5, with 1 representing that staff would be
unlikely to recommend the trust as a place to
work or receive treatment, and 5 representing
that staff would be likely to recommend the
trust as a place to work or receive treatment.
The average score is shown.
Table 35 NHS Outcomes Framework - Patient Experience
NHS Outcomes Framework Domain 4: Ensuring that people have a positive experience of care
Indicator
LCFT
2010
LCFT
2011
Perceptions of staff who would
recommend the provider to friends
or family needing care
3.35
3.53
Source: National Staff Survey
LCFT 2011 v
LCFT 2010
0.18
National
Average 2011
3.42
LCFT v National
Average Variance
0.11
Data is governed by Standard National Definitions
54
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 via several sources
mostly through questionnaires, surveys,
complaints, compliments and stakeholder
forums. The findings of a number of these
service user experience methods follow.
3.3.2 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
developed by both clinicians and service users
are being piloted in one of the crisis teams in
Central Lancashire. The findings from the pilot
will be used to make service improvements and
to agree the measures for use in all services
across Lancashire. During the next few months
the measures are being rolled out to all the
teams in East Lancashire and the eating disorder
services. Patient outcomes were recorded in two
ways: a scoring system against eight questions
and an opportunity to submit comments.
Table 36 shows the scored outcomes from the
questionnaire. Respondents were asked to rank
the service using a Liket scale shown below:
Strongly Agree
Strongly Disagree
-5
-4
-3
-2
-1
0
1
2
3
4
5
Table 36: Crisis Patient Reported Outcome Measures and Patient Reported Experience Measures
Question
1. I felt as involved as I wanted to be in decisions about the care given by the service
4.4
2. I felt Heard, Understood and Respected
4.5
3. I felt confident that the service could meet my needs
4
4. The team’s approach was right for me
4.3
5. Lately, I felt better in myself as a result of the care received from this service
3.7
6. Lately, I have been more able to do things that are important to me as a result of
my care from the service
3.3
7. My quality of life has been improved by the service I have received
3.6
8. I was satisfied with the service I received
4.6
Source: LCFT CRHT
55
Average Scores
Overall the majority of those that responded
were very satisfied with the level of service they
received.
Key Themes that originated from the comments
box were generally positive and focused on key
areas:
Thanking staff for kindness,
care and listening
Getting better and staying well
“
“
“
“
“
“
“
“
“
“
Care delivered by skilled staff
There were a number of negative comments
including:
Abrupt telephone manner of staff
Not having consistent staff, although
service users acknowledged this was
difficult given the nature of the service
Responses are fed back at daily team meetings.
Positive comments helped increase team morale
and any negative responses were readily
accepted and used to support service
improvement. By having the questionnaires
returned directly to the team, it allows for any
concerns or issues to be addressed immediately
and also provides the team with real time
feedback on the experience of their service users.
3.3.3 Dementia
Dementia is a key area of work for the Trust and
over the last 12 months the Trust has seen a
range of service developments and initiatives to
improve the experience of both service users
and carers:
can include myth busting, signposting and
information relating to all aspects of the
Trust’s older adult inpatient services
■ Five
dementia cafés have been developed in
East Lancashire with the aim of enabling
people with dementia, their carers and
family members, to go to a casual social
environment to relax with others who
understand their situation. In addition it
provides an opportunity for them to meet
new people and engage in a previously
enjoyed activity. A professional in dementia
care is always present to offer advice,
signpost or give leaflets if needed. The name
dementia café was suggested by people with
dementia who want to increase awareness
and acceptance of the condition, supporting
early recognition, referral, diagnosis and
treatment which are also key themes of the
Dementia Strategy. The five established cafés
have been well received and attended with
the following comments given as feedback:
“It’s good to see we’re not alone” – Carer
“The advice you have given me is common
sense, I just did not think of it, I feel we’re
not in the dark, you’ve given us so many
ideas and food for thought, it’s a total
light bulb moment” – Carer
“I look at her sometimes and I can see that
she is lost, but today for the first time she
has smiled in a long time, she is finally
comfortable out of the house” - Carer
■ The
‘Your Time Information and Carer
Support Meeting’ in older adult inpatient
services involves staff meeting frequently
with relatives/carers in an informal session to
discuss all aspects of care management. This
“I have really appreciated this time to just
talk things over with others” – Carer
56
■ Older
Adults Community Mental Health
Team (CMHT) have offered dementia care
mapping within a large number of
residential care homes. Care homes have
been advised on appropriate interventions
to aid residents’ wellbeing, especially those
presenting with challenging behaviours. This
has enhanced the residents’ and staff’s
experience and prevented hospital
admissions and/or safeguarding alerts
■ The
older adults’ mental health liaison team
for Blackpool, Fylde and Wyre have worked
collaboratively with Blackpool Teaching
Hospitals NHS Trust to improve the care for
individuals with, or suspected of having,
dementia who are being cared for on a
hospital ward. The training has received
excellent feedback, with staff reporting they
feel more empowered and knowledgeable
regarding caring for people with dementia.
The team were runners up in the Patient
Safety category at Blackpool Teaching
Hospital’s annual award ceremony in
November 2011
■ In
Lancashire and Morecambe, an advanced
nurse practitioner has established an antipsychotic monitoring service to reduce the
prescription of anti-psychotic drugs in the
elderly. This has involved educational
sessions in 16 nursing homes and the
evaluations have been positive, with 100%
of attendees saying they had learnt new
information about anti-psychotic
medication, and 82% stating they had learnt
a lot. A total of 34% of patients having their
anti-psychotic medication monitored had it
discontinued. This compares favourably with
a national study which showed a 20%
discontinuation
■ The
East Lancashire nursing home liaison
team was established in December 2010 to
support people with dementia who exhibit
behaviours causing significant problems. In
eight months, the three nurses have seen 48
clients and there has been a 60%
reduction/cessation of antipsychotics; 40%
reduction/stop in benzodiazepines; and
admissions to dementia beds from nursing
and residential homes has more than halved
57
3.3.4 Other Examples
■ Falls Prevention Service Central Lancashire A postal questionnaire which was developed
by the Royal College of Physicians was
distributed to service users:
97% understood why they had been
referred to the service
73% felt there had been enough help to aid
recovery
79% felt good communication took place
83% felt involved in deciding what actions
should be taken following assessment
95% were invited to start an exercise
programme
89% stated their overall experience of the
falls prevention service was useful
Feedback from the survey has been used to
further develop the service: for example, the
team now has daily triage slots to ensure timely
assessment.
■ The
Community Nursing Service in Blackburn
with Darwen distributed a questionnaire to
service users. The results from this patient
experience survey were overall very
encouraging. The vast majority of scores and
comments were positive, with frequently
used words including ‘friendly’, ‘helpful’ and
‘caring’. Service User feedback regarding
the lack of information about the timing of
visits and late evening visits are being
considered as areas for service improvement
3.3.5 Surveys The Junction Service User Experience
The Junction has its own internal young
person’s evaluation programme 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 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 6.
The following questionnaires were completed between January and June 2011. The number of
young people completing the questionnaires is included
■ Assessment prior to admission (seven young
■ Admission (seven young people)
■ Staying at the Junction (19 young people)
people)
Diagram 6: What young people are saying about The Junction
Assessment prior to admission

Referral and initial contact:
100% of the young people said
they were aware of their referral
!
Information:
43% received information about
The Junction and all thought it
was ‘alright’ or ’great’


!
!
Assessment:
86% had an explanation about
assessment prior to being assessed
The majority (86%) understood
what decisions were going to be
made and 71% felt their views
were listened to during the
assessment
14% had a home visit prior to
admission
29% reported feeling scared or
worried about being assessed
Admission







!
!
Admission
57% reported that the data and
time of admission was convenient
57% had their key worker discuss
their care plans on arrival
86% had The Junction’s routine
explained to them
100% felt welcome, safe and secure
71% felt that the bedrooms could
be made their own with posters
and personal items
100% knew how to contact family
and friends
71% liked the education provision
29% had met their key worker
43% felt that mealtimes and the
food was rubbish
Staying at The Junction







!
!
95% had a copy of their care plan
89% had their medication explained to them and its side effects
79% felt the plans to see their family were ‘ok’ or ‘good’
100% had met their advocate and seven young people had used them
84% knew how to make a complaint
95% knew they could suggest improvements
95% attended improvement meetings as they felt they could make a difference
37% did not felt listened to during care planning
47% felt staying at The Junction helped them
58
After reviewing the outcomes including that
37% of young people did not feel listened to
during care planning, plans have been
developed to address the issues raised which
include the following actions:
■ Information
■ Ensure that
assessing staff/team give The
Junction Information Pack, containing all
information about this Unit
■ This pack also covers issues pertaining to
making bedrooms your own space and also
information about how young people can
make a complaint
■ To review overall content of information
pack to ensure that it is up to date and
develop a process/checklist, utilising
administration staff to ensure that
information is provided to young people
and families at the earliest possible time
■ Pre-admission Visits
■ To develop a structure,
including MultiDisciplinary Team (MDT) members and
education staff, as well as nursing staff,
that maximises the opportunity for a preadmission home visit or visit to The
Junction
■ Agree a clear purpose for home visits and
develop a proforma for information
sharing/gathering
■ Care Plans
■ To utilise
staff meeting forums to stress the
importance of working collaboratively with
young people and carers in care plan
development both during individual
Keyworker sessions and progress meetings
■ Contact all Keyworkers to remind them of
the importance of this process
■ Use care plan audit to re-assess compliance
The Platform Survey
The aim of the questionnaire is to ensure
services provided to young people in CAMHS
Tier 4 are of a high standard and the young
people receiving services are involved and
understand their care. The outcomes of the
work inform personal health planning and
service development.
The following questionnaires were completed
between January and June 2011. The number
of young people completing the questionnaires
is included:
■ Assessment
prior to admission
(12 Young people)
■ Admission
(15 Young people)
■ Staying at The Platform
(six Young people)
■ Leaving The Platform
(seven Young people)
59
Diagram 7: What young people are saying about The Platform
Assessment prior to admission





!
!
Assessment:
83% knew why they were having
their assessment
92% understood how they were
being assessed
75% felt their comments
influenced the assessment
83% had the results of their
assessment explained to them
100% felt there was someone to
talk to
8% (one patient) reported that
they were not informed of the
assessment or why it was being
completed
8% said results were not explained
to them
Admission


87% knew why they had been
admitted

27% felt nervous on arrival but
80% said they felt safe and
welcomed after admission

100% were shown around and
100% had the routine explained
to them





80% felt they could personalise
their bedrooms
73% were involved with the
decision to be admitted
100% got information on how to
contact family and friends
83% had a copy of the care plan
92% understood the care plan
100% got information on
advocacy
Staying at The Junction











!
All the young people:
100% were involved with writing and reviewing their care plan
100% felt there was someone to talk to about how they felt
100% knew who their primary nurse was and 100% knew their Consultant
83% had the reason for their medication explained to them
90% felt that education was good
80% felt the plans to see their family were ‘ok’ or ‘good’ or ‘useful’
100% had met their advocate and everyone had used them
83% knew they could suggest improvements through Participation Consultants
83% attended improvement meetings as they felt they could make a difference
100% knew how to make a complaint
100% were involved in their plans to leave The Platform
50% felt that food was rubbish
60
After reviewing the outcomes, several action plans have been developed which include the
following actions:
■ Care Programme Approach (CPA) reviews
■ To utilise information gathered from young
people and families, as the basis of a new CPA
guidance document
to clearly identify the responsibility for preparing young people and families for
CPA reviews
■ Checklist developed to ensure that all elements/standards of good practice in relation to CPA
reviews is followed and is auditable
■ Document
■ Food
■ The
continued results about the food have led to the entire food provision changing to selfcatering with the employment of two life skills workers. The immediate responses to this
change are overwhelmingly positive
■ Increased participation
■ Review the effectiveness of the current system for data collection
■ Explore ways of incorporating parent/carer data into the evaluation work
■ Develop effective system that utilises staff appropriately to support participation
worker,
whilst maintaining reliability
Secure Services Survey
Unlike other areas of the Trust, service users in secure services remain inpatients for long periods
of time. It was therefore felt appropriate to have a bi-annual questionnaire as well as handing it
out on discharge. Due to very poor responses from the previous three audits, the audit tool was
reviewed and reduced taking into consideration feedback from the key groups including the
Service User Forum, service user community meetings and various staffing groups. The
questionnaires were distributed via the ward managers and placed in a freepost envelope by the
service user once completed. Table 37 shows the outcomes from 83 returned questionnaires and
will act as a baseline for future audits.
Table 37: Secure Services Service User Satisfaction Survey
Questions
1
Does the multi-disciplinary team fully involve you in your care and treatment?
81%
2
Do you have access to Occupational Therapy?
95%
3
Do you have access to Psychological Therapy?
79%
4
Do you feel there are sufficient activities available to occupy you?
71%
5
Are your religious, cultural and spiritual needs being met?
57%
6
Is the ward environment clean and comfortable?
88%
7
Do you feel safe on the ward?
84%
8
Do you have somewhere to lock personal things away?
87%
9
Are the facilities for your family, friends and visitors adequate?
90%
10
Does the quality, quantity and presentation of the food meet your individual needs?
53%
11
Are drinks easily accessible?
89%
12
Overall are you satisfied with your package of care whilst at Guild Lodge?
76%
13
Overall, do you feel satisfied with facilities that exist within Guild Lodge?
83%
Source: LCFT Clinical Audit
61
Baseline 2011
The majority of the results are positive in most
areas and the areas where the results have been
fairly negative are:
■ Question
5 - Are your religious, cultural and
spiritual needs being met? This area is
currently being addressed by the service with
support from the Lancashire Forum of Faiths
if required
■ Question
10 - Does the quality, quantity and
presentation of the food meet your
individual needs? Menus remain under
review with the facilities department and
regular satisfaction questionnaires are
undertaken to receive feedback and make
improvements. Changes have taken place
regarding how food is provided to the wards
using a bulk rather than plated system. This
is based on patient feedback and although
there are still problems it shows actions are
being taken
3.3.6 Contributions of stakeholders
In 2011, the Trust developed a series of
programmes using video diaries and patient
stories to engage staff in improving the quality
of service users’ and carers’ experiences. These
initiatives have demonstrated how patient and
carer video diaries, when used in a structured
programme for service improvement, can lead
to measurable improvements in service quality.
The programme has brought together patients,
carers, frontline nursing staff and service
managers in ways that enabled them to discuss
patient experience in a constructive and
innovative environment.
The initiative began as a partnership with the
Mental Health Improvement Programme
(MHIP). The first trials were carried out in the
Trust’s Adult Inpatient Facilities. DVDs were
made from recordings at each of these sites and
these were shared with staff in the form of a
service improvement workshop. The outputs
from these formed the basis of a local service
improvement plan.
These proved so successful in engaging staff
and patients that a Trust-wide programme has
been developed which includes Community
Services, Older Adults and Secure Services. A key
part of the programme is that all the material
is used to develop local improvement plans
which form part of the Trust’s Quality Strategy.
These are monitored throughout the year and
reviewed after 12 months when the sites are
visited again to carry out the second wave of
recordings with patients, carers and frontline
staff. These are then analysed to identify where
progress has been made in service quality and
how this can be maintained through reflective
practice.
All the stories from the video diaries are stored
on a shared drive with protected access so staff
can use the material for training purposes. The
material has been used for reflective practice
and programmes such as promoting the
Recovery model of care in our Secure Services.
The response from those who have participated
in the programme, such as modern matrons and
service managers, is that the video diaries have
made a significant difference to how the teams
work with patients and carers. For example, at
the Trust’s Ormskirk facility, the modern matron
drew on the video diaries to introduce a
programme of change designed to create more
quality time between nursing staff and
patients. This has resulted in measureable
improvements in clinical outcomes, a decrease
in the average length of stay and a reduction in
re-admission rates. Patients also reported
higher levels of satisfaction and the second
wave of video diaries recorded growing levels
of expectation and appreciation around their
quality of care. Whereas the stories initially
focussed on basic care issues such as lack of
engagement with staff on the ward, patients
now are looking for ways to maintain their
recovery once discharged. In this way the video
diaries provide documentary evidence of
improvements in service experience and the
quality of care staff are providing.
To support this work the Trust is looking to
develop a programme for collecting staff
experiences of working with patients. These are
in the form of staff audio diaries in which they
talk about what is important to them in their
work with service users and carers. This is being
undertaken as part of a Trust-wide programme
to promote Compassionate Care led by the
Trust’s practice development nurses. The staff
stories will be used alongside the patient video
diaries, to highlight areas where there may be
a difference in values and priorities and as a
guide to future service development.
62
Diagram 8: Patient comments taken from Ormskirk Hospital video diary
Support and communication:

Everyone’s been really friendly and
they helped me settle in

You have your one to ones so you
can have a chat, you just go up to
them and say can I have a word
!
I’d like to talk more, the first
night I couldn’t sleep and I
started crying and felt a nurse
should have spent time with
me, she just left me with the
tissues to cry. I’d rather be
treated at home really
Consideration of patient needs:
!
I have a learning disability so I struggle to read magazines
(as an activity on the ward)
!
Don’t have much time with the doctors apart from once a week with a group
of people which is a bit stressful. There were ten last time, it’s a lot to cope
with, it’s stressful with people around you, you get mixed up in your thoughts
!
I found it difficult to talk with the other patients because they’re from different
areas, I think it would have been better if I’d been in Chorley, I would have
been a bit more nearer to my parents
Ward Environment: Activities,
Food and Freedom of Movement




63
I’ve kept busy… potting plants
The food’s good, bed is nice, company is nice
The food’s been good as well, it’s made me want
to do some cooking now
I’ve been out twice, it was really good
!
I think there
should be more
activities, I like
sewing
3.3.7 Patient Complaints
Patient complaints and compliments are important indicators of the quality of care being provided.
Chart 22 and Table 38 identify the numbers for each year and comparative data on Ombudsman
requests.
55
139
55
48
-25
139
48
-25
Number of Compliments and Complaints Received
Chart 22: Number of Compliments and Complaints Received
600
600
500
500
600
400
400
500
289
300
300
289
400
421421
200
200
300
421
100
100
200
421100
00
365
134
134
365
-48
48
134
-100
0
-100
-45
-53
-48
-200
-100
-200
-45
-53
Q1
-200
155
155
221
-4848
155
221
-49
-48
139
139
238
-25
139
25
238
-46
-25
-49
Q2
-46
Q3
421
193
-5353
193
-47
-53
-47
Q4
365365
-69Q1
221
289
221
221
221
290
221221
243 243
290
238
221238 193
193 219 219
194
194 290
243
221
-49 49
243
-48
-49
-64
-48
Q2
-64
238
194
-46 46
289
365
219
-45 45
219
-69
-45
289
194
-37
-46
-37
-37
-37 Q3
290
243
219
193
-47 47 -69 69 -48 48
66
-64 64
-49
-47
-48
-69
66
-46
-64
-49
Q4
Q1
Q2
-46
Complaints - Mental Health
Compliments - Mental2010/11
Health
Compliments
- Community
Complaints - Mental Health
Complaints - Mental
HealthService
Complaints
- Community
Service
Compliments
- Mental
Complaints
- Mental
Health Health
Compliments
- Mental
Health Health
Compliments
- Mental
Compliments
- Community
Complaints- Community
- Mental
HealthServiceComplaints
Compliments
Service
- Community
Service
Compliments
- Community
Service
Complaints
- Community
Service Complaints - Community Service
Compliments
- Mental Health
Compliments - Community Service
Complaints - Community Service
2009/10
66
194
-37
-37
37 -49
37 -46
66
-37
-37
-49
-46
Q3
290
66
49
46
Q4
2011/12
Quarter/year reported
There has been an increase in complaints from community services which was expected following
the transfer of the services to the Trust in June 2011. During 2012/13 network specific reports will
be produced to monitor trends and ensure improvements are shared across services. As part of
the Trust’s commitment to ensuring complaints are handled in a fair and robust way, non-executive
directors will be auditing a sample of complaints.
Table 38: Ombudsman Requests (mental health only)
Number of patients who had their
complaint referred to the Ombudsman
2007/08
2008/09
2009/10
2010/11
2011/12
5
2
13
9
16
Data Source: LCFT Customer Care Department
The number of referrals to the Ombudsman
increased during 2011/12 and this is being
reviewed to identify any lessons learnt or
emerging themes.
Thematic Review of Complaints
Since February 2011 a thematic review of
complaints has been completed on a quarterly
basis. In 2011/12 four reviews were undertaken
and the top four categories highlighted in all
four thematic reports were:
Care and Treatment
■ Level of care and support available
■ Access to services and treatment
Staff related issues including attitude /
behaviour
■ Attitude of staff
■ Inappropriate actions from staff
Communication
■ Communication
■ Communication
with service user
with family
64
Medication
■ Unhappy with medication
■ Withdrawal of medication
■ No medication prescribed
The findings of the review are being considered
through the network governance groups
including the identification of appropriate
actions and the embedding of lessons that have
been learnt. The themes are broadly
comparable across all the networks.
3.3.8 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. All admissions are
subject to a management review. Chart 23
identifies the number of admissions to adult
wards since 2007/083.
Chart 23: Young Person Admission to Adult Wards
45
40
Number of Admissions
35
30
25
20
39
15
57% reduction
on 2010/11
27
10
21
17
5
59% increase
on 2007/08
44% increase
on 2008/09
46% reduction
on 2009/10
9
2008/09
2009/10
2010/11
2011/12
0
2007/08
Data Source: LCFT Information System DATIX
2007/2008
2010/2011
2008/2009
2011/2012
2009/2010
Financial Years
During 2011/12 there was again a reduction in the number of admissions to adult wards. There
are still admissions and the main reasons for these relate to the need for a psychiatric intensive
care unit bed because The Platform is full. The majority of these admissions to adult units are
appropriate. Young people are only admitted to adult units where the environment is made ‘young
person friendly’ and the observation levels are increased to make sure they are safe. The length of
stay is kept to an absolute minimum with input from specialist services.
3.3.9 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 reports monthly to commissioners and there have not been any breaches
during 2011/12. The PEAT visits review privacy and dignity on the wards. The Trust’s declaration of
compliance is located on its website: http://www.lancashirecare.nhs.uk/Privacy-Dignity.php
3
Due to a data validation process the 2008/2009 figure of 28 and 2009/2010 figure of 29 previously published have both been found to be incorrect.
The new correct figures of 27 for 2008/09 and 39 for 2009/10 have now both been included.
65
3.4 Performance against
Key Mental Health Indicators
Table 39: Performance against Key Mental Health Indicators
Mental Health Indicator
2009/10
Target
2009/10
Outcome
2010/11
Target
2010/11
Outcome
2011/12
Target
2011/12
Outcome
Targets
Achieved
100% enhanced Care
Programme Approach
(CPA) patients receiving
follow-up contact
within seven days of
hospital discharge
95%
95%
95 %
96.5%
95%
96.5%

No more
than 7.5%
3%
No more
than 7.5%
4.1%
No more
than 7.5%
3.99%

Admissions to inpatient
services had access to
Crisis Resolution Home
Treatment teams
90%
98%
90%
90.3%
90%
99.1%

Maintain level of Crisis
Resolution Teams set in
the March 2005
planning round
8
8
84
6
6
6

Meeting commitment
to serve new psychosis
cases by Early
Intervention Teams
95%
114.8%
100%
140%

Data completeness:
Identifiers
99%
99.04%
99%
99.7%

Data Completeness:
Outcomes
50%
73.8%
50%
77.9%

Minimising delayed
transfers of care
Data source: CQC, Monitor and LCFT IT Systems
Data governed by Standard National Definitions
3.5 Quality Management Systems
As part of the quality strategy, the Trust has continued to implement initiatives that allow the
measurement and reporting of quality, for example:
■ Patient experience sampling
■ Structured site visits
■ Outcome measures – such as the Inpatient
■ Care pathways for common conditions
Satisfaction Scale
4
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.
66
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.
3.5.1 Quality Initiatives
There are a number of quality initiatives within
the Trust including:
Using Lean quality improvement techniques to
deliver more efficient and better quality
services
The Trust recognises that improving the quality
of service frequently means significant changes
have to be made to the way services are
delivered and managed. The Trust’s Lean Team
has continued to support clinical teams in
removing wasteful and unnecessary steps to
make processes and patient pathways flow
more smoothly. The result is both improvements
in quality of care and efficiency, and patient
satisfaction.
Some of the benefits include:
■ Reducing the meals ordered that are
delivered incomplete or incorrectly to
patients to zero, thereby releasing 52 hours
a year of nursing team time wasted in trying
to correct errors in one ward; and sharing
this approach across 11 other wards for
similar benefits
■ Reducing the time from ‘oven to service’ of
meals by over 60% ensuring patients receive
the highest possible quality meal right first
time, every time at Guild Lodge
■ Reducing the patient journey time in Genito
Urinary Medicine (GUM) Walk In by up to
55% and reducing the time spent waiting by
more than 50%
■ Increased capacity for nurse appointments by
33%, and medic sessions by 25%, within the
Memory Assessment Service (MAS) in North
Lancashire
■ Improving meeting efficiency and
productivity using a ‘Patient Status at a
Glance’ board for daily multi-disciplinary
handover enabling up to 34 weeks per
annum of clinical and education team time
to be reinvested in the service at The
Junction
67
A pilot study merging seven Single Point of
Access Services into one Single Point of Access
service within East Lancashire, applied Lean
thinking to referral, referral management and
primary mental healthcare, with the majority of
referrals now received electronically and
decisions on treatment pathways now made
within five working days. This process also
brought together Adult and Older Adult
Mental Health services.
During 2011/12 the Trust has embedded Lean
Methodology in two of the main strategic
transformation programmes: Agile Working
and Space Utilisation. For example, Lean
improvement techniques and thinking are
supporting the design and roll out of a Mobile
Working project for district nurses and a Tele
Psychiatry pilot programme.
The Productive Ward series in the Secure
Network is now operational in eight wards and
within the Community Hospital at Longridge.
The programme of Rapid Improvement Events
has continued in a variety of settings with the
programme and objectives set by frontline
teams.
This year has also seen an increase in the Trust’s
capability building programme, with the first
cohort of front line managers undertaking the
Lean in Practice programme supporting 12 local
improvement projects, and the development of
administration services, managers in applying
Lean workplace organisation.
Innovation
Innovation is about using new ideas or
technologies to improve productivity, quality
and/or efficiency. The Trust is keen to support
and foster innovation across all areas and there
are already some great examples of innovation
in the Trust. However, the question for the Trust
is: how good is it at sharing these examples of
good practice? The Trust is keen to ensure that
where innovation has been implemented and
demonstrated to work, this is shared with
appropriate services and teams throughout the
Trust, to maximise the learning and spread of
good practice. The Trust is also keen to
encourage more people to be innovative in
their everyday work, and to reduce any barriers
which may exist to innovation being
supported. One of the ways to do this is by
implementing the Trust’s Programme of
Innovation, which includes the establishment of
an Innovation Intranet resource. The Trust’s
Programme of Innovation is based on building
on the seven dimensions of innovation from the
NHS Institute for Innovation and Improvement.
The Programme was shaped by a consultation
event held within the Trust, in which interested
staff, and people who are successful innovators
came together to discuss how innovation could
be better supported in the Trust, and the
possible barriers to innovation.
Work that has progressed includes:
■ Attendance by a number of Trust staff at a
Pfizer innovation event, which provided
invaluable ideas and information which have
influenced the implementation of the
Programme
■ Establishment of an innovation learning set,
which includes representation from all the
networks and key corporate departments,
and is facilitated by the Medical Director and
the Quality and Research Lead
■ The innovation learning set is being tested as
a means of developing and growing
innovation ideas, and training staff from
networks and corporate teams in how to do
this in the most effective way. Those
innovation ideas which are developed
through this learning set and either require
significant financial investment, and/or have
the potential to save significant amounts of
money, will proceed through a ‘Dragon’s
Den’ type process. This will be a supportive
review process, using external consultancy
input and non-executives to review and
provide advice on how to proceed with
these ideas. Service user/carer feedback and
suggestions for innovation ideas is an
important area of the innovation
programme, which is currently in
development. To date, the Trust has
reviewed how innovation can be linked to
the overall Trust strategy for patient
involvement and experience. Service users,
carers, and members of the public were also
able to vote on the proposed innovations at
the recent Innovation Membership Event. A
service user will also be part of the ‘Dragon’s
Den’ Panel. Any ideas that seem viable will
be piloted and if evaluated as effective, will
be developed into a business case and
submitted to the Business Change Forum for
review and consideration as to whether or
not they should be rolled out across the Trust
■ A desired outcome of the learning set is that
the learning, knowledge, and skills that are
developed through this process is
disseminated and shared across the
organisation. One way this can be done is via
the Innovation Intranet page, and another is
through the innovation learning set group
members continuing to use their skills by
setting up additional groups to spread the
learning and develop other ideas; this is
already starting to happen
68
Inpatient Reconfiguration Programme
The Trust is close to finalising plans to replace
our inadequate current accommodation with
new purpose-built inpatient units. The
intention is that the first of these start on site
in Lancaster and Blackpool in the earlier part of
2012/13 and complete by 2013/14. Detailed
planning has yet to start for the new facilities
in Central Lancashire and Blackburn. Once
completed, the new inpatient facilities will
include
all
single
bedroom
ensuite
accommodation, good day spaces on all wards
that will have a maximum size of 18 beds (15
beds for dementia) and every ward will have
free access to its own protected outside garden
space. The planning for the workforce to
support the new service model for inpatient
services includes a greater number of qualified
staff per service user, and additional therapists
for activities during the daytime.
Service users and carers have been involved in
the
plans
for
this
new
inpatient
accommodation both through their on-going
engagement via the Expert User and Carer
Reference Group and also through supporting
the Arts and Healing Environment Group.
Equality and Diversity
The Trust’s commitment to embedding equality,
diversity and human rights into the core values
of the organisation was recognised in 2011 by
receiving partner status in the NHS employers’
Equality and Diversity Partners Programme.
The NHS North West’s Equality Performance
Improvement Toolkit has confirmed that the
Trust has moved from ‘developing’ to
‘achieving’ on five objectives and from
‘developing’ to ‘excellent’ on engagement.
To ensure compliance with equality legislation,
the Trust has been delivering a Single Equality
Scheme (2008-11). This has been evaluated and
a focus identified for future work to ensure
compliance with the Equality Act 2010 and an
on-going demonstration of good practice across
all functions.
Current activity around equality and diversity is
fully informed by service users and their carers,
staff, local community members and partner
agencies. This activity includes the setting of
equality targets and supporting operational
action plans leading to demonstrable health
outcomes for people from diverse groups.
69
Equality Impact Assessments are carried out to
ensure that everything that the Trust does is
inclusive, the results of which are published on
the website. New and reviewed policies,
procedures and functions are not ratified
without an accompanying Equality Impact
Assessment. Below are some of the examples of
the work being undertaken:
■ Staff Forums:
■ Further development
of the Black Minority
Ethnic (BME) Staff Forum. The group now
has identified a chair person who is a
female, Asian member of staff and the
group is currently addressing professional
development opportunities for BME staff
■ Further development of the Lesbian Gay
Bisexual and Transvestite (LGBT) Staff
Forum has supported the Trust in being
awarded the internationally recognised
Charter Mark for inclusion in late 2011. The
group is proactively supporting activity
during LGBT history month in February and
International Day Against Homophobia in
May 2012
■ Health Event for homeless clients within
Blackburn; this involved access to multiagency healthcare e.g. podiatry, vascular
assessment and dental services
■ The gym at Burnley Healthy Living Centre
offers culturally appropriate, gender specific
sessions for the local community. Total
attendances for the first nine months of
2011/12 were 11606 attendances of which
48% were female and 75% BME
■ Gypsy, Romany, Travelling Community Forum
to try to engage this group of potential
service users through workshops
■ Monthly workshop at all children’s centres in
Lancaster, Morecambe and Carnforth for
expectant mothers on mental health
awareness, signs and symptoms, basic coping
strategies and advice on how clients can
access services. Clients have evaluated the
workshops and have found them useful
■ Volunteer Interpreter Project – over 45
community members trained as Community
Interpreters; they are or will be volunteering
for services as interpreters
■ Mental Health Football League – the League
currently has nine teams
■ The Viral Hepatitis team last year increased
awareness of Hepatitis B and C and placed
an advert on Radio Ramadan to improve
uptake of services
■ National
Older People’s day event on Preston
market
■ Health promotion event for Blackburn with
Darwen 50+ partnership at King George’s
Hall
■ Carers’ Awareness Sessions project –
explores need of all carers from all
backgrounds including children/young
people/older people/working adults and the
implications of the caring role
■ A hate crime group meet on a regular basis
and there is a strategy for tackling hate
crime including care planning, and
promotion of equality/raising awareness
through the use of the H8 Crime DVD. There
are ‘champions’ in clinical areas
■ Secure Services have developed a leaflet for
service users and staff – supporting
assessment and assisting in meeting
spiritual/religious needs
■ Developed mental health group work
sessions with service users and staff in the
inpatient unit at Preston Prison. The most
successful outcome has been the gym
sessions where a member of the healthcare
team attends the gym with the patient and
exercises with them; they then go on to talk
about the positive benefits of exercise within
the group sessions
■ Men’s health week in June 2011: Wymott
prison offenders were offered health MOTs
and health education
■ Learning Disability Screening project to
identify learning disability within the prison
population; and jointly develop a care plan
to support the offender through his
sentence and planning for discharge
■ The podiatry team have performed some
voluntary sessions at the Preston Gujarati
Society to raise awareness of the impact of
diabetes on the foot and lower limb.
Additional sessions are planned later this
year within a local mosque to raise further
awareness
■ Partners in Health Mela in Preston, which is a
festival of health and wellbeing, with health
assessments available to those attending
■ Leadership
including the appreciative
leadership programme
■ Staff engagement including the staff survey
■ Health and wellbeing including the strategy
Following the transfer of community services in
June 2011, the Trust has launched an ambitious
programme to integrate and optimise the
services it now provides. The transfer has
enabled the Trust to provide services across the
pathways, delivering a more integrated and
holistic approach to physical and mental health
and wellbeing. This will improve equality of
access to services and facilitate economies of
scales across Lancashire.
The Trust continues to work hard to successfully
embed the NHS Constitution and the Trust’s
own values to ensure 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.
Workforce Planning
The Trust has recently developed an
organisation-wide workforce plan which sets
out the workforce it will need in the future
based on the strategic direction, the network
business plans, and the needs of the community
the Trust serves. The plan considers the current
workforce and then outlines the strategy to
develop and deliver the workforce for the
future. This workforce plan is complementary
to the Annual Plan and will be revised on an
annual basis in line with the Trust’s planning
cycle.
Staff and Quality
Leadership
The Trust recognises the relationship between
positive staff experience and positive patient
experience. The Trust works to improve staff
experience through:
■ Supporting staff including workforce
planning
The Trust has invested significantly in an
innovative Appreciative Leadership Programme
as part of its cultural change programme.
Following on from a pilot in late 2010, the
Programme has been rolled out to over 500
staff and will continue to be rolled out to
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approximately 1000 staff. Those involved
attend a series of workshops, leadership
learning sets, complete an appreciative inquiry
based action research project as well as receive
feedback. Appreciative Leadership is about
applying a positive rather than deficit based
approach to management.
It is important that leaders are openly and
actively ‘living’ the Trust values and are focused
on health improvement for the people of
Lancashire. A Leadership and Management
Development Framework has also been
developed, which includes a comprehensive
programme of development for all levels of
staff, in addition to a programme of Board
development.
The framework, with Trust values at the core,
consists of the following development
pathways:
■ Leading
me – what if everyone was devoted
to delivering their absolute best?
■ Management development – delivering the
business: delivering high performing services
with a reputation for excellence
■ Leadership development – engaging people
to deliver the business: creating new futures
through transformational engagement
Staff Engagement
The Trust continues to recognise the value of
the staff survey data in helping to better
understand where to focus resources in
improving the working lives of staff. Following
the transfer of community services in June 2011,
the Trust undertook an analysis of the survey
data from each predecessor organisation. As a
direct result of the survey findings, a joint high
level action plan was developed and published
for the top ten actions. The Trust issued surveys
to a sample of staff during 2011/12 and,
following an analysis of the results, is
committed to implementing action plans at
both a strategic and local level throughout the
organisation. The latest survey results published
in March 2012 showed an improvement in the
overall staff engagement score from 3.61 to
3.68 which compares favourably to the 2011
national average for mental health/learning
disability trusts of 3.61. The results show that
areas that have improved the most since 2010
are: the Trust’s commitment to work-life
balance; the percentage of staff experiencing
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physical violence from patients, relatives and
the public; effective action by the Trust towards
violence and harassment; and effective team
working.
Health and Wellbeing
The Trust recognises that the health and
wellbeing of its employees is vital to drive the
delivery of the business plans and associated
improvements in patient care. A Health and
Wellbeing Strategy has been developed to
ensure that wellbeing is at the heart of the
employment experience for all staff. The
strategy is underpinned by key strategic
documents and supports existing policy
documents embedded in the organisation. The
five high impact changes, together with six core
services outlined in the ‘Healthy Staff, Better
Care for Patients’ (2001, Department of Health)
document and the recommendations of
the Boorman Review (2009, Department of
Health), have been developed into a
strategic framework focusing on prevention,
intervention
and
promotion.
The
implementation of the framework and delivery
of the strategy is underpinned by a three year
action plan currently under development,
which will build on initiatives already
embedded to support the health and wellbeing
of the Trust’s employees.
4. Annexes
Following submission of a copy of the draft
quality report to the LINks, OSCs and Lead PCT
a number of changes have been made. These
changes are intended to further improve the
quality report and are as a result of comments
made by the Council of Governors, external
auditors, service user consultant, members of
the Trust Board and LINks. The key changes are
in the following areas:
■ Layout
■ Formatting
■ Additional information included to provide
clearer explanations or strengthen sections
■ Rewording of some sentences and
statements of assurance from the board
■ Research figures for recruitment have been
updated from 3829 to 4001 and in dental
study nearly 4000 to 3258
■ Table 2 Quality Overview with comparison
against previous year’s data - Complaints
referred to Ombudsman 2011/12 figure has
changed from 9 to 16
■ Table
11 Outcome from POMH-UK Monitoring of Patients Prescribed Lithium the percentages were inaccurate and have
been updated. The wording has changed to
reflect the scoring:
■ Serum Lithium level (3 monthly)’ variance
of re-audit against National Average has
changed from downward red arrow 6% to
upward green 13%
■ ‘Thyroid Function (6 monthly)’ variance of
re-audit against National Average has
changed from downward red arrow 10%
to upward green 20%
■ Table 21 NHS Outcomes Framework - Safe
patient environment - Indicator “Percentage
resulting in death?” the variance has
changed from 0.1% to 0.3%
■ Table 26 WHAM Audit data - Indicator “Is
the dressing selection compliant with Trust
wound care formulary?” the variance has
changed from 15% to 16%
■ Table 37 Secure Services Service User
Satisfaction Survey - Indicator 12 “Overall,
are you satisfied with the facilities that exist
within Guild Lodge” should be “Overall are
you satisfied with your package of care
whilst at Guild Lodge”
■ Table 39 Performance against Key Mental
Health Indicators, indicator ‘Maintain level
of Crisis Resolution Teams set in the March
2005 planning round’ has had the asterix
removed from the wording and the data for
2011/12 has been included. The footnote 8
hass been removed
■ Chart 17 Pressure Sore - Quarter 3 2011/12
Category 4 pressure sore has changed from
36 to 26 and Quarter 4 2011/12 has changed
from 18 to 16. Quarter 4 2011/12 Category 3
pressure sore has changed from 46 to 40
■ Chart 18 Pressure Category 3 ■ Quarter 3 categories have changed as
follows:
■ School - Changes from 1 to 0
■ Patient’s home - Change from 2 to 3
■ Quarter 4 categories have changed as
follows:
Community - Changes from 30 to 27
Hospital - Change from 7 to 5
■ Chart 19 Pressure Category 3 ■ Quarter 3 categories have changed as
follows:
■ Care home - Changes from 3 to 4
■ Quarter 4 categories have changed as
follows:
■ Community - Changes from 8 to 6
■ Chart
20 & Chart 21 Advancing Quality Have been updated to include January 2012
data and psychosis percentage pass rate
shows November figure as a date field. The
correct figures should be 87%
■ Data in tables 9, 24, 25 and 34 have been
added and updated
■ National surveys - Added ‘percentage points’
■ Equality & diversity - Reworded mental
health football league bullet and corrected
spelling of Wymott
■ CQC compliance has been updated following
receipt of unannounced visit report
■ Page 20 Longridge PROMS - Comments
added in regard to the 4 patients that didn’t
obtain their desired outcomes from their
stay on the ward
■ Page 29 - Clinical coding - Comments added
in regard to secondary procedures failures
■ Page 55 - Crisis Patient Reported Outcome
Measures (PROMS) - Comments on roll out of
questionnaire added
■ Table 12 Use of antipsychotic medicines in
people with learning disabilities - Comment
on Blood Pressure test result recorded have
been added
■ Statements from Lead PCT, LINks and OSCs
have been included in Annex 4
■ Statement of directors responsibilities and
independent auditors report has been
included in Annex 4
Statements from Lead PCT, Local
Involvement Networks and Overview
and Scrutiny Committees
Blackburn with Darwen PCT
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 (LCFT).
The Care Trust Plus commissions services 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.
Throughout the year the commissioners and
Trust have met on a regular basis to monitor
72
and review 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 this quality
account gives a representative view of services
provided in 2011-12.
NHS Blackburn with Darwen can confirm that
Lancashire Care NHS Foundation Trust achieved
completion of all the schemes included in the
CQUIN (Commissioning for Quality and
Innovation) framework, both within the
community and mental health contracts and
this attainment should be complimented.
The account also highlights 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 particular the Trust should be
congratulated on the following:
■ Efforts
to reduce health care acquired
infections
■ Improved performance in staff surveys
■ Improvements in medicines management
and use of lithium and anti-psychotic drugs
■ Demonstration of use of patient feedback
In 2011-12 it was necessary for the coordinating
commissioner to issue a Performance Notice in
response to the CQC review of services at
Balmoral Ward, Parkwood. The commissioner
was impressed with the openness of discussions
with LCFT Directors and in the organisation’s
response, remedial action to return to
compliance and the assurances put in place.
This will remain on the agenda for contract
performance meetings.
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.
However
the
commissioners believe that the following areas
should be included in the priorities for 2012-13
in addition to the indicators contained in the
CQUIN schedules:
■ Improvement
in percentage of staff
receiving mandatory training, appraisal
■ Review of complaints handling in response
73
to increase in cases referred to Ombudsman
time patient feedback and an
improvement in patient feedback with
regard to privacy in acute services
■ Actions resulting from Peer Reviews of
secure and adolescent services
■ Serious Untoward Incident reporting within
timescales and demonstration of learning
■ Real
The following comments relating to the
presentation of the information contained
within the document have been received from
Associate Commissioners:
■ Clarity
on compliance with NICE guidance is
requested to reflect the framework of
commissioners’ policies
■ Identification of areas which relate to
mental health and community (physical
health) services would ease interpretation
for local clinicians and communities in
particularly localities where some services
are provided other NHS providers with a
balance between these service areas
■ The document is considered lengthy and
there needs to be a distinction between the
national requirements for Quality Accounts
and with the reporting of local improvement
and achievements.
We welcome 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. The commitment of the Trust in
developing dialogue with the emerging Clinical
Commissioning Groups is appreciated.
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.
Debbie Nixon
Locality Director,
Blackburn with Darwen
Director of Mental Health Commissioning
Blackburn with Darwen LINk
Blackpool LINk
BwD LINk welcomes this opportunity to
comment on the Quality Accounts. It was
pleasing to see the extent the Accounts
included service user views as we feel this
represents the culture of the Trust particularly
how it has developed over the last 4 years. It
appears service user views are now a significant
proportion of the overall Accounts and we
welcome this approach. The LINk can confirm
that this approach has been replicated in the
Trust’s responsiveness to our questions and
meetings with Trust managers.
Blackpool LINk welcomes the publication of the
Quality Accounts for the third year. We are
pleased to see a huge overall improvement in
the report.
We also note the inclusion of Dementia carers
views and again we feel this is a very
progressive approach by the Trust and we look
forward to this eventually being replicated in
other areas of mental health with more
extensive data on carer’s views.
While noting that mental health service user
views are extensively represented in the
accounts those for community service newly
incorporated into the Trust are less so and we
feel this can only improve as they become more
incorporated into the culture of the Care Trust.
We would therefore expect that service user
experience for community services such as
District Nursing will have much more data in the
accounts for next year.
Our final comment relates to the layout of the
report and we feel this year the report is much
longer and complex than previous years due to
the incorporation of new services. This also
made it a little difficult to follow and we were
sometimes unsure which elements of the Trust
services were included in the different sections.
For example, in the summary of violence to staff
and if this included District Nursing staff. We
realise this is possibly much to do with
perception and adjustment and the transition
of the Care Trust from a purely Mental Health
Trust to one also providing a much broader
range of services, however this is also likely to
cause some confusion among lay readers at this
stage.
Blackburn with Darwen LINk
May 2012
Please see below our comments on the report:
1. Clinical Supervisions – Table 3
“All staff have a right to regular formal
supervision” – whilst there has been a 7%
increase on Community Staff and a 3%
increase on Inpatient Staff, it is
disappointing to read that on “Supervision
will take place in line with professional
codes of conduct”, there has been a 15%
decrease on Community Staff and a 14%
decrease on Inpatient Staff.
2. National Community Patient Survey Results
– Table 4
It is good to read that the Trust is above the
national average on five of the six
indicators. Blackpool LINk would like to
hear what additional work will be
undertaken to improve the first indicator,
“were the purposes of the medication
explained to you?”
3. There needs to be a clearer explanation on
the % increase/decrease, which relates to
the national average, not the previous years
results.
4. Congratulations to the Continence Team,
who won two Nursing Times Awards in
2011, and to the Discharge Planning Team
who have been nominated for the
Partnership Working Award – well done.
5. Falls resulting in a fracture (Patient Safety) Whilst there has been a slight reduction in
the number of falls, Blackpool LINk would
like a full explanation on each fall that that
has occurred and would like to know what
initiatives the Trust is going to implement to
reduce the number of falls.
6. Health Care Associated Infections (Patient
Safety) - The Trust has continually improved
reducing the number of MRSA and
C.difficile cases. Well done.
7. Never Events (Patient Safety) Congratulations to everyone at the Trust for
achieving 0%
8. Violent Patient against Patient Incidents Blackpool LINk would like to have a clearer
explanation on this to be able to
understand it.
9. Staff Mandatory Training and Staff
74
Appraisal’s – Blackpool LINk would like an
explanation from Commissioners as to why
the Targets set, are less ambitious than the
previous year?
10. There is no mention of what involvement
young people have in decisions about their
Care Plans at The Junction, whereas at The
Platform, it is reported that all the young
people (100%) were involved with writing
and reviewing their care plans. The Trust
needs to report on the negatives as well as
the positives.
We also note with concern, that 53% of the
young people did not feel that staying at
The Junction helped them and 37% did not
feel listened to during care planning.
Whilst all of the young people, who
completed a questionnaire (17), said that
they had met their advocate, only 7 young
people had used them. The Trust needs to
do more work with the young people to
ensure that they have an advocate and that
their voice is heard.
We would like to invite representatives from
the Trust to attend future Blackpool LINk
meetings to respond to the queries above.
We look forward to receiving the official report
in due course.
Yours sincerely
Norma Rodgers
Chair of Blackpool LINk
Lancashire LINk
Lancashire LINk welcomes the third year of
Quality Accounts in which the Trust reviews its
2011 / 2012 priorities referring to the quality
improvement strategy and which is generally
positive.
There was excellent performance against Key
Mental Health Indicators; Community Teams
surveys and Inpatient Surveys compared well
with national averages (although teams can still
improve from feedback). Positives included the
reduction of MRSA / Clostridium Difficile cases;
no ‘Never Events’; work with Stakeholders /
Service Users views; Quality Initiatives,
Innovation and Equality and Diversity measures.
The Medicines Management Strategy is
extremely positive.
75
The Trust is compliant with NICE guidance (up
to September 2011); medication prescribing
performance is generally above the National
Average; the patient’s measures of services and
the Trusts clinical measures are generally
positive.
Improvement of data quality systems have led
to improvements in monitoring care quality.
Clinical Coding Audits mostly show excellent
accuracy. A review of Inpatient CAMHS
(including
young
people’s
feedback),
Environment Assessments and Dementia / EIS
indicators all appear good. A mixed staff
supervision / appraisal picture shows
improvements but implies declines in
managerial supervision quality.
New work in 2011 / 2012 included mapping
community care pathways; the new clinical risk
policy / sub-group to review processes; and a
Mandatory Training Programme to meet the
needs of Teams.
Areas identified for improvement included…
Wards problems / subsequent
closure but we note the progress made at
Parkwood Hospital and have asked the Trust
for assurances that this will not be repeated
elsewhere
■ increases in violent incidents against staff
(although mostly ‘no injury or adverse
outcome’). The Trust lists measures taken but
staff’s perceptions of employer action
remain static. The number of patient against
patient violent incidents has reduced by 36%
(further reductions are needed)
■ the need for a higher profile / better support
of carers assessments; and to meet targets
for Serious Untoward Incidents (although
performance has improved)
■ a higher number of inpatient survey’s
returned
■ Balmoral
LINk is concerned…
young people are sometimes kept in
Adult Inpatient Services inappropriately
■ about negative feedback regarding Crisis
Teams practice
■ that there are no Trust performance figures
for Clinical Risk Assessment
■ that medication is explained to just 2/3 of
community service users and just ½ were
offered their care plan
■ about the In-patient Reconfiguration
■ that
Programme, the merging of Older Peoples /
Adult services and the potential impact on
patients and carers
■ that sample sizes are needed for all surveys.
…and continue to liaise around these issues.
The format, layout and use of clear images /
tables / comparisons are good and the tone is
constructive. The language could be simplified
with summaries at the start of parts 2 and 3.
More transparency / explanation are needed
about why targets are not met and action
required rather than referring to ‘additional
work is underway’. Many measures are processbased (with few outcome-based). The new 2012
/ 15 priorities listed have no targets for this year;
they are merely to establish a baseline.
Blackpool OSC
‘Blackpool Council’s Health Committee was
pleased to be given the opportunity to review
and comment upon the Quality Account for
2011 / 12. The Committee has enjoyed a high
level of cooperation with the Trust, together
with excellent communication links during the
period in question. Officers from the Trust have
attended Committee meetings on a regular
basis, whenever requested, in order to present
items and to be held to account by the
Committee.
hospital, which had taken place in December
2011. The inspection had highlighted concerns
regarding the ward environment, staffing levels
and the support and quality of care planning.
The Committee received assurance from the
Trust that the concerns highlighted within the
report had been taken very seriously and that a
range of measures that would lead to
immediate
improvement
had
been
implemented.
The Committee was informed that one of the
major decisions that had been taken in relation
to the CQC report had been to close Warwick
ward at Parkwood in March 2012, which was
three months earlier than had been planned
for. The early closure had enabled the
consolidation of the service skilled staff to be
re-allocated to the remaining two wards. This
was considered as being critical in order to
maintain improvements in the care and
experience of patients.
It was further reported that the Trust was
working to ensure that there was sufficient
capacity in community services to manage the
closure of Warwick Ward earlier than planned.
Matters that were under consideration included
resolving delayed discharges, improving care
planning and assessment and closer working
between the community and in-patient teams.
The Quality Account was made available to
Committee members on 16th April and
considered formally at the Health Committee
meeting on 19th April. Mr P. Sullivan, Director
of Nursing at the Trust, presented the
Committee with an explanation of the key
issues that were contained within the Account,
together with a summary of what the Account
was designed to provide in terms of
information. Whilst Mr Sullivan’s explanation
was welcomed, it was acknowledged that the
Account consisted of 73 pages and that a
written executive summary would have been
helpful.
The Committee raised concerns relating to a
lack of capacity following the early closure of
Warwick ward. It was acknowledged by the
Trust that capacity remained one of the biggest
issues faced by the Trust and that in-patient
facilities were being utilised throughout
Lancashire to cope with demand, including six
or seven beds within the private sector as a
short term measure. It was added that the
clinical teams were working hard to ensure
there were no delayed discharges and that
capacity issues must be considered within the
context of the whole range of services that
were available.
Mr Sullivan responded to a number of questions
from the Committee in connection with certain
technical aspects of the Account. With
reference to particular comments, it was
acknowledged that a key component of the
Quality Account in relation to Blackpool, had
been around the findings of the Care Quality
Commission (CQC) inspection of Parkwood
The Committee raised the worrying levels of
concerns that were highlighted by the CQC
report. The Trust responded by acknowledging
that it had accepted the CQC report in full and
was now taking the opportunity of
implementing improvements that had been
highlighted by the independent regulator.
76
The Committee questioned whether any of the
issues highlighted in the CQC report were
applicable outside of the ward that had been
subject of the inspection. It was explained that
the improvements were now being made across
all of the wards at Parkwood.
The Committee acknowledge the huge amount
of work being undertaken by the Trust in order
to meet the aims and objectives of its
Transformational Programme. In doing so, it
must ensure that existing levels of care are not
compromised in the way that they obviously
were at Parkwood. The Committee intends to
closely monitor the improvement programme
at Parkwood over the coming months and looks
forward to working closely alongside the Trust
in order to ensure that the improvement
programme is sustained on a long term basis’.
programme previously for this Committee, the
Council has undergone a series of efficiencies
and budget reductions and 12 months ago
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 new Committee does
not meet now until the 13th June, when it will
be advised to prioritise firstly on work its
mandated to undertake, whilst directing its
work programme for the next three months
towards the performance and continued
delivery of internal portfolio and departmental
efficiency reviews. Furthermore due to long
term sickness absence of the officer responsible
for the new Children and Health Overview and
Scrutiny Committee and the Scrutiny Manager
I am sorry but we are not able to provide you
with a detailed response to your Quality
Account this year.
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
Children and Health Overview and Scrutiny.
Whilst this may have been part of the work
John Addison,
Scrutiny Officer,
Blackburn with Darwen Borough Council
Lancashire OSC
The Trust has continued to engage with the
Lancashire Health Scrutiny Committee over the
last year through a variety of ways including
progress updates, newsletters and attendance
at meetings.
Specific engagement regarding the on-going
mental health inpatient service reconfiguration
proposals and the subsequent transitional plans
has taken place with the Joint Health
Committee (comprising members from
Lancashire, Blackpool, Blackburn and 3 District
Councils).
Both Committees will maintain their overview
of the development of services and continue to
act as representatives for the residents of
Lancashire.
County Councillor Maggie Skilling
Chair of the Lancashire Health Scrutiny
77
Annex: Statement of directors’ responsibilities in respect of the Quality Report
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 Reports (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 Report.
In preparing the Quality Report, directors are required to take steps to satisfy themselves that:
■ The
content of the Quality Report meets the requirements set out in the NHS Foundation Trust
Annual Reporting Manual;
■ The content of the Quality Report is not inconsistent with internal and external sources of
information including:
■ Board minutes and papers for the period April 2011 to May 2012
■ Papers relating to Quality reported to the Board over the period April 2011 to May 2012
■ Feedback from the commissioners dated 14/05/2012
■ Feedback from governors dated 17/04/2012
■ Feedback from LINks dated 14/05/2012
■ The Trust’s complaints report published under regulation 18 of the Local Authority Social
Services and NHS Complaints Regulations 2009 dated 10/05/2012
■ The Head of Internal Audit’s annual opinion over the Trust’s control environment dated
17/05/2012
■ The 2011 national patient survey
■ The 2011 national staff survey
■ Care Quality Commission quality and risk profiles dated April 2012
■ The Quality Report presents a balanced picture of the NHS Foundation Trust’s performance
over the period covered;
■ The performance information reported in the Quality Report is reliable and accurate;
■ There are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Report, 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 Report is
robust and reliable, conforms to specified data quality standards and prescribed definitions,
is subject to appropriate scrutiny and review; and
■ The Quality Report 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 Report
(available at http://www.monitor-nhsft.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 Report.
By order of the Board
Professor Heather Tierney-Moore
Chief Executive
30 May 2012
Stephen Jones
Chairman
30 May 2012
78
Independent Auditor’s Report to the Council of Governors of Lancashire Care
NHS Foundation Trust on the Annual Quality Report
We have been engaged by the Council of Governors of Lancashire Care NHS Foundation Trust to
perform an independent assurance engagement in respect of Lancashire Care NHS Foundation
Trust’s Quality Report for the year ended 31 March 2012 (the “Quality Report”) and certain
performance indicators contained therein.
Scope and subject matter
The indicators for the year ended 31 March 2012 subject to limited assurance consist of the
national priority indicators as mandated by Monitor:
■ Minimising
■ Admissions
delayed transfers of care; and
to inpatient services had access to crisis resolution home treatment teams.
We refer to these national priority indicators collectively as the “indicators”.
Respective responsibilities of the Directors and auditors
The Directors are responsible for the content and the preparation of the Quality Report in
accordance with the criteria set out in the NHS Foundation Trust Annual Reporting Manual 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
Quality Report is not prepared in all material respects in line with the criteria set out in the
NHS Foundation Trust Annual Reporting Manual;
■ the Quality Report is not consistent in all material respects with the sources specified below;
and
■ the indicators in the Quality Report identified as having been the subject of limited assurance
in the Quality Report are not reasonably stated in all material respects in accordance with the
NHS Foundation Trust Annual Reporting Manual and the six dimensions of data quality set out
in the Detailed Guidance for External Assurance on Quality Reports.
We read the Quality Report 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 became aware of any material omissions.
We read the other information contained in the Quality Report and consider whether it is
materially inconsistent with the sources specified below:
The sources with which we shall be required to form a conclusion as to the consistency of the
Quality Report are limited to:
■ Board minutes for the period April 2011 to May 2012;
■ Papers relating to Quality reported to the Board over the period April 2011 to May 2012;
■ Feedback from the Commissioners dated 14th May 2012;
■ Feedback from the Council of Governors dated 17th April 2012;
■ Feedback from the LINks for Blackpool, Blackburn with Darwen and Lancashire, all dated
2012;
Trust’s complaints report published under regulation 18 of the Local Authority Social
Services and NHS Complaints Regulations 2009, dated May 2012;
■ The 2011 national inpatient survey;
■ The 2011 national staff survey;
■ Care Quality Commission quality and risk profiles dated April 2012;
■ The
79
May
■ The
Head of Internal Audit’s annual opinion over the Trust’s control environment dated 17th
May 2012 and
■ Feedback from the Overview and Scrutiny Committees for Lancashire, Blackpool and Blackburn
with Darwen, all dated May 2012.
We consider the implications for our report if we become aware of any apparent misstatements
or material inconsistencies with those documents. We refer to those sources, (collectively “the
documents”). Our responsibilities do not extend to any other information.
We are in compliance with the applicable independence and competency requirements of the
Institute of Chartered Accountants in England and Wales (ICAEW) Code of Ethics. Our team
comprised assurance practitioners and relevant subject matter experts.
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 2012, to enable
the Council of Governors to demonstrate that it has discharged its governance responsibilities by
commissioning an independent assurance report in connection with the indicators. 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:
■ Evaluating
the design and implementation of the key processes and controls for managing and
reporting the indicators;
■ Making enquiries of management;
■ Testing key management controls;
■ Analytical procedures;
■ Limited testing, on a selective basis, of the data used to calculate the indicator back to
supporting documentation;
■ Comparing the content requirements of the NHS Foundation Trust Annual Reporting Manual
to the categories reported in the Quality Report; 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
Non-financial performance information is subject to more inherent limitations than financial
information, given the characteristics of the subject matter and the methods used for determining
such information.
The absence of a significant body of established practice on which to draw allows for the selection
of different but acceptable measurement techniques which can result in materially different
measurements and can impact comparability. The precision of different measurement techniques
may also vary. Furthermore, the nature and methods used to determine such information, as well
as the measurement criteria and the precision thereof, may change over time. It is important to
80
read the Quality Report in the context of the criteria set out in the NHS Foundation Trust Annual
Reporting Manual.
The nature, form and content required of Quality Reports are determined by Monitor. This may
result in the omission of information relevant to other users, for example for the purpose of
comparing the results of different NHS Foundation Trusts/organisations/entities. In addition, the
scope of our assurance work has not included governance over quality or non-mandated indicators
which have been determined locally by Lancashire Care NHS Foundation Trust.
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 2012:
■ the
Quality Report is not prepared in all material respects in line with the criteria set out in the
NHS Foundation Trust Annual Reporting Manual;
■ the Quality Report is not consistent in all material respects with the sources specified above;
and
■ the indicators in the Quality Report subject to limited assurance have not been reasonably
stated in all material respects in accordance with the NHS Foundation Trust Annual Reporting
Manual and the six dimensions of data quality set out in the Detailed Guidance for External
Assurance on Quality Reports.
Tim Cutler
KPMG LLP, Statutory Auditor
St James Square
Manchester
M2 6DS
30th May 2012
81
Glossary of Abbreviations
BME
Black and Minority Ethnic
CAMHS
Child and Adolescent Mental Health Services
HR
Human Resources
IM&T
Information Management and Technology
NHS
National Health Service
NPSA
National Patient Safety Agency
PAM
People Asset Management
PCT
Primary Care Trust
PFI
Private Finance Initiative
PPI
Private Patient Income
PTSD
Post Traumatic Stress Disorder
SEED
Supportive Environment Encouragement Development
SUI
Serious Untoward Incident
LCFT
Lancashire Care NHS Foundation Trust
FT ARM
Foundation Trust Annual Reporting Manual
KF
Key Factors
HC
Head Count
WTE
Whole Time Equivalent
CIDS
Community Information Data Sets
QRP
Quality and Risk Profile
CQUIN
Commissioning through Quality and Innovation
AQ
Advancing Quality
LGBT
Lesbian, Gay, Bisexual and Transgender
R&D
Research and Development
CETV
Cash Equivalent Transfer Value
CoG
Council of Governors
SAC
Standards and Assurance Committee
PEOG
Patient Experience Oversight Group
SES
Single Equality Scheme
QIPP
Quality, Innovation, Productivity and Prevention
SDMP
Sustainable Development Management Plan
BREEAM
Building Research Establishment Environmental Assessment Method
82
Accounting Officer
Senior person appointed by the Treasury or designated by a
Government department to be accountable for the operations
of an organisation and the preparation of its accounts.
Acute trust
An NHS body that provides secondary care or hospital based
healthcare services from one or more hospitals.
Annual Governance
Statement
An annual statement of how the Trust has assured itself that it
has taken all reasonable steps to recognise the risks to it’s
operational and strategic goals and put in place mechanisms to
mitigate, to an acceptable level, the probability or impact of
those risks.
Benchmarking
Process that helps practitioners to take a structured approach to
share, compare, identify and develop the best practice.
Care pathway
A pre-determined plan of care for patients with a specific
condition.
Carer
Person who provides a substantial amount of care on a regular
basis, and is not employed to do so by an agency or
organisation. Carers are usually friends or relatives looking
after someone at home who is elderly, ill or disabled.
Commissioning
The processes local authorities and primary care trusts (PCTs)
undertake to make sure that services funded by them meet the
needs of the patient.
Community health
services
Local services provided outside a hospital. Many community
staff are attached to GP practices and to health centres.
Council of Governors
Every NHS foundation trust will have a Council of Governors
which is responsible for representing the interests of the NHS
foundation trust members, and partner organisations in the
local health economy in the governance of the NHS foundation
trust. The Council of Governors holds the Foundation Trust
Board to account
CQC
(Care Quality Commission)
The independent regulator of health and social care.
Foundation trusts
NHS organisations that are run as independent, public benefit
corporations, which are both controlled and run locally to
provide a patient-led NHS service. Foundation trusts are
independent from central government and are authorised and
monitored by a sector regulator, Monitor. They have a
governance structure that ensures participation from within the
local communities they serve.
Freedom of
Information Act (FOI)
Government act which gives a general right of access to all
types of recorded information held by public authorities.
GP (General practioner)
A doctor who is qualified to treat a broad range of patients
with varying medical problems.
Infection control
The practices used to prevent the spread of communicable
diseases.
Integrated care
Health responsibilities between the NHS, local authorities
and other agencies or providers which are managed together
so that care trusts can offer a more efficient and better
integrated service.
KSF
(Knowledge and
Skills Framework)
A framework for personal and professional development
describing core and optional competencies necessary for a
particular role or post and which support the job description.
The NHS KSF process involves managers working with individual
members of staff to plan their training and development.
LINks
Local Involvement Networks are individuals and groups from
across the community who are funded and supported to review
and inform local health and social care services.
Mental health trust
Trusts that provide specialist mental health services in hospitals
and local communities.
Monitor
The independent regulator of NHS foundation trusts that is
responsible for authorising, monitoring and regulating them.
National Institute for
Health and Clinical
Excellence (NICE)
Independent organisation that provides national guidance on
the promotion of good health and the prevention and
treatment of ill health.
Operating framework
A Department of Health document which defines a way that
the NHS system will be managed, incentivised and controlled
over a given period.
Patient and public
involvement
Involving the public in shaping a care system’s development,
and keeping patients well informed of clinical processes and
decisions.
Patient safety
Long term strategy for ensuring patient safety in all healthcare
settings.
Payment by Results (PbR)
Transparent rules based system that sets fixed prices (a tariff)
for clinical procedures and activity in the NHS, enabling all
trusts to be paid the same for equivalent work.
Primary care
The collective term for all services which are people’s first point
of contact with the NHS, eg GPs, dentists.
Primary care trusts (PCTs)
NHS bodies with responsibility for commissioning health care
services and health improvements in their local areas.
Procurement
Any organisation's commissioning and purchasing process.
Public health
Public health is concerned with improving the health of the
population rather than treating the diseases of individual
patients.
Risk Register
A document that records risks to the achievement of an
objective, service or project and identifies the actions in place
to reduce the likelihood of the risk.
Secondary care
The collective term for services to which a patient is referred.
Typically this refers to an NHS hospital but would also include
referral to some community mental health services, all of which
would offer specialist medical services and care.
Service users
Anyone who uses, requests, applies for or benefits from health
or local authority services.
Single Equality Scheme
Scheme that represents public commitment to meet the duties
placed on it by equality legislation.
Social care
The range of service available through local authority provision,
which runs along side health provision, and supports vulnerable
people in society at the point of need.
Social enterprise
Businesses with primarily social objectives that reinvest their
profits into the community.
Stakeholders
A wide range of people or organisations that all share an
interest in a particular area of work, including patients and the
public, local authorities and social care providers, charities, and
the voluntary and community sector.
Strategic Health Authority
(SHA)
The local headquarters of the NHS, responsible for ensuring
that national priorities are integrated into local plans, and that
primary care trusts (PCTs) are performing well.
Substance misuse
The misuse of illegal drugs and legal pharmaceuticals.
System of Internal Control
The monitoring process used to assess the quality of the
mechanisms in place to control or mitigate the risks to
achievement of objectives or service delivery.
The Trust
Lancashire Care NHS Foundation Trust
Third sector
Non public private organisations that are motivated by a desire
to further social, environmental or cultural objectives rather
than to make a profit.
Lancashire Care NHS Foundation Trust,
Sceptre Point,
Sceptre Way,
Walton Summit,
Bamber Bridge,
Preston PR5 6AW
www.lancashirecare.nhs.uk
D2503 DIMENSION-CREATIVE.CO.UK
Tel: 01772 695300
e-mail: lct.enquiries@lancashirecare.nhs.uk
www.lancashirecare.nhs.uk