Quality Account
2011 - 12
providing services
we would be happy for our families to use
“The service that has been offered to me has been a life saver and I
mean that literally. It provided me with support, information
understanding.
Comments from service users in 2011 -12
contents
part 1
Table of contents
1
Quality - Chief executive’s view and declaration of Quality
Account accuracy
3
Summary of Quality Account
5
What is the purpose of the Quality Account?
5
Why these areas?
5
Our key achievements in relation to quality in 2011-12 6
7
Our priorities for 2012-13
Mandatory statements
8
Statement of director’s responsibilities in respect of the Quality Account
8
part 2
Who was involved in setting priorities for 2012-13?
How did we collect these priorities?
How did we shortlist?
Our priorities for 2012-13
Service user safety
Service user safety priority 1
Service user safety priority 2
Clinical effectiveness
Clinical effectiveness priority 1
Clinical effectiveness priority 2
Service user experience
Service user experience priority 1
Service user experience priority 2
9
9
9
10
10
10
10
11
11
11
12
12
12
mandatory statements
How NAViGO monitors quality and performance?
Participation in clinical audits
Participation in clinical research
Goals agreed with funders of services
Care Quality Commission registration
13
13
15
16
16
1
“If this service was not there, I don’t think I would be able to get
better, in fact, I know that I wouldn’t.”
Comments from service users in 2011 -12
mandatory statements continued
Data quality
Information governance
Our performance on information governance toolkit
Clinical coding
16
17
17
17
part 3
How we performed on quality last year – 2011-12
18
Performance on Quality Account priorities for 2011-12 19
Achievements across the service in 2011-12
22
Rharian Fields
22
Improving Access to Psychological Therapies (IAPT)
for people with Chronic Obstructive Pulmonary Disease (COPD)
23
Improving quality in physical healthcare in community mental health services
24
Forensic service
24
Memory service accreditation
25
Staff survey
26
National performance reporting requirements
27
Employment and accommodation in
North East Lincolnshire
27
Health of the Nation Outcome Scales (HoNOS)
28
Improving Access to Psychological Therapies (IAPT)
29
glossary of key terms
30
statements from other organisations about the
Quality Account
Link
Service User and Carer Forum
North East Lincolnshire Care Trust Plus
Local authority scrutiny committee
32
33
34
35
2
part 1
quality: chief executive’s view and declaration of
Quality Account accuracy
NAViGO Community Interest
Company is a not for profit
organisation that emerged
from the NHS in April 2011 to
run all local mental health and
associated services in North
East Lincolnshire.
We have all the services you
would expect of a mental
health provider including
acute facilities, but also
specialist services such as
systemic family therapy, highly
developed employment
and training services running
our own and other peoples
ancillary services (catering,
cleaning, maintenance, etc.)
creating jobs and training for
people with mental health
problems, eating disorders and
many more. We designed the
services in conjunction with
people who use them and as
such many are bespoke.
Our mission is simple, to provide
services that we would be
happy for our own families to
use and we are on our way to
achieving this, already 75 per
cent of our staff said if a friend
or relative needed treatment
they would be happy with the
standard of care in any of the
services provided by NAViGO,
compared to only 59 per cent
in other services nationally.
However, we will continue to
strive to increase this result and
want every single member
of our staff to provide the
standard of service they would
as if they were treating a
member of their family.
This Quality Account illustrates
how we place quality at the
heart of our organisation,
delivering award winning
services in partnership with our
local community. We believe
strongly that by working in
partnership with our members
we can reflect a journey
towards a life lived with
purpose and meaning; this is
our testament to the quality of
services we provide.
As an organisation we are
truly unique. We have a voting
membership giving service
users and carers equal rights
to staff. We continually strive
to provide quality services in
partnership with the people
who know our services best,
our staff, our service users and
carers.
Partnerships are crucial to
NAViGO’s success, both locally
and internationally.
Over the last year NAViGO
has established a partnership
with an institution based in
Macedonia, to help support
staff development and training
while also hoping to improve
the physical surrounding for
the service users.
A number of staff from the
institution, which provides care
to a whole range of people
of all ages with both learning
difficulties and mental health
problems, visited NAViGO
services for four weeks to
receive training and to
experience how services are
provided here in the UK and
members of NAViGO staff
have subsequently visited
Macedonia. Fundraising has
also been undertaken for the
institution with a number of
staff involved in various events
including a skydive.
NAViGO also has strong links
with the Caribbean islands
of Antigua and Barbuda,
providing regular RESPECT
training for nursing staff,
police, prison and emergency
services. RESPECT training is
now an integral part of The
Antigua and Barbuda Mental
Health Training Partnership
which encompasses NAViGO,
IAS (UK), Antigua and Barbuda
Ministry of Health, Brian Hoser,
The National Mental Health
Association of Antigua and
Barbuda and the North East
Lincolnshire Mental Health
Service User and Carer
Independent Forum.
3
Closer to home, NAViGO is
heavily involved with many
local organisations in the
health and social care sector
and beyond. A number of
partner organisations sit on
the Membership Board which
governs the organisation
including the Independent
Service User and Carer Forum,
North East Lincolnshire Council,
LiNK, En-gage, Alzheimer’s,
Rethink, Mind and Artlandish.
As you will see throughout
this report, services are also
being developed with other
health care organisations
including locally based social
enterprise Care Plus and the
local general hospital, Diana,
Princess of Wales.
Against a background of
national service cuts, by
working smarter, reducing
waste, ensuring everyone
relates directly to those who
use the services and are
therefore more efficient,
having less managers and
bureaucracy, we have
managed (in our first year
as a social enterprise) to not
only save significant sums of
money required of us, but also
generate surplus money to
reinvest back into our services,
creating accommodation for
vulnerable people as voted
for by our members and
developing new specialist
services such as Rharian Fields,
our new dedicated inpatient
user eating disorder service,
the first of its kind for North East
Lincolnshire.
We have also managed to
secure funding to further
develop different parts of
our services. As part of a
pathfinder programme,
£427,000 of funding has been
awarded to NAViGO by the
Department of Health.
the innovative design of not
just our physical buildings, but
the ways in which our services
work fluidly around them and
have won numerous awards
over the last year including
being named over all winners
of The Guardian Public Service
Awards as well as receiving
the Employee Ownership Rising
Star Award and the Best Public
Sector Employee-Led Mutual
Organisation (ELMO) Award at
The Philip Baxendale Awards.
This has enabled the expansion
of local forensic mental health
services to provide an expert
panel to the magistrates court
and more assertive follow up
for signposted offenders.
In conclusion, we will keep
trying to be more flexible and
changing the way we do
things to create reinvestment
each year, giving our
members a real voice in the
development of our local
services and creating a service
which is truly part of the local
community.
Open Minds have also secured
a £200,000 grant from the
Burdett Trust for Nursing (The
Empowerment Programme) to
develop integrated pathways
for the assessment and
treatment of depression and
anxiety in people with severe
COPD.
Kevin Bond
We are national top scorers
for many indicators thanks to
Chief executive
In accordance with the
NHS (Quality Accounts)
Amendment Regulations 2011
No. 269, I hereby state that to
the best of my knowledge the
information in this document is
accurate.
4
summary of Quality Account
what is the purpose of the Quality Account?
The purpose of the Quality Account is to:
• Evidence to the public the quality of service NAViGO delivers
• Show measureable quality improvement in identified areas and discuss plans to further improve quality
• Involve and respond to service user feedback.
The three areas of priority we have chosen to focus on are:• Service user safety – Ensuring service users do not come to harm whilst in our care
• Clinical effectiveness - Applying the best knowledge, derived from research, clinical experience and preferences of service users to ensure we achieve the best outcomes for our service users
• Service user experience - Listening to and acting on service users views in order that we provide the best service and experience possible.
why these areas?
Service user safety, clinical effectiveness and service user experience were the three categories
Lord Darzi used in his review of the NHS in 2008, “High Quality Care for All”.
Lord Darzi felt that keeping service users safe, providing them with an effective service to produce
the best outcomes, and acting on their feedback, would ultimately lead to health services
focusing on quality rather than speed of delivering the service. In this way health services would
be led by service users and not by government targets.
This vision fits with NAViGO’s vision of providing services we would be happy for our families to use.
5
“One of the most imaginative and inspirational ideas in our public
services. Involving people in the service they are using gives them a
truly meaningful stake in it and in this case helps set them firmly on the
road to recovery.”
David Brindle, The Guardian’s public services editor
our key achievements in relation to quality in 2011-12
NAViGO has achieved the
majority of its performance
targets in 2011-12. These
include targets set by
regulators such as the Care
Quality Commission and the
Department of Health.
Particularly pleasing
performance has been
achieved in relation to the
percentage of service users
in paid employment and
settled accommodation
where NAViGO was one of the
top five performing providers
of mental health services
nationally.
Services across NAViGO have
been developed following
feedback from service users
and carers and the results of
clinical research.
For example, the community
mental health service ran a
successful pilot late in 2011
aimed at supporting people
with severe mental health
problems in managing the
physical health concerns often
associated with mental illhealth.
Service user feedback
was really positive and the
outcome of the pilot showed
a significant number of people
whom the mental health
services worked with, did
actually have either known
physical illness or in many
cases (including one case of
acute appendicitis) unknown
health complaints which
we were able to treat really
quickly in partnership with the
G.P’s.
The wellbeing service is now
being rolled out across case
supervision services on the
back of this successful pilot.
NAViGO has won several
prestigious awards which
reflect the quality of services
it delivers including being
named overall winners of
The Guardian Public Service
Awards as well as receiving
the Employee Ownership Rising
Star Award and the Best Public
Sector Employee-Led Mutual
Organisation (ELMO) Award at
The Philip Baxendale Awards.
Progress has been made
against some of the priorities
set for improving quality locally
in last year’s Quality Account.
NAViGO significantly increased
the number of service users
with recorded Health of the
Nation Outcome Assessments
(HoNOS).
HoNOS is an outcome measure
which is used in the clustering
process known as Payment by
Results (PbR).
Service users are allocated
to care clusters using the
mental health clustering tool
based upon HoNOS (how the
service user is feeling in last
two weeks) and alongside
service user history which in
turn supports care planning
and enables Mental Health
Payment by Results (MH PbR).
The clustering tool supports
providers and funders of
services in measuring health
and social care outcomes
in mental health without the
need to collect additional
data.
Participation in national clinical
audits was also achieved
with NAViGO partaking in
two national audits between
March 2011 and April 2012,
the national dementia audit
and the national schizophrenia
audit.
A local audit programme and
audit committee was also
established.
Priorities which were set in
the previous year’s Quality
Account and required further
work were carried over into the
priorities for 2012-13 which are
listed in part 2 of the Quality
Account.
6
our priorities for 2012-13
After thorough consultation
with our service users,
members and staff, the
following priorities for quality
improvement have been
identified.
These priorities will be
NAViGO’s focus in improving
service user safety, the
effectiveness of its services
and service user experience
between April 2012 and March
2013.
Priorities were chosen after
analysing data including
waiting times, complaints,
feedback from the service
user and carer forum and
service user surveys, and
incidents and accidents.
The shortlist of priorities was
developed based on the ethos
of NAViGO – providing services
we would be happy for our
families to use.
Following presentation of
the potential priorities at the
Service User and Carer’s
Forum, quality improvement
priorities reached the shortlist
where there were trends in
both the qualitative and
quantitative data.
For example, data from
the electronic service user
record showed service users
were sometimes waiting
long periods for a follow up
appointment for one to one
therapy at Open Minds.
Feedback from the Service
User and Carer’s Forum, local
service user surveys and
complaints indicated this was
also an area of concern for
service users and carers.
service user safety priority 1
Any service user safety incidents reported on Datix rated
as having major/catastrophic consequences should have
a documented root cause analysis and associated action
plan discussed and monitored at the clinical governance
committee.
service user safety priority 2
Review the North East Lincolnshire strategy for suicide
prevention and work in partnership with other organisations
(predominately public bodies) in refining the strategy
to ensure it helps guide local practitioners in achieving
better outcomes for people in crisis. The strategy will
include suicide awareness training for staff and a review of
current procedure, to support staff in recognising the signs
of suicidal thinking and ultimately prevent suicide from
occurring.
clinical effectiveness priority 1
Audit the current care and treatment of service users with
a dual diagnosis of drug and alcohol and mental health
problems against National Institute for Clinical Excellence
(NICE) guidelines to establish the effectiveness of current
treatment where care is shared between NAViGO and
other agencies. Recommend improvements to include
policy review and action plans.
clinical effectiveness priority 2
To measure how many people with Dementia have
treatment at home as opposed to hospital during 201213 and to use this as a target for working towards more
treatment delivered at home in subsequent years. To
supplement this data with service user and carer surveys
to determine whether treatment at home provides a more
positive experience and better outcomes for the service
user.
service user experience priority 1
As per priority set in 2010-11, to monitor waiting times for
people needing a crisis team assessment to ensure 97%
of referrals are seen within 4 hours and 85% of referrals are
seen within 2 hours.
service user experience priority 2
To produce monthly monitoring of time taken to assess
and start treatment for people referring to Open Minds,
to ensure 95% of referrals are assessed within 10 days and,
following assessment, the service user’s wait to start their
choice of treatment is reduced.
7
mandatory statements
statement of director’s responsibilities in respect of the Quality
Account
The directors are required under the Health Act 2009, National Health Service (Quality Accounts)
Regulations 2010 and National Health Service (Quality Account) Amendment Regulation 2011 to
prepare Quality Accounts for each financial year. The Department of Health has issued guidance
on the form and content of annual Quality Accounts (which incorporate the above legal
requirements).
In preparing the Quality Account, directors are required to take steps to satisfy themselves that:
• The Quality Account presents a balanced picture of the Trust’s performance over the period covered;
• The performance information reported in the Quality Account is reliable and accurate;
• There are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Account, and these controls are subject to review to confirm that they are working effectively in practice;
• The data underpinning the measures of performance reported in the Quality Account is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review; and
• The Quality Account has been prepared in accordance with Department of Health guidance.
The directors confirm to the best of their knowledge and belief they have complied with the
above requirements in preparing the Quality Account.
By order of the Board
Kevin Bond
Barry Flintoft
Simon Beeton
chief executive
director of operations
director of finance
8
“I’m sure we wouldn’t have made anywhere near the same progress
without your input. Yet again, I can only praise highly your work, and
the difference it really makes to my work in such circumstances, and
to the benefit of those motivated patients I’ve referred to you.”
Dr J Laughton, GP
part 2
who was involved in setting priorities for 2012-13?
NAViGO’s priorities for quality improvement for the financial year April 2012 to March 2013 were
identified in conjunction with service users and carers, NAViGO’s main funder of services, North
East Lincolnshire Care Trust Plus, and NAViGO members of staff.
how did we collect these priorities?
NAViGO is a social enterprise,
it is owned by the staff and
run by community and
staff members. Community
members are service users,
carers or people in the
local area with a genuine
interest in mental health.
The membership sits on the
Board as non-executives
and helps set priorities, plan
and monitor if processes are
working. Members are part of
every committee and issues of
quality are always discussed.
The Quality Account helps
focus this process and activity
into an annual plan.
The process for identifying
priorities began with a review
of our performance in the
previous financial year (April
2011 to March 2012).
This included an evaluation
of priorities featured in last
year’s Quality Account to
establish whether further
work was needed in these
areas or whether enough
work had been done to
justify retiring these priorities,
whilst continuing to monitor
them through regular internal
performance reporting.
Performance Indicators
set nationally for mental
health providers by the Care
Quality Commission and
the Department of Health
were examined to ascertain
whether NAViGO was
performing below target or
had a downward trend in
results which would necessitate
the need for identifying them
as a priority for improvement.
Staff meetings involving
representation from the
Service User and Carer’s Forum
discussed potential quality
improvement priorities based
on the results of the previous
financial year performance
review alongside a range of
qualitative and quantitative
data.
This data featured complaints,
service user safety incidents
and accidents, local service
user surveys, feedback from
the Service User and Carer’s
Forum and Commissioning
for Quality and Innovation
(CQUIN) indicators set by
NAViGO’s main commissioner,
North East Lincolnshire Care
Trust Plus.
how did we
shortlist?
The shortlist of priorities was
developed based on the ethos
of NAViGO:
providing services we would
be happy for our families to
use.
Following presentation of
the potential priorities at the
Service User and Carer’s
Forum, quality improvement
priorities reached the shortlist
where there were trends in
both the qualitative and
quantitative data.
For example, data from
the electronic service user
record showed service users
were sometimes waiting
long periods for a follow
up appointment for one to
one therapy at Open Minds.
Feedback from the Service
User and Carer’s Forum, local
service user surveys and
complaints indicated this was
also an area of concern for
service users and carers.
9
“I was listened to and treated with respect.”
Comments from service users in 2011 -12
our priorities for 2012-13
NAViGO felt it was important to categorise its quality improvement priorities under the headings of
service user safety, clinical effectiveness and service user experience in order to align them to the
government paper, High Quality Care for All, which uses the same headings. It was hoped this
would give added clarity to NAViGO’s priorities and enable comparison between NAViGO and
other providers of health and social care services.
service user safety
Ensuring service users come
to no harm whilst receiving
services is paramount to
NAViGO delivering on its vision
of providing services we would
be happy for our families to
use.
In 2010-11 NAViGO adopted
the Datix incident, accident
and risk management system
to support a positive culture in
relation to reporting incidents,
accidents and near misses
which could hurt service users.
As 2010-11 was the year Datix
was launched in NAViGO the
priority for quality improvement
relating to service user safety
was:
To ensure all errors/near misses/
incidents that could hurt staff/
service users are reported
on the service user safety
database ‘Datix’ and that
lessons are learnt.
A review of the data recorded
on the Datix system shows
that the number of reported
service user safety related
incidents increased. Despite
the National Patient Safety
Agency (NPSA) indicating that
high reporting organisations
typically have a positive
approach to incident reporting
and are keen to learn
lessons, NAViGO felt there
was further work to be done
around learning lessons and
preventing similar incidents
from re-occurring.
Weekly review of the quality
and detail of reported
incidents did not show
thorough action planning or
root cause analysis which is
needed in order for lessons to
be learned. With this in mind,
it was decided that the priority
for 2012-13 would be:
service user safety priority 1
service user safety priority 2
Any service user safety incidents reported
on Datix rated as having major/catastrophic
consequences should have a documented
root cause analysis and associated action
plan discussed and monitored at the Clinical
Governance Committee.
Review the North East Lincolnshire strategy for
suicide prevention and work in partnership
with other organisations (predominately
public bodies) in refining the strategy to
ensure it helps guide local practitioners in
achieving better outcomes for people in
crisis.
The strategy will include suicide awareness
training for staff and a review of current
procedure, to support staff in recognising
the signs of suicidal thinking and ultimately
prevent suicide from occurring.
10
“I was in relapse and the care and the compassion, care and
humanity I received helped me through an overwhelmingly
difficult time.”
Comments from service users in 2011 -12
clinical effectiveness
Ensuring the services we
provide are as effective as
they can be is a significant
part of what NAViGO believes
should define quality.
In 2010-11 NAViGO identified
an area for improvement in
the effectiveness of its services
being the treatment of service
users with both mental health
and learning disabilities.
At the time there were no
documented local guidelines
which set out the best and
most effective treatment
for these service users.
NAViGO’s main funder of
services identified this as a
quality improvement and
set milestones for delivery
and implementation of
the guidelines in NAViGO’s
contract. Guidelines have
now been produced for
service users with both mental
health and learning disabilities.
Further work needs to be
focused around the care
and treatment of other
service users who have a dual
diagnosis, specifically those
who abuse drugs and alcohol
and have mental health
problems. Serious incidents
have occurred in relation
to these service users where
the care is shared between
NAViGO and other agencies
and the need for information
sharing is vital.
clinical effectiveness priority 1
clinical effectiveness priority 2
Audit the current care and treatment of
service users with a dual diagnosis of drug
and alcohol and mental health problems
against National Institute for Clinical
Excellence (NICE) guidelines to establish
the effectiveness of current treatment where
care is shared between NAViGO and other
agencies. Recommend improvements to
include policy review and action plans.
To measure how many people with Dementia
have treatment at home as opposed to
hospital during 2012-13 and to use this as a
target for working towards more treatment
delivered at home in subsequent years.
To supplement this data with service user
and carer surveys to determine whether
treatment at home provides a more positive
experience and better outcomes for the
service user.
Care for people with Dementia is changing
to include more choice for service users
and carers about whether they prefer to be
treated at home rather than in hospital. A
local priority for NAViGO and its main funder
of services, North East Lincolnshire Care
Trust Plus, is to be able to offer this choice
of treatment options and to measure their
effectiveness both in terms of how much
treatment at home may add to stability and
positive outcomes for the service user and
to measure the extent it adds to improved
experience for the family or carer.
11
“After building up the courage to enter open minds, I found it easy to
return and the staff very approachable and friendly. The fact that the
service is there is a reassurance in itself. It reminds you you’re not alone
and many people are going through similar difficulties as yourself.”
Comments from service users in 2011 -12
service user experience
The heart of what NAViGO
does is providing positive
experience and outcomes for
service users and carers.
The importance NAViGO puts
on service users and carers to
drive the quality of its services
is significant and can be
proven by the influence of its
service user and carer forum,
its membership or shareholders,
which has a high service
user representation, and its
commitment to providing
employment and training
opportunities for its service
users within its Tukes enterprise.
The following priorities have
been identified from the
service user and service user
forum, complaints and local
service user surveys.
Although waiting times had
improved for service users
needing a crisis assessment,
from 89% of referrals seen
within 4 hours in 2010-11 to
service user experience priority 1
As per priority set in 2010-11,
to monitor waiting times for
people needing a crisis team
assessment to ensure 97%
of referrals are seen within 4
hours and 85% of referrals are
seen within 2 hours.
Our open access facility
for service users with mild
to moderate mental health
problems, Open Minds, has
been extremely popular
with people in North East
Lincolnshire. The demand
for accessing services such
as cognitive behavioural
therapy (CBT) and stress
management groups without
a referral from a general
practitioner has been so
high that unfortunately it has
resulted in a delay in people
starting treatment, where their
choice of treatment is in high
demand.
All service users are assessed
within 10 days which is the
beginning of their therapy.
Following assessment they are
offered a choice of treatment
which could include exercise,
stress control, or psychological
intervention. Depending on
the treatment the service
user chooses, there may be
a delay in starting treatment
based on the demand for
that particular therapy at the
time. Feedback from service
users has suggested that whilst
their overall experience of the
service has been excellent,
fewer delays in starting
treatment for some therapies
would make their experience
better still. Open Minds is
constantly reviewing ways
service users can access the
service in order to improve
service user experience.
93% of referrals seen within 4
hours in 2011-12, NAViGO felt
it should be aiming to see at
least 97% of people within the
4 hour waiting time target in
the NAViGO contract.
It was also deemed high
priority to ensure that the
majority of these referrals were
seen within the first 2 hours. In
2011-12 80% of referrals were
seen within a two hour period.
This percentage needs to rise
to at least 85%.
service user
experience priority 2
To produce monthly
monitoring of time taken to
assess and start treatment
for people referring to Open
Minds, to ensure 95% of
referrals are assessed within
10 days and, following
assessment, the service user’s
wait to start their choice of
treatment is reduced.
12
mandatory statement
The following sections are mandated for inclusion in all Quality Accounts. This is to enable the
public to compare NAViGO with other providers of health and social care.
how NAViGO monitors quality and performance
NAViGO’s performance team produces data from the service user administration system
(Maracis) to inform progress against national performance indicators set by the Care Quality
Commission, the Department of Health and the Local Authority.
Performance is also monitored locally against priorities set in contracts with funders of services,
namely North East Lincolnshire Care Trust Plus. All performance indicators are monitored at least
monthly using a traffic light system (green for on or above target, amber for slightly below target
and red for well below target). Data is broken down into service areas and discussed at monthly
meetings with service leads. Any issues are passed down to operational staff and action plans
for improvement are agreed. Any constant under-performance is escalated to the director
of operations and the Local Board. The Local Board and the main service funder receive a
performance report including a summary of exceptions where targets have not been met every
quarter.
Any data quality issues within the service user administration system are identified on a daily basis
using internal reports. This includes missing data where it is a vital part of the service user’s record,
such as the National Health Service number (NHS number). NHS numbers are traced using an
electronic system which ensures health records are linked to the correct service user.
participation in clinical audits
Clinical audit provides a way to review and reflect on current practice to assess whether a
healthcare provider is doing what it should be doing according to national and local guidance.
Clinical audit is important because its aim is to continuously improve the quality of care provided
to service users.
National confidential enquiries collect data on adverse events to identify shortfalls and improve
future clinical care; they also highlight short falls/failures in service organisation. In 2011-12 there
were no national confidential enquiries Mental Health Trusts were required to report on as part of
the Quality Account.
During 2011/12, NAViGO Health and Social Care Community Interest Company (CIC) participated
in 1 (one) national clinical audit and 0 (zero) national confidential enquiries studies, out of 2 (two)
national clinical audits and national confidential enquiries which it was eligible to participate
in. This was in addition to NAViGO’s local clinical audit programme and a national audit not
applicable to the Quality Account.
The national clinical audit that NAViGO participated in and for which data collection was
completed during 2011/12 is listed in the table below, alongside the number of cases submitted as
a percentage of the number of registered cases required by the terms of that audit.
national audits applicable
to Quality Account
prescribing in mental health
services
national audit of
schizophrenia
participation
(yes/no)
no
percentage (%) of required
cases submitted
not applicable
yes
100
13
A number of local audits were also carried out during 2011-12 and monitored via the NAViGO
Clinical Audit Committee. Some of these completed audits are depicted in the table below.
local audits
completed in 2011-12
numbers
partaking in
the audit
actions agreed
Named Worker Audit
20
1. Implement advisory recommendations to improve
documentation within case notes
Audit of NICE Guidance for Obsessive
Compulsive Disorder
(OCD)
26
1. Educate doctors about the use of clomipramine in OCD and
the current recommendations of NICE for the treatment of severe
OCD
2. Disseminate information on OCD from Royal College of
Psychiatry to service users and their families with extra note about
local support groups and local service provision
3. Medical staff use standardised and validated scale to diagnose
OCD and its severity for example Yale-Brown
4. Educate medical staff about specialist OCD MDT service
5. Highlight to staff the criteria that NICE guidelines expect to be
documented and the findings of OCD audit
Re-audit of Care
Programme
Approach (CPA)
records
130
1. To scan all signed care plans into Maracis
2. To identify carers in adult acute services which are currently not
consistently collecting this information
3. Adult services to monitor in supervision with each practitioner
carers have been identified and offered assessments
4. All care plans to be typed within the electronic record
5. To scan all consent to treatment forms into Maracis
6. All services to monitor in supervision with practitioners using
missing data report. Performance to be reviewed at service and
organisational level at the Board and infrastructure meetings
Audit of NHS Litigation
Authority (LA) Record
Keeping Standards
130
1. To scan all consent to treatment forms into Maracis to allow for
further audit on standard 11 during 2012
2. Training to be provided for all clinical staff on NHSLA record
keeping standards. To particularly highlight the requirements of
dating, timing and signing errors in written entries in the paper-light
file and the need to not use ditto marks and abbreviations even
with commonly used terminology such as CPA, HoNOS, ECG
3. All documentation generated by NAViGO practitioners should
be typed
4. To amend CPA paperwork to include prompts for Adverse
Reactions
Baseline clinical
audit of the usage of
clozapine for service
users with refractory
schizophrenia
20
1. To write Local Policy
2. Improve documentation/ training at CPD Meetings
3. Re-audit with larger sample size
4. To organise the service of family interventions
5. To develop CBT work for psychosis and obtain Royal Society of
Psychiatrist leaflet
6. Advocacy service referral or involvement
14
“I never thought this would be possible but the team have made a
great improvement to the client’s outlook by 100% and it has been a
great benefit to him and his family.”
Comments from service users in 2011 -12
participation in clinical research
Clinical research involves
gathering information to
help us understand the best
treatments, medication or
procedures for service users. It
also enables new treatments
and medications to be
developed.
Also, in the last three years,
twenty six publications have
resulted from our involvement
in research, which shows our
commitment to transparency
and desire to improve service
user outcomes and experience
across the NHS.
The number of service users
receiving NHS services
provided by NAViGO in
2011/12 that were recruited
during that period to
participate in research
approved by a research ethics
committee was two hundred
and six. Eight carers were also
recruited to participate in one
of the research studies.
One of the key areas of
research within NAViGO is the
on-going research study by
Professor Ann Mortimer, M.D.
and Dr Colin Robertson, Ph.D
into Transcranial Magnetic
Stimulation (TMS) to treat
chronic depression.
Participation in clinical
research demonstrates
NAViGO’s commitment to
improving the quality of care
we offer and to making our
contribution to wider health
improvement.
Our clinical staff stay
abreast of the latest possible
treatment options and active
participation in research leads
to successful service user
outcomes.
NAViGO was involved in
conducting nine clinical
research studies in mental
health during 2011/12 and
there were twenty clinical
staff participating in research
approved by a research ethics
committee during this period.
Our research study using
Transcranial Magnetic
Stimulation (TMS) to treat
chronic depression, uses a
special technique called
Electroencephalogram
(EEG) guided TMS that
identifies for each person their
brainwave patterns that are
strongly associated with their
depression.
We can then use these
patterns as target areas to
treat with TMS.
In general the treatment
success of chronic depression
is not very good, however our
research results provides very
good evidence that six out of
ten people show significant life
changing experiences with this
treatment. We are continuing
to recruit to this study to
provide further evidence of
the significant effects of our
EEG guided treatment.
The purpose of our research
is to provide the evidence
base to establish a treatment
service.
We have good evidence that
our novel EEG guided TMS is
personalised to each service
user, as it identifies the key
target areas for treatment.
It is free from any serious
side effects, is safe and noninvasive as there is nothing
to ingest, in contrast to drugs
which have can have many
side effects and have to be
taken on a continuous basis.
The treatment is time limited
as each session lasts typically
no more than three quarters
of an hour: the overall course
completed within one month
can be cost effective.
Furthermore, our results show
the effects are durable. That
is, people continue to improve
even after the treatment
course is completed.
Building on this we have
expanded our research to
include schizophrenia, and in
the near future gain ethical
approval for a research
programme that will have the
capability to offer TMS across
a wide range of conditions
to include anxiety, obsessive
compulsive disorder (OCD)
and Post Traumatic Stress
Disorder (PTSD).
15
goals agreed with funders of services
Primary care trusts hold the NHS budget for their
area and decide how it is spent on hospitals
and other health services. This is known as
‘commissioning’. North East Lincolnshire Care
Trust Plus is the main funder of services at
NAViGO. They set us targets based on quality
and innovation.
A proportion of NAViGO’s income in 2011/12
was conditional on achieving quality
improvement and innovation goals agreed
between NAViGO and any person or body
they entered into a contract, agreement or
arrangement with for the provision of NHS
services, through the Commissioning for Quality
and Innovation payment framework (CQUIN).
Further details of the agreed goals for 2011/12
and for the following 12-month period are
available electronically on the NAViGO
website: www.navigocare.co.uk
Care Quality Commission registration
The Care Quality Commission regulates and
inspects health organisations. If it is satisfied
the organisation provides good, safe care, it
registers the organisation.
NAViGO Health and Social Care is required
to register with the Care Quality Commission
(CQC) and its current registration status is
registered. The Care Quality Commission has
not taken enforcement action against NAViGO
Health and Social Care during 2011/12.
The Trust has worked hard in achieving all
standards of care to a satisfactory level at
its last inspection in September 2011 and
continues to work to improve quality of services
provided and to provide assurance to the
Board.
data quality
Part of NAViGO’s commitment to providing quality services is to ensure it keeps accurate,
complete and up to date records. Data quality measures include whether service users’ NHS
numbers were present in their health records.
NAViGO submitted records during 2011/12 to the Secondary Uses Service for inclusion in the
Hospital Episode Statistics which are included in the latest published data*.
The percentage of records in the published data, which included the service user’s valid NHS
number was:
• 99.8% for admitted service users care;
•100% for outpatient care
The percentage of records in the published data, which included the service user’s valid General
Medical Practice Code was:
• 100% for admitted service users care;
• 100% for outpatient care
*Latest published data February 2012
These results are well above the national average.
NAViGO will be taking the following actions to improve data quality.
Please refer to the section on “How NAViGO monitors quality and performance” on page 13.
16
information governance
Information Governance
ensures necessary safeguards
for, and appropriate use of,
service user and personal
information.
The director accountable
for managing service user
information and ensuring
service user confidentiality is
also known as the Caldicott
Guardian. NAViGO’s Caldicott
Guardian is Dr Barry Flintoft,
Director of Operations.
As a new organisation,
NAViGO is utilising the skills of
North East Lincolnshire Care
Trust Plus through a service
level agreement which covers
information governance and
security. NAViGO’s information
governance framework has
been developed in partnership
with the Care Trust Plus’
Information Governance and
security manager.
We continue to take our duty
to protect personal information
and confidentiality very
seriously and are committed to
taking all reasonable measures
to do so, both for electronic
information and paper
records.
At Trust Board level, our
director of finance is
accountable for managing
the service level agreement
with North East Lincolnshire
Care Trust Plus which covers
all information assets and any
associated risks and incidents.
Our Caldicott guardian
is responsible for the
management of service user
information and service user
confidentiality.
Information Governance
and information risks are
managed and controlled via
the Information Governance
toolkit submissions and
the clinical governance
committee.
There is regular reporting
to NAViGO’s clinical
governance committee on
how it is performing against
the standards set in the
Information Governance
toolkit.
The toolkit and supporting
evidence focuses on:
• The formal assignment of responsibilities to named individuals or groups
• Documented policies subject to formal review, approval and dissemination
• Checks and measures of staff understanding, and compliance with policies and processes.
our performance on information governance toolkit
Our information governance assessment
report overall score for 2011/12 was 60%
and was graded ‘not satisfactory’. As a new
organisation, this was the first time we had been
assessed against the Information Governance
Toolkit and we expect to see an improved
performance next year.
Although we have many of the required
systems in place, we lost points because we
did not always have enough documentary
evidence of this. We are working to address
this before next year’s assessment. A full action
plan, approved by NHS Connecting for Health,
to meet the required documentary evidence
has been put in place and actions have
been allocated to members of the NAViGO
Management team. Actions include dates
for achievement and a process for monitoring
the action plan is in place through monthly
NAViGO clinical governance committee
meetings.
clinical coding
Clinical codes are a way of recording service user diagnosis and treatment.
NAViGO Health and Social Care was not subject to the Payment by Results clinical coding audit
during 2011/12 by the Audit Commission.
17
“The community mental health team that I have at this time are one
of the best I have had in the past 10 years.”
Comments from service users in 2011 -12
part 3
how we performed on quality last year – 2011-12
Part 3 of the Quality Account evaluates NAViGO’s overall performance in 2011-12. This includes
a review of whether or not we have achieved the priorities set in the previous year’s Quality
Account, which may carry forward to the coming year’s priorities in part 2 should they not be fully
achieved.
We then talk about what we have achieved in the last year, which we feel will contribute to
improved quality for our service users.
Lastly we summarise our achievements in relation to national reporting requirements set by
regulatory bodies such as the Department of Health, and the Care Quality Commission. This
should allow comparison between NAViGO’s performance measures, which link to quality, and
other providers of mental health services who are required to report on the same performance
measures.
18
performance on Quality Account priorities for 2011-12
The following performance review of last financial year (March 2011 to April 2012) will summarise
NAViGO’s performance against the quality priorities set in the previous year using a traffic light
rating system. Green meaning we fully achieved our objectives, amber meaning we almost
achieved objectives but recognise there is still work to do, and red meaning there is significant
work still to do to realise our objectives.
service user safety
theme
objective
actions achieved
outcome
service user safety
To ensure all errors/
near misses/
incidents that could
hurt staff/service
users are reported
on the service user
safety database
‘Datix’ and that
lessons are learnt
‘Datix’ risk
management
system
implemented and
incidents logged
on a daily basis.
Lessons learned
and root cause
analysis to be
improved in the
coming year
Priority for 2012-13
to be: Any service user safety
incidents reported
on Datix rated as
having
major/catastrophic
consequences
should have a
documented root
cause analysis and
associated action
plan discussed and
monitored at the
Clinical
Governance
Committee
To reduce the
number of service
users from being
Absent Without
Leave (AWOL)
Researched best
practice on
reporting instances
of AWOL from
other mental health
providers. Ensured
all services users at
risk of absconding
are monitored by
two members of
staff whilst outside
in smoking areas
Number of service
users AWOL as
reported nationally
reduced.
Continue to
monitor via monthly
internal reports
using the ‘Datix’
risk management
system
Physical violence
from service users/
their relatives or
members of
the public
‘Datix’ risk
management
system
implemented and
incidents logged
on a daily basis.
RESPECT techniques
utilised
Decreased
percentage of staff
(14% in 2011-12 as
opposed to 19% in
2010-11)
experiencing
physical violence
from service users.
Utilise de-briefing
sessions as
frequently as
possible where
physical violence
against staff occurs
and link these
sessions with
RESPECT methods
to identify where
lessons could be
learned
achieved?
19
clinical effectiveness
theme
objective
actions achieved
outcome
clinical
effectiveness
Improve the
coverage of Health
of the Nation
Outcome Scores
(HONOS), ensuring
all eligible service
users have a
HoNOS Payment by
Results (PbR) Care
Cluster recorded
on the clinical
service user
administration
system - Maracis
PbR training
completed for
all clinical staff.
Awareness of PbR
in staff meetings
95% of service users
had a PbR cluster
recorded by
December 2011
which meets
national and local
targets
Participation in the
national audit
programme
Clinical Audit
committee
established to
monitor local and
national audits.
Two national audits
undertaken out of
three applicable
to mental health
providers
Continue to
enhance audit
programme and
quality of audit
action planning.
Monitor internally at
Clinical Audit
committee
Care for service
users with dual
diagnosis
Guidelines have
now been
produced for
service users with
both mental health
and learning
disabilities
Further extend to
dual diagnosis for
mental health and
drug and alcohol
abuse. Priority for
2012-13 to be: Audit
the current care
and treatment of
service users with
a dual diagnosis of
drug and alcohol
and mental health
problems against
National Institute for
Clinical Excellence
(NICE) guidelines,
to establish the
effectiveness of
current treatment
where care is
shared between
NAViGO and other
agencies.
Recommend
improvements to
include policy
review and action
plans
achieved?
20
service user experience
theme
objective
actions achieved
outcome
service user
experience
Service user
experience of
waiting times in
crisis (Harrison
House)
Waiting times
improved for
service users
requesting crisis
assessment from
89% of referrals
seen within 4 hours
in 2010-11 to 93% of
referrals seen within
4 hours in 2011-12
Continue to
improve
performance in this
area and set further
targets for 2012-13.
Priority for 2012-13:
To monitor waiting
times for people
requesting
assessment by the
crisis team to
ensure 97% of
referrals are seen
within 4 hours and
80% of referrals are
seen within 1 hour
Service user
experience in
Outpatient
Department
New processes in
place to check
service user
information prior to
attending
appointments.
Service user
satisfaction survey
concluded service
users much happier
with their overall
experience of
being seen in
outpatients
Continue to
monitor service user
satisfaction
internally via local
service user surveys
and put any
subsequent actions
for improvement in
place
CQC community
mental health
survey 2010
Survey carried out.
Actions for
improvement
identified and
allocated to senior
members of staff for
implementation
Compare results
from 2011 survey
(currently in
progress) to 2010
results to assess
whether
improvements
have been made.
Monitor actions
internally
achieved?
21
“I feel like someone is holding my hand and after fighting this eating
disorder on my own for the last three years it is a good thing. I don’t
feel that I am on my own anymore.”
Comments from service users in 2011 -12
achievements across the service in 2011-12
NAViGO has had a busy first year. Along with the prestigious awards won, detailed in the chief
executive’s summary in part 1, many more developments have been made to a service which is
flourishing, guided by what its members and service users want.
Rharian Fields
Rharian Fields is home to the specialist eating
disorder team. This service allows people
who may have conditions such as Anorexia
and Bulimia to be cared for and treated
by a dedicated team, in a purpose built
environment within the region rather than
having to travel long distances for treatment.
Although NAViGO already provides an
outpatient eating disorder service, this new
service will allow for the team to apply even
more innovative practice and to keep at the
forefront of national service, building on the
current outpatient programme, to provide
group therapy, day care and a re-feeding
service as well as a dedicated, discreet inservice user unit.
The dedicated eating disorder team consists
of a psychiatrist, nurses, social workers,
psychologists, therapists and a nutritionist all
of whom have received specialist training in
the assessment and management of eating
disorders both in the UK and at an international
level. The service is recognised on the national
list of providers and has already obtained a
service contract with Northern Lincolnshire and
Goole NHS Foundation Trust.
22
Open Minds
Open Minds provides the talking therapies
(IAPT) service for people with common mental
health problems in North East Lincolnshire and
was recently awarded a £200,000 grant for
service development from the Burdett Trust for
Nursing (The Empowerment Programme).
In line with government guidance and strategy
around the benefits of extending talking
therapies to people with physical long term
conditions, the grant will be used over two
years to develop integrated pathways for the
assessment and treatment of depression and
anxiety in people with severe COPD.
Evidence shows that COPD is the second most
common cause of emergency admission to
hospital and that up to 67% of people with
COPD experience depression, anxiety and
panic attacks.
This psychological co-morbidity can increase
the number of hospital admissions and reduce
quality of life for people with COPD.
However, treatment of depression, anxiety and
panic using Cognitive Behavioural Therapy
(CBT) can reduce hospital admissions and
improve mental and physical health and
quality of life.
This innovative service development will bring
together the provision of talking therapies (CBT)
with existing COPD services at Hope Street
Clinic and Diana Princess of Wales hospital.
Professionals from each organisation will work
together in partnership to provide integrated
pathways between the hospital wards, Hope
Street Clinic and Open Minds; providing the
right care in the right place at the right time.
Two dedicated Psychological Therapists and
a Data Analyst have been recruited in order
to develop the service. The service will offer
assessment and treatment for people that have
been admitted to hospital with severe COPD or
have been referred to Hope Street (and have
had several admissions to hospital). Sessions
will take place on the respiratory wards before
people are discharged from hospital and will
also take place at Hope Street or in people’s
homes.
Referrals will be taken from June 2012 and
during May 2012; people that have COPD and
have been admitted to hospital most frequently
will be contacted and offered an assessment.
The service will monitor and measure
reductions in hospital admissions, bed days and
Accident and Emergency (A&E) attendances.
Improvements in physical health and outcomes
for Pulmonary Rehabilitation (PR) programmes
will also be measured as well as improvements
in depression, anxiety and panic and quality
of life. Service user involvement has also been
crucial in the development of the project and
feedback from service users will be collected
and used to make improvements throughout
the project.
Results providing evidence of the benefits of the
service will be used at the end of the two years
to submit a proposal to the GP Commissioning
Consortium (GPCC) for funding to continue and
develop the service to include people with less
severe COPD.
23
improving quality in physical healthcare in community mental
health services
The community mental health service ran a
successful pilot late in 2011 aimed at supporting
people with severe mental health problems in
managing the physical health concerns often
associated with mental ill-health. The idea
behind the project was to test the notion that
there is actually a higher occurrence of certain
physical illness such as diabetes, coronary
heart disease, high cholesterol, and breathing
related problems amongst other things, and
where there were problems discovered, look at
ways for us to help more quickly or intervene as
required to stop them becoming worse.
Where there were physical health concerns
detected, the service users were then in most
cases referred through to the G.P quickly
for treatment choices. There were also a
large range of information leaflets provided
upon request informing of different self-help
techniques from self-examination, healthy
eating and caffeine intake, through to
smoking cessation and sexual health as well as
numerous other subjects. We could also advise
of where to go for help with certain needs or
of what services could be considered by the
team.
To do this the mental health team ran a
regular wellbeing clinic over a 3 month period
in Weelsby View Health Centre and invited
80 people from the team’s caseload to take
part, and of these 40 people responded and
were seen in a wellbeing clinic appointment.
They were offered blood tests, and routine
observations such as Blood Pressure, urine tests,
and other health related screening which are
not usually routinely provided by a mental
health service.
Service user feedback was really positive
and the outcome of the pilot showed a
significant number people whom the mental
health services worked with, did actually have
either known physical illness or in many cases
(including one case of acute appendicitis)
unknown health complaints which we were
able to treat really quickly in partnership with
the G.P’s. The wellbeing service is now being
rolled out across case supervision services on
the back of this successful pilot.
forensic service investment
As part of a pathfinder programme, £427,000
of funding has been awarded to NAViGO
by the Department of Health enabling the
expansion of local forensic mental health
services to provide an expert panel to the
magistrates court and more assertive follow up
for signposted offenders.
This is a multi-agency development and
NAViGO will be working together with
the Humberside Probation Trust, the Drug
Intervention Programme (DiP) and the
combined Grimsby courts to provide a
professional, multi-agency, rapid response
panel to assess individuals where magistrates
have expressed concern over their mental
health.
The panel will consist of a forensic practitioner,
an offender manager and a DiP worker who
will provide an assessment and written report
back to the court within a three to four hour
timeframe, significantly speeding up court
outcomes and reducing the normal delays
associated with remands/adjournments.
To be chosen as one of only 20 pathfinder sites
from over 200 schemes in the country is a real
achievement for NAViGO and testament to
the excellent work undertaken by the forensic
mental health team.
The funding is part of a wider initiative
announced by Paul Burstow, minister of state for
care services, which will see £19.4 million spent
nationally on the development of new and
expanded diversion services in 2012/13.
24
memory service accreditation
The Memory Services National Accreditation
Programme works with services to assure and
improve the quality of memory services for
people with memory problems / dementia and
their carers.
It engages staff in a comprehensive process
of review, through which good practice and
high quality care are recognised, and services
are supported to identify and address areas for
improvement.
Accreditation assures staff, service users and
carers, funders of services and regulators of the
quality of the service being provided.
NAViGO went through a rigorous assessment
process which involved reviewing service user,
staff and carer feedback and auditing its own
practices against the accreditation standards.
An independent team of people, including
clinicians and a service user/carer, then visited
NAVIGO to assess the results of its findings and
to discuss best practice.
NAViGO was delighted to have achieved an
accreditation status of ‘excellent’, the top
category possible to achieve.
This means that NAViGO achieved the majority
of standards to a high level and is now a
recommended provider of Memory Services
approved by the Memory Services National
Accreditation Programme for at least two
years.
NAViGO is able to demonstrate that it meets
national guidelines and standards, such as the
NICE Quality Standard for Dementia.
25
staff survey
As a provider of NHS services, NAViGO is
required to undertake a yearly staff survey.
The survey results form part of the monitoring
required by CQC and is also used by the
Department of Health.
2011-12 saw NAViGO undertake its first staff
survey as a standalone organisation with some
impressive results.
The response rate was unprecedented and at
79 per cent NAViGO had the highest return rate
of all social enterprises within the UK.
Given NAViGO’s mission statement is to deliver
services we would be happy for our family to
use, it was pleasing to see already 75 per cent
of respondents said that if a friend or relative
needed treatment they would be happy with
the standard of care provided by NAViGO. 79
per cent also felt that care of service users is
NAViGO’s top priority, an increase of 10 per on
last year and higher than the national average
of 66 per cent.
The majority of the results showed
improvements however there were areas
identified which will be examined in more
detail.
NAViGO is developing an action plan based
on the results as it is important to continue to
improve engagement of staff and embed the
finding is employees working lives.
we hear you
loud and clear
72 %
response rate...
our best ever
we are in the
national top ten
for responses
NHS staff
survey 2011
26
“My housing is in the right location, very central to my needs. I have
been very happy content and settled where I am. I always get a
phone call and continue to support us, very friendly team.”
Comments from service users in 2011 -12
national performance reporting requirements
employment and accommodation in North East Lincolnshire
Being in sustainable employment and longterm settled accommodation are key factors
in reducing the likelihood and impact of social
exclusion for at-risk adults. It can have positive
effects on health and well-being.
This is why the Government set targets for
Mental Health providers under a Public
Service Agreement which strives to improve
employment and accommodation prospects
for people on the Care Programme Approach.
The Mental Health Minimum Data Set is the
vehicle which monitors the number of service
users on the Care Programme Approach (CPA)
in settled accommodation and employment
and informs the results of the Department of
Health Performance Framework.
NAViGO is particularly proud to be in the
top 5 performing mental health providers
in the country when it comes to securing
settled accommodation and employment
opportunities for its service users.
The trend graphs below show NAViGO’s
progress against the national England average
performance from March 2009 to September
2011 which is the latest available published
data.
*Q1 2011-12 uses internal data due to issues with the released MHMDS for the quarter.
27
Health of the Nation Outcome Scales (HoNOS)
HoNOS is an outcome measure which is used
in the clustering process known as Payment by
Results (PbR). Service users are allocated to
Care Clusters using the mental health clustering
tool based upon HoNOS (how the service user is
feeling in last two weeks) and alongside service
user history which in turn supports care planning
and enables Mental Health Payment by Results
(MH PbR).
The clustering tool supports providers and
funders of services in measuring health and
social care outcomes in mental health without
the need to collect additional data. It will also
form the basis for NAViGO’s contract and
how it will be paid from 2013-14. Rather than
issuing a block payment for services provided,
funders of services will calculate the cost of
providing services based upon the level of
need historically which will be calculated by a
fixed cost per cluster and the number of service
users in those clusters.
NAViGO has worked hard to implement HoNOS
and Payment by Results. The trend graph
below based upon the data submitted to the
Mental Health Minimum Dataset shows that as
at December 2011 almost 95% of service users
have had a HoNOS assessment recorded on
Maracis.
28
“Superb personal service. My one to one counsellor was excellent and
I felt she could relate totally to how I felt and help me to address my
feelings and thoughts. Thank you so much for your help and support
when I needed it most”
Comments from service users in 2011 -12
Improving Access to Psychological Therapies (IAPT)
Open Minds, part of NAViGO, provides the
talking therapies (IAPT) service for people with
common mental health problems in North East
Lincolnshire. Part of the national reporting
requirements for IAPT services are the IAPT Key
Performance Indicators (KPI).
NAViGO is proud to be amongst the top
performing providers of IAPT services
nationally in relation to these indicators, which
demonstrate how positive its outcomes for
service users have been in 2011-12.
The table below shows the latest data
IAPT KPI
Proportion of
referrals who
have entered
treatment
People who
have entered
treatment as
a proportion
of people with
anxiety and
depression
Proportion of
people moving
to recovery
Proportion of
service users
moving off sick
pay and
benefits
NAViGO
published by the Information Centre as at
September 2011. NAViGO is performing in the
top quarter of IAPT providers nationally.
The data shows that almost 60% of people
receiving treatment from NAViGO’s IAPT
service, Open Minds, are recovering from their
mental health problem compared with 44% on
average nationally.
12% of people accessing the service who were
on benefits and sick pay have been assisted
back into work, which is almost double the
national average percentage at just 6.6%.
Quartile
91.20%
England
Average
60.10%
Top
Benchmark
Position
8
3.10%
2.10%
Top
25
59.70%
43.90%
Top
14
12.29%
6.60%
Top
11
29
glossary of key terms
Care Quality Commission (CQC)
The CQC regulates all health and adult social care services in England, including those provided
by the NHS, local authorities, private companies or voluntary organisations. It also protects the
interests of people detained under the Mental Health Act.
Carer
A carer is someone who looks after their relatives or friends on an unpaid, voluntary basis often in
place of paid care worker.
Cognitive behavioural therapy (CBT)
This is an approach to treatment that involves working with people to help them change
their emotions, thoughts and behaviour. A person’s personal beliefs are addressed in order to
understand and change behaviour.
Commissioning for Quality and Innovation (CQUIN)
The CQUIN payment framework enables the people who fund services (commissioners) to reward
excellence, by linking a proportion of English healthcare providers’ income to the achievement of
local quality improvement goals.
Crisis team
The crisis home treatment service works directly with people who are experiencing a severe
mental health crisis and need immediate and more intensive care and treatment, mostly at
home.
Department of Health (DoH)
The DoH provides leadership for public health, the NHS and social care in England. Its purpose is to
improve England’s health and well-being and in doing so achieve better health, better care, and
better value for all.
Dual diagnosis
This refers to two or more disorders affecting one person, for example, mental illness and
learning disability. It is also used for people who have a mental health problem and also misuse
substances, such as illegal drugs, legal drugs or alcohol.
Electronic service user record
Details of a service user’s current health and history held on a computer.
Forensic Mental Health Services
Specialist services for people with mental health problems, who have been arrested, are on
remand or have been to court and found guilty of a crime.
High Quality Care for All
A national report published on 30 June 2008, resulting from a year-long review of the NHS, led
by health minister and surgeon Lord Darzi. High Quality Care for All sets out the government’s
30
approach to health policy, focusing on quality outcomes for service users rather than the speed
of delivering the service. It encompasses three key areas for measuring quality: service user
outcomes and experiences and clinical outcomes which come under the headings of ‘service
user safety’, ‘service user experience’ and ‘clinical effectiveness’.
National Institute for Clinical Excellence (NICE)
It provides clinical staff and the public in England and Wales with guidance on current treatments.
NICE is an independent organisation that provides national guidance and standards on the
promotion of good health and the prevention and treatment of ill health.
National Patient Safety Agency (NPSA)
The NPSA leads and contributes to improved, safe service user care by informing, supporting and
influencing the health sector.
NHS Connecting for Health
NHS Connecting for Health (NHS CFH) maintains and develops the NHS national IT services.
Non-executive
An individual who sits on the business board. They have the same powers and responsibilities as
directors but are not involved in the day to day running of services.
Open Minds
Open Minds provides care and support for people age 16+ who are experiencing common
mental health problems, such as stress, depression and anxiety.
Root cause analysis
Root Cause Analysis is a way of investigating the key reason why an incident occurred, to ensure
lessons are learned to prevent similar occurrences. Incidents investigated using root cause
analysis are often serious and may involve harm to a service user.
Service user
A service user is someone who uses health services and may also be referred to as: service user or
client.
Service User and Carer’s Forum
The Forum is for mental health service users and carers in North East Lincolnshire to have a say in
the planning, development and monitoring of local mental health services.
Social enterprise
A social enterprise is a business whose goals are mainly social, and whose profits are put back into
its services or the community.
Systemic Family Therapy
Family therapy can help support families through communications problems and other issues to
help improve the family environment.
Tukes
Tukes provides training, skills development and work experience in real working environments for
people with mental health problems and others.
31
statements from other organisations
about the Quality Account
North East Lincolnshire Local Involvement Network (LINk)
North East Lincolnshire
Local Involvement Network (LINk)
Hosted by VANEL at:
14 Town Hall Street, GRIMSBY, DN31 1HN
Tel: 01472 315437
Mobile: 07930 101 907
Fax: 01472 231122
Email: link@vanel.org.uk
www.nellink.org.uk
Dear Kevin Bond,
13/06/2012
RE: NAViGO Quality Accounts NEL LINk Response
North East Lincolnshire Local Involvement Network (LINk) appreciates being involved in
the NAViGO Quality Accounts. Our LINk members were given the opportunity to feedback
on the draft.
North East Lincolnshire Local Involvement Network (LINk) has had ample
opportunity to verify the commitments given in this Quality Account to
partnership working through joint working and the attendance of the NAViGO
Chief Executive at general meeting to explain the ethos and operation of the
organisation to our members. Additionally, a representative from our
Governing Body members has been given the opportunity to serve on the
Membership Board.
The Quality Account is straightforward and appears to be accurate. We would
particularly commend the robust methodology employed for deciding upon
the priorities for the coming year, and the clear and honest reporting of
performance for 2011-12. NAViGO is to be congratulated on its scoring
against the national benchmarks and this reinforces the view of the LINk that
the organisation provides high quality mental health services.
Yours sincerely,
Ian McDonald,
LINk Chair
32
NE Lincs Mental Health Service User and Carer Independent Forum
NE Lincs Mental Health Service User and Carer Independent Forum
Postal address c/o 14 Town Hall Street, Grimsby DN31 1HN
Tel/ (01472) 233312 Email:info@ nelforum.org.uk
Independent Forum members welcomed the opportunity to comment on the draft Quality
Account for 2011 – 2012. This document was discussed at the weekly Forum meeting on
13th June 2012 after it had been available for members to consider for the previous two
weeks. Members were pleased to see that the feedback from earlier consultation about
priorities for the coming year had been incorporated into the plan, underlining the value
which NAViGO places on service user and carer input in the process of planning, developing
and monitoring services. This commitment to the involvement of service users and carers
was further demonstrated in 2011 -2012 by the establishment of Community Membership as
an integral part of the management of the company, with Community Representatives
having equal status as Staff Representatives on the management boards.
Independent Forum members felt that NAViGO should be proud of the developments in
services which had taken place over the last year and which were highlighted in the report.
The achievements were particularly commendable given the huge change experienced
during the transition to a Community Interest Company.
They noted the reference to the success of the pilot of the wellbeing service and were
pleased to see a more holistic approach being taken. The tendency to treat mental illness in
isolation and to attribute physical symptoms to the mental illness has long been an irritation
to service users. This is one example of the benefits of co- location and the development of
closer relationships with GP practices. Members were also pleased to see the continuing
development of TMS, looking forward to the day when a treatment service can be
established.
With regard to performance on Quality Account priorities for 2011 – 2012 Independent
Forum members acknowledge the improvements that have been made in the service user
experience and note the intention to set further targets for these areas in 2012 – 2013 as
well as additional priority objectives. This approach demonstrates an intention of continuous
improvement.
In terms of the priority areas for 2012-2013 Independent Forum members had the
opportunity to contribute to the shortlist and agreed that the areas selected had been those
which had been raised by them over the last year as a cause for concern. In publishing
these priority areas for the coming year members felt that their feedback and contribution to
the development of services was valued.
Overall, members felt that the document was well laid out, with clear information, gave an
accurate summary of the service provision over the last year and the requirements for 20122013. The inclusion of a glossary and explanations of terms within the body of the text (eg
payment by results) were useful additions.
THE FORUM IS AN INDEPENDENT SERVICE USER & CARER INITIATIVE PROMOTING SERVICE USER & CARER INVOLVEMENT
North East Lincolnshire Mental Health (Service User & Carer) Independent Forum
Incorporated Charity Registered in England & Wales 1093511
Company Limited by Guarantee Number 4450913
Registered Office Hadley Ridge North End, Goxhill, North Lincolnshire DN19 7JX
33
North East Lincolnshire Care Trust Plus
Commissioner’s statement
The North East Lincolnshire Care Trust Plus (CTP) Board are pleased to
comment on and approve the Quality Accounts for NAViGO for 11/12.
We recognise as commissioners that 2011/12 has been another challenging
year for NAViGO with the first year as a social enterprise and the changes to
the CTP, as well as the implementation of a new mental health commissioning
strategy. These accounts reflect on the year 2011/12, which was the first year
that NAVIGO operated as a social enterprise.
The CTP has always been committed to ensuring that services are of the safest
and highest quality. We congratulate all staff for their contribution to the
achievements over the past year and their on-going work to improve the
quality of services. There will always be challenges to meet and both
commissioners and providers will strive for the highest quality in all care
provided, putting patients at the heart of everything we do. 2012/13 will
remain challenging and we have agreed the priorities of improvement
together, in order that we can have a balanced view focusing on successes
whilst highlighting areas for continued development and improvement within
2012/13.
Over the last two years, we have developed a model of care for services
valuing people working alongside the person, their families and carers to
support enablement and inclusion, and we have worked with NAViGO to
implement this service model. We have also worked closely with community
members, your representatives, to ensure we focus on those things which
mean the most to people and listen to your views of the care you received changing this when necessary and always seeking to improve.
As a result we have focused a large proportion of our time on quality, looking
at the things that really matter to our community – safe services, high levels of
customer satisfaction, and improved clinical outcomes.
We are pleased to have witnessed the on-going commitment and enthusiasm
and energy for delivering a high quality service to the public and we are sure
this will be reflected in the further development and implementation of the
quality frame and improvement in outcomes for the local community.
34
North East Lincolnshire Council
Deputy Chief Executive
Liz Jones
21 June 2012
To whom it may concern,
Re: Quality Account - NAViGO Health and Social Care Community Interest Company
On behalf of the North East Lincolnshire Health, Housing and Wellbeing scrutiny panel, thank you for
providing an opportunity to comment on the quality account for NAViGO Health and Social Care
Community Interest Company. The document gave a good overview of the achievements and
performance of the past year and details of the priorities moving forward.
Priorities – The quality account indicates that there has been wide consultation with stakeholders to
set the priorities and having community members on the board emphasises that NAViGO is
community led.
Positive outcomes – It is encouraging to see that good performance has been achieved in relation to
the percentage of service users in paid employment and settled accommodation, as this has a big
impact on wellbeing.
Performance – It would be useful to have a little more information to explain why the objective – care
for service users with dual diagnosis - had not been achieved in 2011/12.
Presentation – Although the document is quite lengthy, it is well laid out and easy to follow. The traffic
light rating system used in the performance review section makes it clear to see whether the
objectives were achieved or not in 2011/12.
Research – It is pleasing to see NAViGO’s commitment to improving the quality of care they offer
which is demonstrated through the participation in clinical research.
The scrutiny panel would welcome NAViGO to attend a future panel meeting to see the progress
being made towards the priorities outlined in the quality account, and how this is contributing to the
achievement of the following two outcomes in North East Lincolnshire Council's Council Plan for
2012/15:
All children and young people grow up healthy, emotionally secure and confident
The mental health and wellbeing of all people is improved, especially those in the most deprived
communities
It would also be a good opportunity to have earlier engagement in the development of the quality
account for 2013/14.
Yours faithfully
Cllr Elliott
Chair of the Health, Housing and Wellbeing Scrutiny Panel
North East Lincolnshire Council
35
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Copies of this Quality Account can be obtained from our website http://www.navigocare.co.uk/
index.php?id=providing-quality-services and the NHS Choices website http://www.nhs.uk
Printed copies can be obtained by contacting:
The performance team on (01472) 252366 extension 265.
36