2011/12
CONTENTS
Section
2
Title
Page
1
PART ONE
1.1
Introduction and statement on quality by Chief Executive and Chairman
3
1.2
Statement by Medical Director – executive lead for quality
4
1.3
Our vision, values, strategy and services
5
2
PART TWO
2.1
Priorities for improvement 2012/13
7
2.2
Statements of assurance from the Board
11
2.2.1
Review of services
11
2.2.2
Participation in clinical audits
11
2.2.3
Research and development
23
2.2.4
2011/12 CQUIN goals
23
2.2.5
Care Quality Commission
24
2.2.6
Data quality
25
3
PART THREE
3.1
Review of quality performance 2011/12
27
3.2
Consultation process
29
3.3
External perspectives on quality of service
30
4
Signposts and further information
35
5
Glossary
36
6
Appendices
41
PART ONE
1.1
INTRODUCTION AND STATEMENT ON
QUALITY BY CHIEF EXECUTIVE AND CHAIRMAN
We are delighted to present, on behalf of the Trust Board, the Mersey Care NHS Trust Quality
Account for 2011/12. This provides details of how we have improved the quality of care we provide,
particularly in the priority areas we set out in our previous Quality Account (2010/11). The purpose
of our Quality Account is to:
• Enhance our accountability to our service users, carers, the public and other stakeholders of our
quality improvement agenda
• Enable us to demonstrate what improvement we have made and what we plan to make
• Provide information about the quality of our services
• Show how we involve, and respond to feedback from, our service users, carers and others
• Ensure we review our services, decide and demonstrate where we are doing well, but also where
improvement is required.
We continue to make quality the defining principle in the Trust and demonstrate quality
improvements in the care and services we provide. To assist us in determining our priorities for
quality improvement for 2012/13, a range of engagement events were held with staff, service
users, carers and key stakeholders. These events have strengthened our approach to providing a
high quality experience of care which is both safe and effective. We will remain open and
transparent about what we can, and will do, to improve quality and by involving other
stakeholders we will find ways to work differently and more productively.
We acknowledge the concern of our stakeholders in the prevailing economic circumstances and
will continue to deliver improvements in quality whilst increasing value. This remains the principle
objective of the Trust. We acknowledge the work of the Quality Steering Group over the past
year, which involved service users and carers and which stimulated effective consultation and
engagement.
None of the improvements described could have been delivered without the commitment of our
staff and the involvement of service users and carers in the work that we do. Through
collaboration, learning and sharing knowledge and experience, we have achieved real
improvements in the way we deliver care. A number of these improvements are demonstrated in
the results from the National Patient and Staff Surveys. Our improvement is also recognised by the
various regulators responsible for assessing the Trust’s performance against a range of quality
measures.
As we move towards becoming a Foundation Trust we are especially proud of our new Members
Council and the contribution to be made by all who have a stake in helping us improve our quality.
We invite you to come and join us as a member of the Trust and be part of our campaign to deliver
better mental health.
Please go to https://secure.membra.co.uk/MerseyCareApplicationForm/
for an application form.
We hope that you find our Quality Account helpful and informative. The information supporting
the content of the Quality Account is to our knowledge accurate and will be published by the
Board on 30th June 2012.
On behalf of the Board:
Beatrice Fraenkel - Chairman
Alan Yates - Chief Executive
3
1.2
STATEMENT BY MEDICAL DIRECTOR – EXECUTIVE LEAD FOR QUALITY
The Trust Board has a statutory duty of quality and is responsible for the quality of care delivered
across all services that Mersey Care NHS Trust provides. The Trust recognises that people come
into Mersey Care at times of great distress, anxiety and confusion and for some this involves a
restriction of their liberty. Mersey Care aspires to help each person live the fullest life possible,
embracing a recovery focused approach. The Trust works with individuals to understand their
experiences, explore the meaning of their difficulties and help find ways to change or cope better.
Positive, collaborative and respectful working relationships are fundamental to these activities.
Mersey Care’s Quality Strategy was approved by the Trust Board a year ago. This confirmed that
quality was the organising principle of the Trust’s overriding strategy, and it supported the vision
for quality, which is expressed as:
• valuing the individual
• using a holistic and recovery model
• based upon the human rights principles of fairness, respect, equality, dignity and autonomy
• delivering an excellent experience of care which is both safe and effective.
As the Board member leading the development and delivery of the Trust’s Quality Strategy and
Quality Account, I have ensured that careful consideration has been taken of the feedback sought
during the past year. I have also led a Quality Steering Group to oversee quality improvements in
the priority areas and details are included in this Quality Account. This has enabled the Trust to
develop better understanding of the needs of those who use our services and to provide a high
quality service.
I look forward to working with service users, carers, staff and other stakeholders in delivering
improvements in quality over the next year.
Dr David Fearnley - Medical Director
4
1.3
OUR VISION, VALUES, STRATEGY AND SERVICES
Mersey Care NHS Trust is a specialist provider of adult mental health, substance misuse and
learning disability services. We provide services to individuals with acute, severe and enduring
mental health, learning disability and substance misuse needs. We are one of only three
organisations nationally providing high secure services.
We provide services to three overlapping health and social care economies:
• Liverpool, Sefton and Knowsley (predominantly Kirkby) for local services
• Cheshire and Merseyside for low and medium secure services
• The North West of England, Wales and West Midlands for high secure services.
The population and communities we serve are diverse. There are variations in age, ethnicity, social
deprivation and health needs.
Our vision is to be recognised as a leading organisation in the provision of adult mental health,
substance misuse and learning disability service that has at its heart health and wellbeing. This
vision is underpinned by our core values of rights, respect and responsibility.
We aim to realise this vision through the Trust Strategy whose aims are:
• To improve the quality and increase the value of services
• To enhance partnership arrangements to deliver a better range of integrated services
• To consolidate, develop and expand the range of services provided
• To become a better organisation by building on our involvement with stakeholders and
strengthening governance.
In July 2009, we introduced a new management and leadership structure, Clinical Business Units
(CBUs). Clinical Business Units were introduced to strengthen leadership, devolve decision making
and strengthen clinical engagement in the management, planning and delivery of services. There
are six CBUs and a further grouping of support services under the heading Specialist Management
Services (SMS). The six CBUs are:
• Addictions CBU
• High Secure CBU
• Liverpool CBU
• Positive Care Partnerships CBU
• Rebuild CBU
• SaFE Partnerships CBU
Each CBU has a Clinical Director and a Service Director responsible for clinical and service
leadership and management of a delegated budget. A summary of the care services provided by
each CBU is contained in Appendix 1 (P41).
5
“Good being seen
by NMP
rather than waiting
for a doctor...”
NMP: non-medical prescriber
6
PART TWO
2.1
PRIORITIES FOR IMPROVEMENT 2012/13
In preparation for our Quality Account for
2011/12 the Trust has undertaken a process of
involvement and engagement with key
stakeholders to establish their views on what
our key priorities should be. Representatives
from the following groups have been involved
and invited to provide views on our priorities
and the draft quality account:
After consultation and discussion with the Trust
Board the areas of quality improvement for
2012/13 will be to:
• Local Involvement Networks (LINk) for
Liverpool, Sefton and Knowsley
• Promote harm free care through the use of
the National ‘Safety Thermometer’ and
continued analysis of incidents and
complaints
• Local Overview and Scrutiny Committees
• NHS Merseyside
• Mersey Care NHS Trust Members Council
• Local service user groups
• Trust Executive Team
• The Quality Steering Group
• Trust Board
In addition to receiving views from the above,
the Quality Steering Group has considered
suggestions for quality improvement priorities
and has decided that it would be beneficial to
have new priorities linked to the three main
elements of quality:
• Patient safety
• Clinical effectiveness
• Patient experience
Lots of ideas and thoughts were shared, not
just by staff and the Quality Steering Group,
but by service users, the LINk and other
stakeholders and these have all been given due
consideration.
• Improve access to services, especially at
times of crisis, and for psychological therapy,
by clinical audits of current access and the
availability of evidence based interventions
• Develop a Quality Dashboard for use at
individual, team, CBU and Board level. This
will include the measures for harm free care,
patient experience and effectiveness, and
gather key quality metrics for wide
dissemination and learning
• Review progress of care clustering as part of
Payment by Results (PbR) for mental health,
focussing on transition between clusters, and
care pathways for recovery and co-existing
physical health needs
• Set up ‘Mersey Care AQuA’ as a successor to
the Quality Steering Group, to help stimulate
a quality improvement culture
• Quality reviews of cost improvement plans
to be held with CBU directors and Specialist
Management Services managers at the
extended executive team meetings
in 2012/13.
The above priorities are all linked to the Trust’s
Quality Strategy and ensure the areas of safety,
clinical effectiveness and patient experience
remain at the top of our agenda.
7
Linked to the Trust’s areas of quality improvement for 2012/13 are the national and local CQUINs
(the Commissioning for Quality and Innovation payment framework) for local services, which for
2012/13 are listed below:
NATIONAL
1
4.1.2 Discharge Summaries
• 95% of discharge summaries to contain
the recommended Clinical Reference
Group (CRG) minimum data set
NHS Safety Thermometer
Improve collection of data in relation to
pressure ulcers, falls, urinary tract
infection in those with a catheter, and
venous thromboembolism.
• 95% of discharge summaries to be
typed and faxed to the patient’s GP
within 48 hours
This CQUIN will require monthly surveying
of all patients (as defined in the NHS
Safety Thermometer guidance) to collect
data on four outcomes (pressure ulcers,
falls, urinary tract infection in patients
with catheters and venous
thromboembolism).
• Full discharge letter to be sent to GP
within 10 working days of discharge
(excluding bank holidays)
• 95% of all patients to be sent a copy of
their discharge summary within 48
hours
A completed Safety Thermometer survey
for all relevant patients must be included
for each month in the relevant quarter’s
submission to trigger payment.
REGIONAL
2
• 95% of patients discharged from
inpatients to be prescribed an
appropriate supply of medication.
4.2.1 Outpatient Communication –
Changes in medication.
Advancing Quality
• 97% of changes to be notified to GP via
a typed fax within 48 hours
Compliance and improvement in the
performance of the key measures for each
of the clinical areas identified below:
• Those who require urgent change in
medication will have prescribing
arranged by the Trust.
Dementia
Psychosis
LOCAL
3
Communication
4.1.1 Improve Inpatient Communication
• Estimated date of discharge discussed
within seven days for 97% of admissions
8
• 97% of first clinic/outpatient letters to
contain agreed level of
information/data set
Patient Experience
Patient experience surveys to be
undertaken in inpatient, older adult
community mental health teams and
assertive outreach teams (additional to
the services included within 11/12).
Services to achieve the national
requirements of “Improving
responsiveness to the personal needs of
patients.”
4
4.2.2 Outpatient Communication –
clinic/outpatient letters
• 97% of outpatient/clinic letters to be
typed and faxed to patient’s GP within
10 working days.
4.3
Submission of implementation plan to
support the full transition from paper to
electronic transmission of discharge
summaries.
5
Access
5.1
Improved access for mental health clinical
advice for GPs from senior clinical
staff/consultant psychiatrists
• GPs to have access to a telephone
advice line, Monday to Friday excluding
bank holidays. Advice line to be
available 3 hours per day. Advice line
will be accessed via one telephone
number made available and widely
publicised to GPs.
5.2 Response times
• 97% of assessments in A&E to
commence within 2 hours for urgent
referrals
• 97% of assessments to commence in 24
hours for home treatment interventions
7
7.1.1 97% of all inpatients who are prescribed
antipsychotic medication will have
clinical interventions as appropriate.
7.1.2 All inpatients who are prescribed
medication listed will receive screening
and health promotion/brief advice relating
to alcohol consumption screening, weight
reduction, smoking cessation, sexual
health and substance misuse as
appropriate.
7.2
• 97% of primary care referrals will be
triaged and discussed on the day of
receipt.
• Each practice will be allocated a
relationship manager for secondary
mental health services
• Attempt to support those individuals to
have the annual health check in primary
care
• An updated information pack will be
developed for each GP. Contents to be
agreed with Clinical Commissioning
Group leads
• Where this is not possible the Trust will
make arrangements for the annual
health check to be undertaken via
alternative means
• A GP satisfaction survey will be carried
out. Content will be agreed with Clinical
Commissioning Groups. An action plan
to be developed based on the findings
of the survey
6
Dementia
6.1.1 97% of carers of people who have been
newly diagnosed with dementia will have a
preliminary assessment of their needs.
6.1.2 97% of service user assessments and
letters will have a statement of their
carer’s needs.
6.1.3 97% of all identified carers will be offered
a carer assessment and/or directed to
social care for assessment for carers
support/breaks.
6.2 97% of people newly diagnosed with
dementia and their carers will be referred
to a post diagnostic support group or
equivalent.
To improve the physical health of
outpatients who are prescribed antipsychotic medication and are on Care
Programme Approach (CPA)
• Validate primary care Severe Mental
Illness (SMI) Registers to identify any
shared patients for whom GPs have
been unable to undertake an annual
health check
5.3 Contact and information for practices
• Relationship manager to visit each
practice quarterly.
Physical Health
To improve the physical health of people
who are prescribed antipsychotic
medication
• 97% of patients who are on CPA and
antipsychotic medication to have an
annual assessment and profiling of side
effects.
7.3
People with a learning disability under the
care of specialist mental health services
• 97% of all individuals with a diagnosed
learning disability will have the required
clinical interventions
• 97% of all those who have a learning
disability will receive screening and
appropriate health promotion/brief
advice
• Where the individual has a diagnosis of
learning disability the Trust will support
the individual to attend primary care for
their annual health check
• If the individual is not willing to engage
with primary care for their annual health
check the Trust will undertake clinical
interventions as appropriate and offer
brief advice and share the results with
their GP.
9
“The staff always were
sensitive, caring and
provided adequately
the information
required...”
10
2.2
STATEMENTS OF ASSURANCE FROM THE BOARD
2.2.1 REVIEW OF SERVICES
During 2011/12 Mersey Care NHS Trust provided and/or subcontracted forty-two NHS services.
Mersey Care has reviewed all the data available and the quality of care in all of these 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 Mersey Care NHS Trust for 2011/12.
2.2.2 PARTICIPATION IN NATIONAL AND LOCAL CLINICAL AUDITS AND NATIONAL
CONFIDENTIAL ENQUIRIES
The Trust has a strategy for clinical audit based on “Clinical Audit: A Simple Guide for NHS Boards
and Partners (HQIP January 2010) which recognises:
• The importance of incorporating clinical audit throughout the organisation as a systematic tool
to address issues which arise about the quality of care which are of strategic importance
• How clinical audit can be used to improve the performance of the Trust and to meet its strategic
objectives.
An annual programme of Clinical Audit is approved by the Integrated Governance Committee on
behalf of the Trust Board to ensure its relevance to Board strategic interests and concerns. The
Clinical Audit Group ensures that results are turned into action plans, implemented and re-audits
are scheduled.
NATIONAL CLINICAL AUDITS
During 2011/12 Mersey Care NHS Trust participated in four (100%) National Clinical Audits in which
it was eligible to participate.
1. Prescribing in Mental Health Services (POMH)
2. National Clinical Audit of Schizophrenia
3. National Clinical Audit of Psychological Therapies
4. National Clinical Audit of Falls and Bone Health.
NATIONAL CONFIDENTIAL ENQUIRIES
During 2011/12 Mersey Care NHS Trust participated in one (100%) National Confidential Enquiries
in which it was eligible to participate.
1. National Confidential Inquiry (NCI) into Suicide and Homicide by People with Mental Illness
(NCI/NCISH).
11
The table below details the number of cases submitted to each audit or enquiry for which data
collection was completed during 2011/12 as a percentage of the number of registered cases
required by the terms of that audit or enquiry.
National Clinical Audits and National Confidential Enquiries that Mersey Care NHS
Trust was eligible to participate in 2011/12
Title
Number of cases
submitted
Percentage of number
of registered cases
• Monitoring of patients prescribed
Lithium
17
100%
• Assessment of the side effects of
depot antipsychotics
43
100%
• Prescribing antipsychotic medication
for people with dementia
29
100%
National clinical audit of Schizophrenia
Consultant: 72
72%
Patient: 39
19.5%
Carer: 21
10.5%
17
100%
Prescribing in mental health services:
National confidential enquiry (NCI)
into suicide and homicide by people
with mental illness (NCI/NCISH)
NATIONAL CLINICAL AUDIT REPORTS RECEIVED
The full report of the National Clinical Audit of Psychological Therapies was published in
November 2011. The report was shared with the Heads of Service (Psychology) and the
Psychological Practice Group for consideration of the development of action plans.
The full report of the National Clinical Audit of Falls and Bone Health was published in May 2011.
The report was shared with Business Unit Managers and Trust Wide. An action plan was developed
and the Physiotherapy Department given responsibility for monitoring the implementation.
LOCAL CLINICAL AUDIT
The reports of six local clinical audits were reviewed in 2011/12 by Mersey Care NHS Trust:
a) Schizophrenia
b) Bipolar
c) Care Programme Approach
d) Supervision of clinical practice
e) Handling medicines
f) Record keeping (health records).
12
A) SCHIZOPHRENIA
AIM
The aim of the audit was to monitor compliance with NICE (National Institute for health and
Clinical Effectiveness) clinical guideline 82, Schizophrenia, for patients accessing treatment within
High Secure Services, Liverpool, Positive Care Partnerships and Rebuild CBUs.
RESULTS
OBJECTIVES/STANDARDS
The audit results illustrate variations between the
levels of compliance between the CBUs.
The objectives of the audit align to
aspects of the guidance.
0
10 20 30 40 50 60 70 80 90 100
1.
Ethnicity
2.
Family Intervention
3.
Cognitive Behavioural Therapy
(CBT)
4.
Information
one
two
three
four
0
5.
Occupational Needs
Physical Health Checks
7.
Joint Decisions (Antipsychotic
Medication)
8.
Monitoring Progress
Use of Depots
40
one
6.
9.
20
two
three
10. Antipsychotic Medication
four
11. Treatment Resistant Schizophrenia
five
12. Advance Directives / Statement
five
six
six
High Secure Services
seven
Liverpool seven
eight
eleven
eight
Positive Care Partnerships
nine
Rebuild
ten
twelve
eleven
nine
ten
GOOD PRACTICE OBSERVED
• People are provided with information regarding the benefits and side effects of antipsychotic
medication
• Changes in symptoms and behaviour, including side effects, are monitored
• Use of depot antipsychotic medication is considered
• Combined antipsychotic medication is not initiated except for short periods.
ACTIONS TO IMPROVE QUALITY
The audit highlighted a resource gap with regard to psychological services available within the
Trust; leading to further work to measure the gap in service provision, which will lead to a cost and
benefit analysis during evaluation.
13
B) BIPOLAR
AIM
The aim of the audit was to monitor the management and treatment of bipolar disorder against
national guidelines.
RESULTS
OBJECTIVES/STANDARDS
The audit results illustrate variations between the
levels of compliance between the CBUs.
The objectives of the audit align to
aspects of the guidance.
1.
0
20
40
60
80
100
2.
one
two
three
four
five
Valproate is not being prescribed
routinely for women of childbearing
0
age.
20
Lithium, olanzapine and valproate
should be considered for long-term
treatment of bipolar disorder.
one
3.
Monitoring of Lithium Levels
4.
Monitoring of Side Effects
5.
Monitoring of Blood Levels
6.
Monitoring of Clinical State
7.
Benefits of Medication
8.
Risks of Medication
9.
If a patient is taking an
antidepressant at the onset of an
acute manic episode, the
antidepressant should be stopped.
two
10. There should be an annual health
review.
six
three
11. Psychological therapy is offered
after an acute episode.
seven
Liverpool
four
Positive Care Partnerships
eight
nine
ten
SaFE
five
eleven
GOOD PRACTICE OBSERVED
• Lithium, Olanzapine and Valproate are considered for long-term treatment
• A patient’s clinical state is monitored
• Side effects are monitored.
ACTIONS TO IMPROVE QUALITY
A new form titled ‘Consent to Treatment Discussion’ has been developed and is completed by the
Responsible Clinician to ensure that the benefits of medication are discussed with the patient.
14
40
6
C) CARE PROGRAMME APPROACH: KEY PERFORMANCE INDICATORS (KPI)
AIM
The aim of the audit was to assess staff knowledge in relation to the Care Programme Approach
and Key Performance Indicators to allow the CPA forum/lead to address issues raised in why areas
of the Care Programme Approach are not being completed.
RESULTS
OBJECTIVES/STANDARDS
The audit results illustrate the level of compliance.
The objectives of the audit were agreed
by the CPA Audit sub-group.
0
20
40
60
one
two
80
1.
Staff must collect information
regarding Accommodation Status.
2.
Staff must collect information
regarding Employment Status.
3.
Staff must collect information
regarding HoNOS.
4.
Staff must collect information
regarding PbR Clustering.
5.
Staff must collect information
regarding service users on CPA and
information relating to 12 monthly
CPA reviews.
100
0
20
40
60
one
two
three
2011
four
three
five
six
four
seven
eight
five
GOOD PRACTICE OBSERVED
• Information is being collected by staff regarding Health of the Nation Outcome Scores
(HoNOS) scoring
• Information is being collected by staff in order to undertake Care Programme Approach reviews.
ACTIONS TO IMPROVE QUALITY
The audit results will be considered to assist the review of the Care Programme Approach process
and system used within the Trust, including the revision of documentation used.
15
D) SUPERVISION OF CLINICAL PRACTICE
AIM
The aims of the audit were to monitor compliance with Trust Policy SD33, Supervision Policy,
regarding access to supervision and related issues, and monitor any improvement in practice since
the initial audit of this topic undertaken in 2009.
RESULTS
OBJECTIVES/STANDARDS
The audit results illustrate the level of compliance.
The objectives of the audit align to
aspects of the guidance.
0
20
40
60
80
100
1.
A Clinical Supervision Agreement
document is completed.
2.
A supervision recording form is
completed during supervision
sessions.
3.
Supervision of clinical practice takes
place during the working week.
4.
Staff prepare themselves prior to a
supervision session.
5.
Any actions are agreed during a
supervision session.
6.
Any actions are incorporated into
staff Personal Development Plans.
7.
Encouragement is given to reflect on
practice issues, practice skills and
current knowledge.
one
one
two
three
two
three
four
five
four
8.
Clinical Supervision should enhance
career development and life long
learning.
six
seven
five
2009
six
2011
eight
nine
ten
seven
eleven
eight
twelve
thirteen
fourteen
GOOD PRACTICE OBSERVED
The results showed an improvement in all standards since the first cycle.
ACTIONS TO IMPROVE QUALITY
Staff will continue to incorporate actions agreed during supervision into Personal Development
Plans.
16
0
20
40
E) HANDLING MEDICINES
AIM
The aim of this re audit was to monitor the compliance of Trust Policy SD12, Policy and Procedure
for the Handling of Medicines, across Mersey Care NHS Trust and highlight improvements to
practice following the implementation of recommendations made from the initial audit.
RESULTS
OBJECTIVES/STANDARDS
The audit results illustrate the level of compliance.
The objectives of the audit align to aspects of
the guidance.
0
20
40
60
80
100
1.
Medicines are kept in a locked cupboard
0
or lockable medicines trolley.
one
2.
Medicine trolleys are only removed from
their fixings during medicine rounds.
two
3.
The nurse in charge holds the keys for the
medicine cupboard and trolleys.
4.
Keys for the medicine cupboard and
trolley never leave the ward nor left
unattended.
5.
Pharmacy staff to visit the ward on a
three monthly basis to undertake an
inspection of storage, security and safety
of medicines.
6.
Internal and external preparations are
segregated.
7.
Medicines stored in the refrigerator are
stored between 2˚C and 8˚C.
8.
The medicine fridge is locked.
9.
Food and drink is not stored in the
medicine fridge.
three
four
five
six
20
40
one
two
seven
eight
10. The disinfectant cupboard is used for
preparations which are not used for
service users, for example Virkon.
nine
11. The reagents cupboard is used to store
urine testing strips, blood testing strips
and litmus paper.
ten
12. Sterile fluids for infusion and irrigation are
stored in a designated area on the ward.
three
eleven
13. Stock is rotated.
twelve
14. Ward stock does not include
concentrated or diluted potassium
chloride.
thirteen
fourteen
Addictions
High Secure Services
GOOD PRACTICE OBSERVED
Liverpool
High compliance was observed in most areas.
Positive Care Partnerships
ACTIONS TO IMPROVE QUALITY
Immediate actions were implemented during the
inspections / audit visits, including:
• Fridge locks were ordered to replace broken ones
Rebuild
SaFE
• Out of date stock was removed
• External stock was segregated and labelled.
17
F) RECORD KEEPING (HEALTH RECORDS)
AIM
The aim of the audit was to monitor the standard of record keeping of clinical health records by all
specialities against the requirements of the Information Governance (IG) Toolkit and Trust Policy.
RESULTS
OBJECTIVES/STANDARDS
The audit results illustrate the level of compliance
The objectives of the audit align to
aspects of the guidance.
0
20
40
60
80
100
one
1.
The record is meaningful and
relevant i.e. in plain English, factual
and jargon free.
2.
The record is keyed in as soon as
possible after an event has occurred.
3.
There is evidence that a care plan /
statement of care is discussed with
the service user.
Liverpool
Positive Care Partnerships
two
SaFE
three
GOOD PRACTICE OBSERVED
The audit results showed high compliance is all areas.
ACTIONS TO IMPROVE QUALITY
The Trust’s Health Records manager and Governance manager are in the process of developing a
list of generic abbreviations and terms used across professional groups which will be presented to
the Health Records Committee for consideration, with the intention to permit the use of frequent
and known abbreviations/terms.
18
THE CLINICAL AUDIT PROGRAMME 2011/12
The following table details a position statement of all clinical audits at the end of March 2012.
Title
Progress / Status
National Clinical
Audit Schizophrenia
The Royal College of Psychiatrists (RCPSYCH) completed data
cleansing in January 2012 and released the final response
rates for the Trust on 23 February 2012. The final responses
from Mersey Care for each of the three questionnaires was:
Consultants: 72 of a possible 100
Rating
GREEN
Service users: 39 of a possible 200
Carers: 21 of a possible 200
The RCPSYCH have not yet shared the expected date of
report publication.
National Clinical
Audit Psychological
Therapies
The full report from the National Audit of Psychological
Therapies (NAPT) was published in November 2011. A repeat
audit is scheduled for the end of 2012, which will enable
evaluation of improvements achieved by services.
National Clinical
Audit Falls and Bone
Health
An action plan was developed by the Governance Manager
and a representative of the Physiotherapy team in December
2011 to reflect the issues highlighted in the report produced
by the Royal College of Physicians. Implementation of actions
will be monitored by the physiotherapist.
GREEN
Annual Community
Patient Survey
The action plan developed by the Patient Survey Action Group
was approved by the Integrated Governance Committee in
January 2012. The Patient Survey Action Group will continue
to monitor the implementation of actions.
GREEN
NICE Quality
Standard: Dementia
The Clinical Audit Department completed data collection in
February 2012 on a small number of patients to benchmark
across the region. The results will be compared regionally in
April/May 2012. It is anticipated that the audit outcomes will
be presented to the Integrated Governance Committe (IGC) in
July 2012.
AMBER
NICE Quality
Standard: Depression
The clinical audit department completed data collection in
February 2012 on a small number of patients to benchmark
across the region. It is anticipated that the audit outcomes will
be presented to the IGC in May 2012.
AMBER
NICE Quality
Standard: Alcohol
This new quality standard is being discussed by the
Governance Lead for Addictions CBU and the clinical leads
within the service. It is anticipated that further work will be
included in the clinical audit programme for 2012/13.
AMBER
NICE Clinical
Governance:
Violence and
Aggression
High Secure Services are developing an action plan in March
2012 to identify areas for improvement following a recent
audit undertaken in the service. It is anticipated that the audit
outcomes will be presented to the IGC in May 2012.
NICE Clinical
Governance:
Falls
This topic is covered by involvement in the national clinical
audit of falls and bone health; no further work required.
GREEN
AMBER
GREEN
19
20
Title
Progress / Status
NICE Clinical
Governance:
Self Harm
NICE published new guidance on this in December 2011; which
will be benchmarked across relevant CBUs as part of the
2012/13 audit programme.
HoNOS
(Care Pathways):
SaFE Partnerships have recently completed a study/audit and
will be discussed within the CBU in the first instance. It is
anticipated that the audit outcomes will be presented to the
IGC in May 2012.
Rating
GREEN
AMBER
Safeguarding
(national guidance)
Mersey Internal Audit Agency (MIAA) have recently
undertaken a review of the progress made on the
recommendations from the 2010/11 audit and have given
significant assurance. No further work is required at this stage.
Clinical Supervision
(re-audit)
This audit was completed in October 2011. The outcomes were
presented to the IGC in January 2012.
Resuscitation
(re-audit)
This audit has been postponed due to changes in
accountability of resuscitation and identified revisions
required to the policy. This topic will be re-assessed for
priority and consideration for inclusion on the 2012/13 clinical
audit programme.
GREEN
Handling Medicines
(re-audit)
Data collection was completed in December 2011. A draft
report is due to be shared with CBUs at the end of March
2012. It is anticipated that the audit outcomes will be
presented to the IGC in May 2012.
AMBER
Detention
Documents (MHA)
The introduction of an EDMS (Electronic Document
Management System) invalidated the use of a previous audit
tool. This audit will be rewritten and included in the 2012/13
clinical audit programme.
GREEN
GREEN
GREEN
Consent to
Treatment Checklist
(MHA)
The introduction of an EDMS (Electronic Document
Management System) invalidated the use of a previous audit
tool. This audit will be rewritten and included in the 2012/13
clinical audit programme.
Care Programme
Approach: Key
Performance
Indicators
The audit outcomes were presented to the IGC in January
2012. Further work will be included in the 2012/13 clinical
audit programme.
GREEN
Care Programme
Approach:
Outpatients
The results were discussed with the Trust’s lead for CPA in
February 2012. Further work will be included in the 2012/13
clinical audit programme.
GREEN
Care Programme
Approach: Early
interventions
The results were discussed with the Trust’s lead for CPA in
February 2012. Further work will be included in the 2012/13
clinical audit programme.
GREEN
GREEN
Title
Progress / Status
Care Programme
Approach: Community
Mental Health Team
The results were discussed with the Trust’s lead for CPA in
February 2012. Further work will be included in the 2012/13
clinical audit programme.
GREEN
Care Programme
Approach: Crisis
Resolution Home
Treatment
The results were discussed with the Trust’s lead for CPA in
February 2012. Further work will be included in the 2012/13
clinical audit programme.
GREEN
Suicide Prevention
(pilot audit)
The National Patient Safety Agency launched a toolkit for use
by Community Team Managers in December 2011. This, along
with the Ward Managers’ Toolkit, is being discussed with CBU
Governance Groups by the Governance Manager, supported
by the Director of Patient Safety between January and March
2012. Further work will be included in the 2012/13 clinical
audit programme.
AMBER
Management of
Clinical Risk
through Supportive
Observation (SD04)
This topic was added to the programme in October 2011;
however full details of the audit requirements were not
available. Therefore the topic is currently being re-assessed
for prioritisation and inclusion in the 2012/13 clinical audit
programme.
CQUIN target for
local services only:
Discharge Planning
This CQUIN target is reported via the Performance
Department on a quarterly basis and quarter three was
reported on in January 2012. Information relating to 82
discharges was reported on. The Trust’s target is 90%
compliance and the results highlighted two areas for concern:
• 19.48% of patients had an estimated date of discharge
within 7 days
Rating
GREEN
GREEN
• 40.24% of patients received a copy of the discharge
summary on the day of discharge.
Quarter four will be reported on in April 2012 by the
Performance Department.
Information
Governance Toolkit:
Record Keeping
Health Records
(re-audit)
Data collection was completed by the Clinical Audit
Department in January/February 2012. The report will be
developed in March and shared with the Trust’s Health
Records Manager in mid-March 2012. The report will then be
shared with CBUs for the development of action plans where
applicable. It is anticipated that the audit outcomes will be
presented to the IGC in May 2012.
AMBER
21
“ I am very happy
with the help and
care provided to me.
The mental health
nurse was extremely
helpful ...“
22
2.2.3
RESEARCH AND DEVELOPMENT
The number of patients recruited during 2011/2012 to participate in research approved by a
research ethics committee was 948 from 31 approved studies. In addition, 115 staff and a carer
participated in 11 studies. In the previous reporting period 2010/2011, 562 participants took part in
research compared to a total of 1064 this year (an 89% increase). Of these 1064 recruits, 690
were from NIHR adopted portfolio studies. The total number of open studies (including those not
yet recruiting, actively recruiting and in write up) increased from 66 last year to 73 in the current
reporting period (a 10.5% increase).
Trust participation in, and approval of, NIHR adopted portfolio studies has continued to improve.
We participated in 31 NIHR adopted studies throughout the reporting period, compared to 29 last
year. Improvement in recruitment and promotion has been sustained through the Clinical Studies
Officer, appointed in liaison with the Mental Health Research Network, through funding provided
from the Comprehensive Local Research Network. Our success has been recognised by the
agreement for funding of an additional Clinical Studies Officer next year. We continue to host two
members of staff from DeNDRoN, another of the six topic-specific Clinical Research Networks
funded by the Department of Health, which has supported our successful involvement in two of
their network adopted studies.
The Trust has been very successful in gaining a three year research funding bid, with Liverpool
John Moore’s University as our British partner, in a European wide project funded by INTERREG
IVB NWE which is a financial instrument of the European Union's Cohesion Policy and funds
projects which support transnational co-operation. Other partners in the project are from
academia and health in The Netherlands, Belgium and Germany. The bidding process was highly
competitive with only 13 projects, out of 39 applications, being approved. The research, entitled
Innovate Dementia, will look at innovation in relation to dementia. Our British partnership will take
a lead in nutrition and exercise as part of the wider European study. The project overall will focus
on business innovation in the various regions and bring health care, academia and technological
developments closer together to develop practical improvements in the care of dementia.
Participation in this study provides the Trust with a unique and exciting opportunity to develop
collaborations and initiatives with potential to have a positive impact on the services we deliver
across the Trust and beyond dementia services.
The Trust continues to support collaborative research initiatives and applications for external
funding with several of our academic partners, with the aim of increasing our involvement in
valuable, high quality, service lead, local and national priority research areas.
The Trust hosted a highly successful inaugural research conference in March, which showcased the
volume, quality and diversity of the research being undertaken. The event supported our capacity
to develop new collaborations and joint working initiatives with colleagues in academia and other
NHS establishments.
2.2.4 2011/12 CQUIN GOALS
In 2011/12 1.5% of Mersey Care NHS Trust income was conditional on achieving quality
improvement goals agreed between the Trust and its Commissioners, through the Commissioning
for Quality and Innovation (CQUIN) payment framework. The Trust was assigned three sets of
CQUIN indicators for 2011/12, relating to local services, low and medium secure services, and high
secure services. As at the end of March 2012, Mersey Care NHS Trust has achieved overall each set
of indicators in the CQUIN framework. Appendix 2 provides a summary of Local, Low and Medium
Secure and High Secure Services CQUIN Performance for 2011/12.
Further details of the agreed goals for 2011/12 are available electronically at
http://www.institute.nhs.uk/world_class_commissioning/pct_portal/cquin.html
23
2.2.5
CARE QUALITY COMMISSION
Mersey Care NHS Trust is required to register with the Care Quality Commission and its current
registration status is: ‘Registered without any improvement conditions’.
The CQC has not taken enforcement action against Mersey Care NHS Trust during 2011/12 and
Mersey Care NHS Trust has not participated in any special reviews or investigations by the CQC
during the reporting period.
The registration system of the CQC makes sure that people can expect services to meet essential
standards of quality and safety that respect their dignity and protect their rights. The system is
focused on outcomes and places at its centre the views and experiences of people who use
services. The outcomes are grouped into six key areas:
• Involvement and information
• Personalised care, treatment and support
• Safeguarding and safety
• Suitability of staffing
• Quality and management
• Suitability of management
Since October 2010 the Trust has received a monthly ‘Quality Risk Profile’ from the Care Quality
Commission. A Quality Risk Profile is a tool that brings together a wide range of information to
provide an estimate of the risk of potential non-compliance with the Essential Standards of Quality
and Safety defined by the CQC.
It is dynamic and updated over time as new data becomes available. Our Quality Risk Profile helps
the CQC make a judgement about our performance and supports the monitoring of quality
internally by identifying areas of lower than average performance to enable us to take targeted
action where necessary. It is carefully monitored on behalf of the Trust Board by the Integrated
Governance Committee in addition to monitoring of our internal assessment of compliance with
the essential standards.
At the end of the reporting period, the Quality Risk Profile indicates that Mersey Care NHS Trust
has no high risk of non-compliance with the Care Quality Commission Essential Standards for
Quality and Safety.
Mersey Care NHS Trust was subject to a Care Quality Commission inspection of the Star Unit in
October 2011 as part of a targeted inspection programme of hospitals and care homes that care
for people with learning disabilities. The inspection concluded that the Unit was meeting all the
essential standards of quality and safety that were reviewed and no recommendations were made.
Further information about the Care Quality Commission registration status of Mersey Care can be
found at:
http://caredirectory.cqc.org.uk/caredirectory/searchthecaredirectory.cfm?widCall1=customWidget
s.content_view_1&cit_id=RW4&element=REGISTER&page=1
24
2.2.6
DATA QUALITY
Good quality information underpins the effective delivery of patient care and is essential if
improvement in quality of care are to be made. Improving data quality, which includes the quality
of ethnicity and other equality data, will improve patient care and improve value for money.
Mersey Care will be taking the following actions to improve data quality:
• We will implement all recommendations from internal audit which provide us with assurance of
the quality of our data
• We will continue to develop and implement an annual cycle of data quality assurance audits
(facilitated by the Data Quality Team) and respond to the findings of those reports
appropriately.
Mersey Care submits records during 2011/12 to the Secondary Uses service for inclusion in the
Hospital Episode Statistics.
The percentage of records in the latest data which included the patient’s valid NHS number was:
99.7% for admitted patient care
99.1% for outpatient care.
The percentage of records in the latest data which included the patient’s valid General Medical
Practice Code was:
100% for admitted patient care
100% for outpatient care.
INFORMATION GOVERNANCE
The Mersey Care Information Governance Assessment report overall score for 2011/12 was 75% and
was graded ‘Green’ (satisfactory). This is a significant improvement on 2010/11 (which was 53%
and not satisfactory).
CLINICAL CODING ERROR RATE
Mersey Care NHS Trust was not subject to the Payment by Results clinical coding audit during
2011/12 by the Audit Commission
25
“I feel better
since this team
have been
involved.
Excellent service.”
26
PART THREE
3.1
REVIEW OF QUALITY PERFORMANCE 2011/12
In June 2011, the Trust published its second
year of Quality Accounts, reporting on the
quality of services in 2010/11 against three
areas of priority: improving the care pathway,
improving the patient environment and
improving stakeholder involvement. Following
extensive engagement with key stakeholders, it
was decided that within these three areas there
were the following seven specific areas on
which to focus quality improvement action:
KEY AREA OF IMPROVEMENT 2
• Health of the Nation Outcome Scales
Improvements Achieved:
• Cost Improvement Plans
• Review completed. Minor changes to
documentation agreed and implemented
Cost Improvement Plans
Aim: regular review and interrogation of cost
improvement plans using a quality focused
impact assessment tool will be undertaken to
identify potential risks to quality, and support
Clinical Business Units to improve quality and
ensure efficient care planning.
• Recovery, health and wellbeing approach
• Incidents and complaints
• Safeguarding
• Membership
• Quality development.
With the commitment and dedication of its
staff the Trust has made excellent progress in
all of these areas.
KEY AREA OF IMPROVEMENT 1
Health of the Nation Outcome Scales (HoNOS)
Aim: Health of the Nation Outcome Scales will
be recorded for all relevant service users,
analysed and used to ensure continual
improvement in defined outcomes. This process
will be linked to the Trust’s clinical audit
programme to ensure evidence based care
pathways are implemented.
• Initial list of indicators shared with Clinical
Business Units
• All Cost Improvement Plans have been
individually risk assessed for financial
deliverability and the impact on quality. The
key themes and risks have been shared and
discussed with all Clinical Business Units and
Specialist Management Services to assess the
interdependency of plans
• Summary Plans and confirmation of the risk
assessment and agreement of the Medical
Director and Executive Director of Nursing
presented to the Trust Board on 29 March
• There is agreement to repeat the sharing and
supportive challenge within the wider
executive meetings during 2012/13.
Improvements achieved:
Action plans to achieve targets were developed
by each Clinical Business Unit.
• Reports are now created on the electronic
portal (data warehouse)
• Weekly communications were issued Trust
wide
• Over 13,500 service users assigned
to a mental health cluster between
April/December 2011 – 98% of eligible
service users.
Clinical Business Units are analysing movement
between clusters and outcomes.
27
KEY AREA OF IMPROVEMENT 3
KEY AREA OF IMPROVEMENT 5
Recovery, health and wellbeing approach
Safeguarding
Aim: Development of a recovery, health and
wellbeing approach as part of the innovative
‘Implementing Recovery through
Organisational Change’ (ImROC) project which
will identify and share outcome measures
based upon ten areas of organisational change
that are thought to improve recovery (including
appropriate and timely access to physical
health care resulting in reduced levels of
morbidity for Trust service users).
Aim: Development of more effective
safeguarding services for children and adults
Improvements achieved:
• The ImROC project has continued to develop
strategy, co-production and personalised
care
• The ‘Launch Pad’, an emerging recovery
college, was recently started
• Service user co-workers are in place, with
each of the project leads to develop peer
support initiatives.
KEY AREA OF IMPROVEMENT 4
Incidents & Complaints
Aim: A rolling ‘Top 5’ programme will aim to
reduce the frequency of the three most
common types of incident, and two most
common types of complaint each year.
Evidence based guidance and clinical audit
outcomes will be used to produce monthly
reductions in incidents of violence and
aggression, falls and self harm. Complaints
about care and treatment and staff attitude
will be analysed and action plans developed
in response.
Improvements achieved:
• Assaults reduced by 19%, slips, trips and falls,
by 13%. Self-harm incidents rose slightly by
6% but the severity of harm fell. This work
has helped stimulate better reporting and
analysis of incidents
• The top two types of complaints have also
reduced. Training has taken place for staff
with the focus on these key areas of risk
• Psychiatric Intensive Care Unit assault figures
have reduced noticeably and working
methods have been amended.
28
Improvements achieved:
• Quality Reporting Processes for Safeguarding
Children and Vulnerable Adults
• Mersey Internal Audit: Significant Assurance
achieved in 2011-12
• Service user and carer leaflet developed.
Rebuild service users have agreed to assist in
development of easy read safeguarding
policies
• An unannounced inspection by the Care
Quality Commission in October 2011, which
was part of a national programme of
inspections, found that the STAR Unit,
Mossley Hill was compliant with the essential
standards of safety and quality in relation to
safeguarding (unlike the majority of Trusts
inspected so far, which had concerns noted).
KEY AREA OF IMPROVEMENT 6
Membership
Aim: Development of the membership and
governorship in preparation for Foundation
Trust authorisation.
Improvements Achieved:
• The Members Council was established in
January 2012 and has met for the first time
• The Trust achieved its target for recruiting
members – currently over 10,000 members.
KEY AREA OF IMPROVEMENT 7
Quality Development
Aim: Continuation of service user and carer
engagement in quality development, including
the Quality Account and Quality Strategy
(which will be developed in 2011/12), and
development of better measures of the
experience of care (e.g. Patient Reported
Outcome Measures and use of the patient
experience tracker system).
Improvements achieved:
• Service user representative member of the
Quality Steering Group
• Regular meetings with LINks
• Pilot surveys using the ‘Patient Experience
Tracker’ have taken place and there are now
24 devices in the Trust.
KEY ACHIEVEMENTS 2011/12
• Care Quality Commission unannounced visit
of the STAR Unit at Mossley Hill found the
unit to be fully compliant with the standards
assessed
• SaFE CBU has been successful in opening
Reed Lodge, a purpose built ten bedded
Step-Down facility, to expand the care
pathway based on our service user needs and
in line with commissioner intentions
• Successful implementation of the Healthy
Lifestyles Programme on two wards in High
Secure Services CBU, which resulted in
significant weight reduction and increased
uptake of physical activities. As a
consequence, the pilot will be further
extended over the coming year
• High Secure Services CBU achieved a 50%
reduction in seclusion and segregation
through shared multidisciplinary efforts,
underpinned by recovery principles, focusing
on enhanced training initiatives for all
clinicians and support for ward based nurses
• In Positive Care Partnerships CBU the team
from Newhall Community Mental Health Team
devised a unique colouring book, called ‘Our
Hospital’, which helps young children (three
to seven year olds) whose parents have
mental health problems. The project was
voted Winner of Winners in the Trust’s 2011
Positive Achievement Awards.
• All wards in Positive Care Partnerships CBU
have achieved AIMS (Accreditation for
Inpatient Mental health Services), with
Clarence Ward and the Park Unit achieving
accreditation as ‘Excellent’.
• The Memory Service in Liverpool CBU was
the first service nationally to be accredited
by the Royal College of Psychiatrists as
‘Excellent’ in 2010. The service has been reaccredited and retains its ‘Excellent’ status.
• In Liverpool CBU a new service started in
January 2012 aiming to improve the
management of physical health and
wellbeing for people with mental illness. The
service will incorporate existing health
promotion, screening, self management and
recovery initiatives.
3.2 CONSULTATION PROCESS
The Trust consulted in a number of ways in
preparing the accounts for publication. In line
with its statutory obligations it actively
engaged with service users and carers, LINks
groups and other stakeholders to obtain their
views about the quality of Mersey Care’s
services and our priorities for the future. This
was achieved through a number of planned
events that took place throughout the whole of
2011/12.
The Trust has regular quality review meetings
and performance reporting arrangements
established with its commissioners. The data
contained within the account had been subject
to ongoing commissioner scrutiny and has been
further reviewed and formally signed off as part
of the consultation. The draft account was also
shared with the Overview and Scrutiny
committees of the local authorities with an
invitation to provide any comments about the
accounts for inclusion prior to publication.
Internally, clinical leaders and their teams have
been heavily involved in reviewing our priorities
and collating the information contained in the
report to refine and profile any key issues prior
to consideration by the Trust Board.
Our final Quality Account has benefited greatly
from the feedback given by all of our
stakeholders through the consultation process
resulting in less ‘technical’ and more ‘user
friendly’ detail being included in the final
document.
29
3.3 EXTERNAL PERSPECTIVES ON QUALITY OF SERVICE
LIVERPOOL LINk
As in the previous two years Liverpool LINk welcomes the opportunity to comment on Mersey
Care’s Quality Account for 2011/12.
The document demonstrates a range of ways in which Mersey Care is committed to and working
towards delivering a quality service which puts service users and carers at the heart of its work.
We would particularly like to congratulate the Trust on the achievement of all its Commissioning
for Quality and Innovation (CQUIN) goals for 2011/12 and on the positive report on the STAR Unit
following an unannounced inspection by the Care Quality Commission. We are also delighted to
note the Trust’s attitude towards encouraging the reporting of incidents which has coincided with
a reduction in the incidents resulting in ‘harm’. We also believe that an investment in staff
wellbeing will lead to improvements in staff attitude, fewer complaints and a better quality of
environment for both service users and staff.
The Trust’s engagement with Liverpool LINk continues to improve year on year and we have been
particularly pleased with the quarterly meetings, at which the Trust’s Quality Steering Group has
fed back on progress towards quality priorities and actions being taken to meet quality goals. We
are also pleased that Trust staff are working towards closer integration of quality and equality
delivery as we believe these to be very closely linked. This is something that we would like to see
highlighted more clearly in the future.
Our relationship with the Liverpool Clinical Business Unit (CBU) continues to thrive and we have
particularly valued our inclusion in planning the upcoming changes at Windsor House, the design
of the TIME project and the potential impact of the Community Model of Care on Assertive
Outreach service users.
LINk visits to the Patient Appointment Centre, Access Team, Broadoak, the Eating Disorders
Service and the Psychiatric Intensive Care Unit (PICU) have allowed us to ask questions and see
quality services being delivered at first hand. We would now like to develop a similar relationship
with Positive Care Partnerships CBU in North Liverpool.
We believe the involvement of service users and the public in setting quality priorities has been
open and transparent, although there is always more work to be done in providing user-friendly
feedback on progress.
An area which could perhaps have been highlighted within this document is Mersey Care’s
innovative work with current and former service personnel.
We would also welcome more widespread and ongoing use of Patient Experience Trackers across
inpatient wards and community teams. A combination of standardised questions which could be
compared across CBUs/Teams with more specific/tailored ‘snapshot’ questions for each service
would be a valuable source of ‘real time’ feedback on quality.
TIM OSHINAIKE AND JOHN ROBERTS
LIVERPOOL LINk
30
SEFTON LINk
Sefton LINk would like to thank the Trust for their continued partnership work with the LINk over
the past 12 months. This response was completed following a review of the draft copy of the
Quality Account and from LINk members receiving a presentation.
Mersey Care NHS Trust has worked positively with us over the past 12 months and we are keen that
this continues over the coming year. More community focused work is taking place.
Quarterly meetings between the Trust and LINks have been held which provide updates on the
work and progress of the Trust’s Quality Steering Group. From these meetings, we have been
interested in the work of the Trust in developing 21 clusters with outcome measures to track
improvement as part of payment by results. This is an area we would like to work with the Trust on
over the coming year to ensure that community members are aware of this new initiative.
We have been involved in the Trust’s Neighbourhood Model of Care work and regularly attend the
project board for the new South Sefton Neighbourhood Centre project. Members are also starting
to become more involved in this work in relation to design aspects and access. Representatives
attended one of the LINks coffee mornings to share information about the changes to Waterloo
Day Hospital and answer questions from community members. This was received positively.
It would have been useful to see the work that the Trust has undertaken with military personnel
highlighted as this work is innovative and shows how the Trust is working within the community.
In a similar way it would have been useful for the Trust to highlight the assessment undertaken by
the Care Quality Commission as part of the Office for Standards in Education, Children’s Services
and Skills (OFSTED) children’s safeguarding inspection for which they were scored highly for their
contribution.
With reference to the clinical audit programme, we have highlighted to the Trust that where an
audit has not been able to take place or has been postponed then this should be noted within the
table rather than being given a ‘green’ rating.
The document is easy to read and understand and provides a good overview of the services
provided by the Trust. We raised the use of abbreviations throughout the document and we have
been informed by the Trust that full titles will be used throughout the document and the glossary
maintained. However without the statements from the Chief Executive, Chairman and Medical
Director it is hard to gain an understanding of Quality from a leadership perspective.
We look forward to our work with the Trust over the coming 12 months to ensure that local people
receive quality services.
KNOWSLEY LINk
Knowsley LINk welcomes the opportunity to provide this commentary in support of the Mersey
Care Quality Account for 2011/12. The Quality Account report was provided to LINks in a timely
manner and presented thoroughly during a question and answer session held in May.
Throughout the last 12 months Knowsley LINk has met regularly with Mersey Care members of
staff to discuss progress around Quality Accounts and the services provided. An opportunity was
also provided to have input to the priority setting activities for the Quality Account for the coming
12 months.
In reviewing the content of this account, Knowsley LINk members found the information to be
comprehensive and presented in detail. The achievements through the past year have been
effectively captured within the Quality Account. It is pleasing to see the use of innovative
methods to capture patient experience information through the Patient Experience Tracker
devices. It is hoped that the Trust utilises the views captured to demonstrate how changes in
services have been implemented based on the views captured through this activity.
The priorities identified for the coming year are challenging and focused around areas of quality
which are reflective of the views of LINks and community members. The priority to improve
access to services for people at crisis point is welcomed and as part of this work LINk would be
keen to see the Trust developing an understanding of the barriers that exist to accessing services.
31
2012 COMMISSIONING PCT STATEMENT
In line with the NHS (Quality Accounts) Regulations 2011, NHS Merseyside can confirm that we
have reviewed the information contained within the account checked this against data sources
where this is available to us, as part of existing contract/performance monitoring discussions and
is accurate in relation to the services provided. We have reviewed the content of the account and
can confirm that this complies with the prescribed information, form and content as set out by the
Department of Health.
As Director for Service Improvement and Executive Nurse for NHS Merseyside I believe that the
account represents a fair and balanced view of the 2011/12 progress that Mersey Care NHS Trust
has made against the identified quality standards. The Trust has complied with its contractual
obligations and has made good progress over the last year with evidence of improvements in key
quality and safety measures.
Mersey Care NHS Trust has taken positive steps to engage with patients, staff and stakeholders in
developing a comprehensive set of quality priorities and measures. NHS Merseyside has an
excellent relationship with the Trust and recognises their commitment to working closely with
Clinical Commissioning Group to ensure the ongoing delivery of high quality services.
NHS Merseyside is supportive of the process Mersey Care NHS Trust has taken to engage with
patients, staff and stakeholders in developing a set of quality priorities and measures for 2011/12
and applaud their continued commitment to improvement.
TRISH BENNETT
DIRECTOR OF SERVICE IMPROVEMENT & EXECUTIVE NURSE
NHS MERSEYSIDE
LIVERPOOL CLINICAL COMMISSIONING GROUP
NHS Liverpool Clinical Commissioning Group welcomes the opportunity to receive and comment
on Mersey Care NHS Trust Quality Account for 2011/12.
In preparation for the formal establishment of the CCG in April 2013, NHS Liverpool have led the
contractual arrangements over the past year and this account is consistent with reports received
and development of priorities for 2012/13.
It is clear to the CCG that Mersey Care NHS Trust has a clear commitment to quality improvement
and engagement with patients and staff. Clear progress has been made through the year.
We have established excellent working arrangements between the CCG and the Trust and look
forward to developing our relationship further over the coming years as we collaboratively seek to
improve health outcomes for the population of Liverpool.
DR. NADIM FAZLANI
CHAIR, LIVERPOOL CENTRAL LOCALITY
NHS LIVERPOOL CLINICAL COMMISSIONING GROUP
DR. SIMON BOWERS
CHAIR, LIVERPOOL MATCHWORKS LOCALITY
NHS LIVERPOOL CLINICAL COMMISSIONING GROUP
RAY GUY
CHAIR, LIVERPOOL NORTH LOCALITY
NHS LIVERPOOL CLINICAL COMMISSIONING GROUP
32
OVERVIEW AND SCRUTINY COMMITTEE (HEALTH & SOCIAL CARE)
The Committee received a presentation from Steve Bradbury, Head of Quality and Risk, Mersey
Care NHS Trust, on the Trust’s draft Quality Account for 2011/12, and the work of the Trust in
general.
The presentation outlined the following:
• The remit/work of the Trust;
• Clinical Business Units within the Trust;
• Priorities for 2011/12, including:
o Health of the Nation Outcome Scales;
o Cost Improvement Plans;
o Recovery, health and wellbeing approach;
o Incidents and complaints;
o Safeguarding;
o Membership;
o Quality development; and
• Priorities for 2012/13.
The Committee had previously been supplied with the full version of the Trust’s draft Quality
Account.
Mr. Bradbury also responded to members’ questions on the Account and general service provision.
RESOLVED
That the draft Quality Account for 2011/12 from Mersey Care NHS Trust be received.
33
“I could not have
come this far without
the support of the
nurses...”
34
4 SIGNPOSTS AND FURTHER INFORMATION
The Quality Account
Essential Standards of Quality and Safety
Further information about the content of this
Quality Account can be requested from the
Head of Quality & Risk:
CQC Guidance outlining the Essential
Standards of Quality and Safety can be found
at:
Steve Bradbury: 0151 471 2640
http://www.cqc.org.uk/public/what-arestandards/government-standards
Steve.bradbury@merseycare.nhs.uk
Trust Services
Further detail about the services delivered by
each CBU can be found at:
http://www.merseycare.nhs.uk/What_we_do/d
efault.aspx
Quality Strategy
A copy of our Quality Strategy can be
requested from the Head of Quality & Risk:
Steve Bradbury: 0151 471 2640
Steve.bradbury@merseycare.nhs.uk
ImROC (Implementing Recovery through
Organisational Change).
Further information about the ImROC project
can be found at:
http://www.centreformentalhealth.org.uk/recov
ery/supporting_recovery.aspx
Information Governance
Details of the Information Governance Toolkit
can be found at:
https://nww.igt.connectingforhealth.nhs.uk/abo
ut.aspx?tk=407133719719095&cb=08%3a55%3a
37&clnav=YES&lnv=5
Performance Reports
Copies of Trust Board Performance reports can
be requested from the Trust Secretary or
assessed via:
http://www.merseycare.nhs.uk/Who_we_are/Tr
ust_Board/Trust_Board_first_page.aspx
Service User Survey
A copy of the CQC Patient Survey Report of
2010 (Survey of people who use community
mental health services 2010) for Mersey Care
NHS Trust can be found at:
http://www.cqc.org.uk/survey/mentalhealth/R
W4
Health of the National Outcome Scales
Further information about HoNOS can be found
at:
http://www.rcpsych.ac.uk/training/honos/whati
shonos.aspx
Corporate and CBU specific developments
Further details of any of the corporate and or
CBU specific developments outlined in the
Quality Account can be requested from the
Trust Secretary.
Clinical Audit
A copy of the Trust’s Clinical Audit Strategy can
be requested from the Trust Secretary.
Clinical Audit: A simple Guide for NHS Boards
and Partners can be found at:
http://www.hqip.org.uk/assets/Dev-Team-andNJR-Uploads/HQIP-NHS-Boards-Clinical-AuditSimple-Guide-online1.pdf
35
5 GLOSSARY
Advancing Quality
Advancing Quality (AQ) is an innovative NHS quality programme
focused on enhancing standards in patient care. It aims to give patients
a better experience of health services, and ultimately, a better quality of
life.
AQuA
AQuA is a membership health improvement organisation. Its mission is
to stimulate innovation, spread best practice and support local
improvement in health and in the quality and productivity of health
services.
Care Quality
Commission (CQC)
The Care Quality Commission (CQC) is the independent regulator of all
health and adult social care in England. Its aim is to make sure better
care is provided for everyone, whether in hospital, in care homes, in
people’s own homes, or elsewhere.
Clinical Audit
The review of clinical performance against agreed standards
Clinical Business
Units (CBUs)
Structure of management and leadership across the Trust. Enable an
autonomous way of working in the delivery of clinical services and
decision making. Services are focused on improving quality and
increasing value enabling clinical staff close to the service to make
decisions about the future quality and efficiency of the service.
Commissioning for
Quality and Innovation
(CQUIN)
The CQUIN payment framework enables commissioners to reward
excellence, by linking a proportion of English healthcare providers'
income to the achievement of local quality improvement goals. The
framework aims to embed quality within the commissioner/provider
discussions and to create a culture of continuous quality improvement,
with stretching goals agreed on contracts on an annual basis.
Cost Improvement Plans
A plan which delivers the same or improved level of clinical or nonclinical service for a reduced cost.
Foundation Trust
NHS Foundation trusts are not-for-profit, public benefit corporations.
They are part of the NHS and provide over half of all NHS hospital and
mental health services.
NHS Foundation Trusts were created to devolve decision making from
central government to local organisations and communities. They
provide and develop healthcare according to core NHS principles - free
care, based on need and not ability to pay.
NHS Foundation Trusts can be more responsive to the needs and wishes
of their local communities – anyone who lives in the area, works for a
Foundation Trust, or has been a patient or service user there, can
become a member of the Trust. These members elect the board of
governors (see Members Council).
36
Health of the Nation
Outcome Scales
These are 12 simple scales on which service users with severe mental
illness are rated by clinical staff. The idea is that these ratings are
stored, and then repeated - say after a course of treatment or some
other intervention and then compared. If the ratings show a difference,
then that might mean that the service user's health or social status has
changed. They are therefore designed for repeated use, as their name
implies, as clinical outcomes measures.
Healthcare Quality
Improvement
Partnership (HQIP)
HQIP was established to promote quality in health services, and in
particular to increase the impact that clinical audit has in England and
Wales. It is led by a consortium of the Academy of Medical Royal
Colleges, the Royal College of Nursing and National Voices.
ImROC (Implementing
Recovery through
Organisational Change)
This project aims to test a methodology for organisational change in six
demonstration sites and help us improve the quality of our services to
support people more effectively to lead meaningful and productive
lives. The project provides an opportunity to demonstrate an innovative
approach to quality improvement and cultural change across
organisations. The project will assist us to undertake self-assessments
against ten indicators, plan changes and report our outcomes over two
years.
Information Governance
Assessment
The purpose of the Information Governance Assessment is to enable
organisations to measure their compliance against the law and central
guidance and to see whether information is handled correctly and
protected from unauthorised access, loss, damage and destruction.
Where partial or non-compliance is revealed, organisations must take
appropriate measures (e.g. assign responsibility, put in place policies,
procedures, processes and guidance for staff), with the aim of making
cultural changes and raising information governance standards through
year on year improvements. The ultimate aim is to demonstrate that the
organisation can be trusted to maintain the confidentiality and security
of personal information. This in turn increases public confidence that
‘the NHS’ and its partners can be trusted with personal data.
The Information Governance Toolkit is a performance tool produced by
the Department of Health (DH). It draws together the legal rules and
central guidance set out above and presents them in one place as a set
of information governance requirements we are then required to carry
out self-assessments of our compliance against the Information
Governance requirements.
Integrated Governance
Committee
This is a committee of the Trust Board. Fundamentally the Committee
exists to ensure that governance is effective. The Committee has
responsibility for the high level review of corporate and clinical
governance, including the Trust’s arrangements for the management
of risk.
37
Members Council
This is an advisory Committee of the Board. The Council will:
• Advise the Board on the longer term direction of the Trust; strategic
objectives and service development plans.
• Advise the Board on how to achieve and develop business
objectives consistent with the needs of members and the wider
community.
• Provide comment to the Board on any significant changes to the
delivery of the business plan.
• Act as guardians to ensure that the Board operates in a way that fits
with the statement of purpose.
38
National Confidential
Enquiry
The national confidential enquiry into suicide and homicide by people
with mental illness (NCI/NCISH) is a research project funded largely by
the National Patient Safety Agency (NPSA). The project examines all
incidences of suicide and homicide by people in contact with mental
health services in the UK as well as cases of sudden death in the
psychiatric inpatient population. The aim of the project is to improve
mental health services and to help reduce the risk of these tragedies
happening again in the future.
National Patient Survey
(Annual Service
Users Survey)
A survey co-ordinated by the Care Quality Commission that collects
feedback on the experiences of people using Mersey Care services. The
survey can be community or inpatient focused. The results are used in a
range of ways, including the assessment of Trust performance as well as
in regulatory activities.
Patient Experience
Tracker
A system that provides a simple and robust way of rapidly and
frequently capturing and analysing results from a large number of
service users without the need for paper based questionnaires and
analytical resources. It provides a benchmark for practice and
development of improvement strategies. The system consists of small,
portable mobile data capture units which are considered easy to use for
service users and staff which capture data for analysis and report
generation.
Payment by results
The aim of Payment by Results (PbR) is to provide a transparent, rulesbased system for paying trusts. It will reward efficiency, support patient
choice and diversity and encourage activity for sustainable waiting time
reductions. Payment will be linked to activity and adjusted for case mix.
Importantly, this system will ensure a fair and consistent basis for
hospital funding rather than being reliant principally on historic budgets
and the negotiating skills of individual managers.
PEAT (Patient
Environmental
Action Team)
An annual assessment of inpatient healthcare sites in England that have
more than ten beds. It is a benchmarking tool to ensure improvements
are made in the non-clinical aspects of patient care including
environment, food, privacy and dignity.
PROMs (Patient
Reported Outcome
Measures).
Patient choice over treatment and care is a central feature of the NHS.
Patients' experience of treatment and care is a major indicator of quality
and there has been a huge expansion in the development and application
of questionnaires, interview schedules and rating scales that measure
states of health and illness from the patient’s perspective. Patient
Reported Outcome Measures (PROMs) provide a means of gaining an
insight into the way patients perceive their health and the impact that
treatments or adjustments to lifestyle have on their quality of life. These
instruments can be completed by a patient or individual about
themselves, or by others on their behalf.
QIPP (Quality
Innovation
Productivity and
Prevention
Programme)
QIPP is a large scale transformational programme for the NHS involving
all NHS staff, patients and the voluntary sector. It aims to improve the
quality of care the NHS delivers whilst making up to £20 billion of
efficiency savings by 2014/15, which will be reinvested in frontline care.
There is a number of national work streams designed to support the NHS
to achieve the quality and productivity challenge. Some deal broadly
with the commissioning of care, for example covering long-term
conditions, or ensuring patients get the right care at the right time.
Others deal with how we run, staff and supply our organisations, e.g.
supporting NHS organisations to improve staff productivity, non-clinical
procurement, the use and procurement of medicines, and workforce.
Quality Steering Group
A working group whose fundamental purpose is to support the
development and implementation of the Quality Strategy and Quality
Account.
Research Governance
Committee
This is a sub-committee of the Trust Board that provides assurance to the
Trust Board (via the Integrated Governance Committee) that the Trust
fully complies with the requirements of the Department of Health’s
Research Governance Framework for Health and Social Care by
establishing and maintaining standards.
Safeguarding
The Government has defined the term ‘safeguarding children’ as: The
process of protecting children from abuse or neglect, preventing
impairment of their health and development, and ensuring they are
growing up in circumstances consistent with the provision of safe and
effective care that enables children to have optimum life chances and
enter adulthood successfully.
Safeguarding adults - the systems, processes and practices in place to:
ensure adequate awareness of issues about abuse of adults; ensure
priority is given to safeguarding people from abuse; help prevent people
experiencing abuse in the first place and recognise and act appropriately
when there are allegations of abuse and support the person who has
experienced abuse.
TIME project
TIME is short for: To Improve Mental health Environments.
Our primary aim is to provide high quality, modern, therapeutic mental
health environments in the communities where they are needed. We
believe these new facilities will provide the best mental health
environments in the country.
39
” I am getting th e
h elp and support
I need to mo ve
on in life ...”
40
6 APPENDICES
APPENDIX 1: SERVICES DELIVERED BY CLINICAL BUSINESS UNITS
CBU
Service
Speciality
High Secure Services
High secure services (mental health
and personality disorder inpatients)
High Secure
SaFE Partnerships
Addiction
Medium secure services (inpatient and community)
Medium Secure
Low Secure Unit (LSU) (inpatient and outreach)
Low Secure
HMP Liverpool Mental Health Inreach Team
Adult Mental Health
HMP Liverpool Primary Care Psychology Inreach
Psychological Services
HMP Altcourse CMHT Clinical Psychology Service
Psychological Services
Drugs Service (inpatient and community)
Addictions
HMP Liverpool Drug Dependency Unit (DDU)
Substance Misuse
Alcohol Service (inpatient and community)
Substance Misuse
Alcohol Services Knowsley (ASK)
Substance Misuse
Liverpool Community Alcohol Service (LCAS)
Positive Care
Partnerships (PCP)
Liverpool
Rebuild
Adult Mental Health Services (inpatient and community)
Adult Mental Health
Older Peoples Services (inpatient and community)
Older Peoples
A&E Mental Health Assessment and Liaison
Adult Mental Health
EMI Liaison
Older Peoples
Crisis Resolution and Home Treatment (CRHT)
Adult Mental Health
Assertive Outreach Team (AOT)
Adult Mental Health
Early Intervention in Psychosis (EIP)
Adult Mental Health
ADHD (Attention Deficit Hyperactivity Disorder)
Adult Mental Health
Perinatal Mental Health
Adult Mental Health
Adult Mental Health Services (inpatient and community)
Adult Mental Health
Psychiatric Intensive Care Unit (PICU)
Adult Mental Health
Older Peoples Services (inpatient and community)
Older Peoples
A&E Mental Health Assessment and Liaison
Adult Mental Health
EMI Liaison
Older Peoples
Crisis Resolution and Home Treatment (CRHT)
Adult Mental Health
Assertive Outreach Team (AOT)
Adult Mental Health
Early Intervention in Psychosis (EIP)
Adult Mental Health
Psychotherapy and Consultation Service
Psychological Services
Eating Disorders
Psychological Services
Criminal Justice Liaison Team
Adult Mental Health
Network Employment
Adult Specialist
Learning Disabilities (inpatient and community)
Learning Disabilities
Rehabilitation Service (inpatient and community)
Adult Specialist
Brain Injuries Service (inpatient and community)
Adult Specialist
Aspergers Team
Learning Disabilities
Community Residential Service (CRS)
Learning Disabilities
Dispersed Housing Scheme (DISH)
Adult Specialist
41
APPENDIX 2: SUMMARY OF LOCAL, LOW AND MEDIUM SECURE
AND HIGH SECURE SERVICES CQUIN PERFORMANCE FOR 2011/12
Local Services 2011/12 CQUIN Performance (as at month 12) – Achieved overall
Goal/Description
Performance
1 Improving Responsiveness to Personal Needs
Development of service user experience surveys in selected services.
Achieved
2 Advancing Quality
Regional stretch targets in relation to dementia and psychosis.
Under Achieved
3 Public Health
Assessment of smoking, BMI and addiction status and
provision of brief interventions for service users.
Achieved
4 Physical Health and Assessment Profiling for Anti Psychotic Medication
Assessment and interventions for all service users newly prescribed
antipsychotic medication.
Under Achieved
5 Mental Health Inreach
Improved liaison for primary care with secondary care services.
Achieved
6 Effective Discharge Planning
Improved communication with service users and primary care following
discharge from inpatient wards.
Under Achieved
Low and Medium Secure Services 2011/12 CQUIN Performance (as at month 12) – Achieved overall
42
Goal/Description
Performance
1 Essen Scale
Implementation of improvements as a result of using the Essen scale.
Achieved
2 HoNOS
Implementation and use of the Health of the Nation Outcome Scale in secure services.
Achieved
3 Length of Stay
Development of length of stay reporting and analysis of results.
Achieved
4 25 Hours Meaningful Activity
Embed development of service user defined activity plans by ensuring a
minimum of 25 hours structured activity for each service user.
Achieved
5 Involvement, Choice and Responsibility
Development of shared understanding of pathway between service users and staff.
Achieved
6 Recovery Planning
Promotes use of recognised tools for recovery planning as part of the care planning.
Achieved
High Secure Services 2011/12 CQUIN Performance (as at month 12) – Achieved overall
Goal/Description
Performance
1 Physical Health and Wellbeing
Develop and improve physical health care with a focus on long term conditions.
Achieved
2 Recovery Planning
Implement a recognised tool for recovery planning.
Achieved
3 Consistent Acceptance Thresholds
Quality assure the acceptance thresholds for admissions across hospitals to
ensure consistency.
Achieved
4 Utilising Patient Experience
Utilise patient experience to improve services and empower patients to move
along their care pathway.
Achieved
5 Innovative Wards
Implementation of releasing time to care/productive ward.
Achieved
6 Maintain and Potentially Reduce BMI
Improve physical health care by changing delivery of meals to a bespoke service
to meet individual needs.
Achieved
43
This Quality Account can be made available in a range of
languages and formats on request.
It is available to download from the NHS Choices website:
www.nhs.uk/Pages/HomePage.aspx
or the Mersey Care NHS Trust website:
www.merseycare.nhs.uk