Moving forward together
Quality accounts for 2011/12
Contents
Section 01
Tracking progress....................................................................... 02
Priorities for improvement......................................................... 04
Section 02
Regulatory information.............................................................. 07
Section 03
Patient safety..............................................................................14
Clinical effectiveness..................................................................19
Patient experience..................................................................... 24
Involvement............................................................................... 28
Feedback................................................................................... 29
Section
01
Quality accounts for 2011/12 | St Andrew’s Heathcare
01
Tracking progress
01
St Andrew’s has a proud tradition over 170 years of collaboration and innovation
– enabling us to work with others, and deliver the right services to the people
who need them. In an environment where NHS budgets are increasingly
constrained, the population is living longer and the cost of care is increasing,
this is exactly what we need to do to meet the needs of future service users.
The Secretary of State recently opened our
new medium secure mental health service in
Northampton, the award-winning William
Wake House. In the House of Commons he
described St Andrew’s as a charitable model
for the future of NHS care, and told his fellow
MPs that the new facility “...will provide
first-rate, state-of-the-art care for mental
health patients”. We are proud to have
received this recognition of the work of our
expert teams, and the value the Charity adds
to mental health care.
02
St Andrew’s Heathcare | Quality accounts for 2011/12
As a Charity we reinvest all our surpluses in
advances in care and treatment, including
brand new services. Our latest service,
St Andrew’s Nottinghamshire, includes our
national, leading innovation in medium secure
care for men with autistic spectrum
disorders, as well as being a much-needed
regional centre of excellence for secure
learning disability care. This year we have
also been busy with the refurbishment of
St Andrew’s Essex, with therapeutic areas
and accommodation being redeveloped to
provide the best possible environment for
recovery for men and women with mental
illness and personality disorders. Several
units at Northampton are also benefitting
from refurbishment in line with the latest
low secure standards.
Within all of our services, shorter lengths of
stay and a clearly defined and managed
recovery pathway are the prime focus. Learning from our service users’ views, we
have taken the lead in publishing the first
national research on key tools such as the
‘Recovery Star’, and we were chosen to be
the only independent provider pilot site in the
Implementing Recovery Organisational
Change (ImROC) programme. As part of our
vision to be a teaching hospital, in 2011/12
our clinicians published over 81 academic
papers and two books, with a strong focus
on service excellence and patient outcomes.
Over 300 service users consented to being
involved in research sanctioned by external
NHS research ethics committees.
We believe St Andrew’s has an exciting
future as the leading charitable provider of
public healthcare and a proud member of
the NHS family.
Professor Philip Sugarman
Chief Executive Officer
Tracking progress
01
Welcome to our Quality Accounts for St Andrew’s
Healthcare covering the period from 1 April 2011 to 31
March 2012. This official publication outlines the findings
of a review of our performance and our future plans to
further improve.
This recognition reflects our commitment
to delivering the highest quality of care
to our service users through excellent
clinically effective services and by providing
the best possible environment in which
they can continue their journey of recovery.
We have set ambitious targets for quality
for the coming year. We will be working
with our service users to focus on their
experiences and how we can increase
their involvement in their care.
Since our last report the Charity has been
recognised as ‘Third Sector Provider of the
Year’, our newest hospital, William Wake
House, has won a prestigious national
construction award and our catering team
won the Hotel Services category at the
‘Independent Healthcare Awards’. At a Soil
Association Best of Hospital Food event
at Clarence House, HRH Prince Charles
also commended the quality of
St Andrew’s food.
We also fully embrace the national
emphasis on quality assurance in
healthcare, and have appointed a Director
of Quality and Governance to lead a team
responsible for ensuring that the Charity
delivers safe, effective, high quality care
to all of its service users.
On behalf of St Andrew’s Healthcare I
confirm that, to the best of my knowledge,
the information in the following document
is accurate and was approved by the
Charity’s Board on 25 May 2012.
Dr Fiona Mason
Chief Medical Officer
Quality accounts for 2011/12 | St Andrew’s Heathcare
03
Priorities for improvement
01
During the 2011/12 reporting period the Charity has fundamentally reviewed
its approach to managing, developing and assuring the quality of its services.
The recommendations of this review are still being implemented. In parallel
with this work the Charity has reviewed its five year strategy and set some
ambitious targets for developing the quality of its services in 2012/13.
Over the next five years the Charity has a
strategic aim, in relation to quality, to:
“... be the market leader
providing safe, outcome
focused healthcare while
ensuring continuous
improvement and
supporting innovation.”
Quality Priorities
Our strategy has set three key objectives to
guide our achievement of this aim over the
next five years. These are:
1. To have an embedded culture of
excellence.
2. That staff, Commissioners, service users
and their carers will work together to
ensure treatment, which promotes
recovery and reduces risk, is provided in
appropriate high quality environments.
In preparing these accounts, the Charity
discussed quality priorities with service
users, staff and trustees. The results of
these conversations have led to us
agreeing the improvement priorities
for 2012/13.
The priorities for 2012/13 which
will take us towards achieving
our objectives are laid out in the
table below.
3. To provide effective clinical services led
by nationally recognised clinicians.
Why this is important
Objectives
Measurement of success
Quality
Domain
Quality
Initiative
Clinical
Effectiveness
My Shared
Pathway
We want all our service
users fully involved in decisions
about their care and treatment.
Roll out of My Shared Care
Pathway across the Charity.
Increase in service users using
My Shared Care Pathway
processes and tools.
Effective
Therapeutic
Practice
Our service users and carers
need to be assured that their care
and treatment is based on the
latest evidence based guidance.
Improve our ability to monitor
compliance with NICE
Quality Standards.
Baseline data available with audit
of compliance established.
Quality
Improvement
Plans
We need to be confident that
our investment of resources and
time in quality improvements are
locally relevant and based on
objective performance information
and service user and carer
experience and feedback.
Quality improvement plans will
be developed and implemented
for each registered location
based on sound information
and feedback from service
users and carers.
Each registered service will
provide a quarterly update on
progress against their priorities
and an end of year report.
Compliance
with essential
standards
We have not achieved full
compliance with CQC
standards in all registered
services throughout the year.
We need to improve our internal
checking process so we continue
to move towards full compliance
in all areas.
Each registered location will have
an annual schedule of internal
checks against the CQC
essential standards.
Each registered service will have
updated their current baseline
position against the minimum
standards.
Registered services’ quality
improvement plans will address
identified areas of
non-compliance will be in place.
All services will achieve full
compliance with the
essential standards.
04
St Andrew’s Heathcare | Quality accounts for 2011/12
Priorities for improvement
Quality Priorities
01
Why this is important
Objectives
Measurement of success
Quality
Domain
Quality
Initiative
Patient
Experience
Patient surveys
We want to improve how we
gather and use service user
feedback to drive continuous
improvement in patient
experience.
Introduction of service specific
patient experience reports and.
patient satisfaction surveys
All hospitals will demonstrate
quarterly improvement in patient
experience measures.
Recovery
The ImROC project covers a
number of work streams focused
of developing services based on
a recovery ethos. This is important
because it enables people’s
personal interests, strengths
and assets to be emphasised
in their recovery journey.
Complete our Improving
Recovery project (ImROC).
Project milestones achieved.
Complaints
On too many occasions last
year it took us too long to respond
to people’s complaints. We need
to ensure when things do go
wrong our service users and
their carers get a full and timely
response and are assured that
we are improving our services
where required.
Improvement in complaints
management and reporting.
95% of complainants will get a
full response to their complaint
within 30 days.
Therapeutic
activity
‘Star Wards’ is a national initiative
which supports wards to
improve people’s experience while
in hospital. It has a particular focus
on encouraging recreational and
meaningful activity on wards.
Each registered service to
achieve a minimum of 50% of
their wards with ‘Star Wards’
accreditation by the end of
the year.
All registered locations to include
their plans to achieve ‘Star Wards’
accreditation in their annual
quality plan.
Hospital out
of hours
Our service users and carers
need to be confident that all
our registered services are as
capable of managing urgent
healthcare situations as safely at
night as they do in the day.
Strengthen our resilience to
manage all healthcare events
and situations in all our registered
services at any time of
day or night.
Achieve 24 hour hospital project
milestones for 2012/13.
Low secure
standards
Our service users in low secure
areas should be confident that
their wards meet the new
national standards.
Ensure nominated low secure
wards meet the new low
secure standards.
100% of low secure wards have
completed a gap analysis and low
secure wards are compliant with
low secure standards.
Prescribing
Our service users need to be
assured that they are prescribed
medicine safely and in line with
guidelines.
Introduce a Charity wide Prescribing
Formulary and new procedures
for off licence prescribing.
100% of prescribing is compliant
with Formulary and off license
procedure.
Patient Safety
This report will be used regularly to monitor performance against
targets and invite feedback from our partners. St Andrew’s will
track progress in the following ways:
• Document the targets and key information on our intranet
• Report updates against targets to Board meetings
• Invite input on key targets and ongoing performance
from service users.
Quality accounts for 2011/12 | St Andrew’s Heathcare
05
Section
This section provides information in the
official format required under the National
Health Service (Quality Accounts)
Regulations 2010.
Part 2, containing the information relevant to the quality of NHS
services provided or sub-contracted by the provider during the
reporting period which is prescribed for the purposes of section
8(1) or (3) of the 2009 Act by paragraph (2).
Reporting period: 1 April 2011 to 31 March 2012
Name of provider: St Andrew’s Healthcare
06
St Andrew’s Heathcare | Quality accounts for 2011/12
02
Regulatory information
02
St Andrew’s
Healthcare provided
services in the field of
mental health, learning
disability and brain
injury to over
700
service users
Review of services
Participation in clinical audits
During the reporting period 1 April 2011
to 31 March 2012 St Andrew’s Healthcare
provided services in the field of mental
health, learning disability and brain injury to
over 700 service users, commissioned by
more than 130 different NHS Services
or organisations.
During the reporting period 1 April 2011 to
31 March 2012, four national clinical audits
and zero national confidential enquiries
covered NHS services that St Andrew’s
Healthcare provides.
St Andrew’s Healthcare has reviewed all
the data available to them on the quality of
care in respect of all the services for which
it provides clinical NHS services.
The income generated by the services
reviewed in 2011/12 represents 100%
of the total income generated from the
provision of NHS services by St Andrew’s
Healthcare for 1 April 2011 to 31 March 2012.
During that period St Andrew’s Healthcare
participated in 100% of the national clinical
audits it was eligible to participate in.
The national clinical audits that St Andrew’s
Healthcare was eligible to participate in
during the reporting period are zero
confidential enquiries and four national
clinical audits.
The national clinical audits and national
confidential enquiries that St Andrew’s
Healthcare participated in during the
reporting period were:
Audit
• Prescribing Observatory for
Mental Health
- Prescribing antipsychotics for people
with dementia
- Assessment of the side effects
of depot antipsychotics
- Monitoring of service users prescribed
lithium
- Use of antipsychotic medication
in CAMHS.
The national clinical audits and national
confidential enquiries that St Andrew’s
Healthcare participated in, and for which
data collection was completed during the
reporting period 1 April 2011 to 31 March
2012, are listed alongside the number of
cases submitted to each audit or enquiry
as a percentage of the number of
registered cases required by the terms
of that audit or enquiry.
Participation
Participant numbers*
Sample size
Prescribing antipsychotics for people with dementia
Yes
40 service users
100%
Assessment of the side effects of depot antipsychotics
Yes
72 service users
100%
Monitoring of service users prescribed lithium
Yes
18 service users
100%
Use of antipsychotic medication in CAMHS
Yes
64 service users
100%
*Figures based on service users who met the criteria in the auditing period.
Quality accounts for 2011/12 | St Andrew’s Heathcare
07
Regulatory information
The reports of two of the national clinical
audits were reviewed by St Andrew’s
Healthcare during the reporting period
1 April 2011 to 31 March 2012 and we
intend to take the following actions to
improve the quality of healthcare provided:
Prescribing antipsychotics for
people with dementia
• Discussed and reviewed at Medicines
Management Group
• Action plan developed and in place
• Pharmacy Newsletter to staff regarding
the audit results and required actions
• Medicines Policy updated (for issue April
2012) and Medication Care plans under
development for key high risk medicines
or areas of prescribing including
prescribing in dementia
• Initial medication care plans already on RiO,
our electronic patient record system
• Medication training is also under review
– training plan developed and sent to
training team to develop new medication
training in line with updated medicines
policy and procedures during quarters
1 and 2 in 2012/13.
Assessment of the side effects
of depot antipsychotics
• Discussed and reviewed at Medicines
Management Group
• Action plan developed and in place
• Pharmacy newsletter to staff regarding
audit and results and required actions
• Medicines Policy updated (for issue April
2012) and Medication Care plans under
development for key high risk medicines
or areas of prescribing
• Depot care plans already on RiO
include requirements for monitoring
and a recommendation of side effect
monitoring tool
• Currently assessing how the tool could
be added to RiO as a template.
The reports of a further 110 local clinical
audits were reviewed by St Andrew’s
Healthcare in the reporting period and we
intend to take a range of actions to improve
the quality of healthcare provided.
Further details are available
electronically from the Clinical
Audit team; please email
lewilson@standrew.co.uk
for this information.
There were 319 service users receiving
NHS services provided or sub-contracted
by St Andrew’s Healthcare during the
reporting period 1 April 2011 to 31 March
2012 who were recruited during the period
to participate in research approved by a
research ethics committee.
Use of the CQUIN payment
framework
A proportion of St Andrew’s Healthcare’s
income in the period 1 April 2011 to 31
March 2012 was conditional on achieving
quality improvement and innovation goals
agreed between St Andrew’s Healthcare
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.
The Charity achieved 100%
CQUIN payment.
Further details of the agreed goals
for the reporting period and for the
following 12 month period are
available electronically by emailing
our contracting team at the following
address; aspencer@standrew.co.uk
St Andrew’s Healthcare has eight
registered locations:
St Andrew’s Healthcare is required to
register with the Care Quality Commission
and is currently registered for:
1. Adolescent Service
• Assessment or medical treatment of
persons detained under the Mental
Health Act.
2. Men’s Service
3. Neuropsychiatry Service
4. William Wake House
5. Women’s Service
6. Essex
St Andrew’s Healthcare currently has the
following conditions on registration
7. Birmingham
• The registered provider must not provide
services for people under thirteen years
of age at the location St Andrew’s
Healthcare, Adolescent Services,
Northampton
Each location is subject to periodic review
by the Care Quality Commission. Between
1 April 2011 and 31 March 2012 St
Andrew’s Healthcare has had eight
unannounced visits across its registered
locations. During this time period the
CQC have not published any enforcement
actions against any of St Andrew’s
Healthcare registered locations.
• The registered provider must only
accommodate a maximum of 132 service
users at the location St Andrew’s
Healthcare, William Wake House,
Northampton.
St Andrew’s Heathcare | Quality accounts for 2011/12
Research
Statements from the Care Quality
Commission
• Treatment of disease, disorder or injury
08
02
9. Nottinghamshire
St Andrew’s Healthcare has not
participated in any special reviews or
investigations during the reporting period.
Regulatory information
02
The table below provides a summary of the findings of each of the six most recent published 1 visits for each registered location. It also
provides an update on the actions St Andrew’s Healthcare has or is in the process of taking to address the areas identified for improvement.
Registered
Location
Date of Last
Inspection
Standards
Checked
Outcome of
Inspection
Improvement
Actions Identified
Progress
Adolescent Service
13/01/2012
1
Compliant
N/A
N/A
4
Compliant
N/A
N/A
7
Compliant
N/A
N/A
10
Minor concerns
14
Compliant
N/A
N/A
16
Compliant
N/A
N/A
Standards
Checked
Outcome of
Inspection
Improvement
Actions Identified
Progress
Registered
Location
Date of Last
Inspection
Birmingham**
Need for improvements
All requirements for
in cleanliness and
improvement have now
maintenance of environment
been met. At the time of
in John Clare and
writing this report we
Church Wards.
were awaiting the outcome
of unannounced visit on
08/03/2012*.
Has not been inspected since registration
Registered
Location
Date of Last
Inspection
Standards
Checked
Outcome of
Inspection
Improvement
Actions Identified
Progress
Essex
20/07/2011
4
Moderate concerns
Need for improvements
in ensuring service users
have the opportunity to
review and comment on
their care plans.
The location has developed
its care planning process to
ensure service users always
have the opportunity to
contribute to their care plan.
7
Compliant
N/A
N/A
10
Compliant
N/A
N/A
14
Compliant
N/A
N/A
16
Compliant
N/A
N/A
21
Compliant
N/A
N/A
Registered
Location
Date of Last
Inspection
Standards
Checked
Outcome of
Inspection
Improvement
Actions Identified
Progress
Men’s Service
31/10/2011
1
Compliant
N/A
N/A
4
Compliant
N/A
N/A
7
Compliant
N/A
N/A
10
Compliant
N/A
N/A
14
Compliant
N/A
N/A
16
Compliant
N/A
N/A
Quality accounts for 2011/12 | St Andrew’s Heathcare
09
Regulatory information
02
Registered
Location
Date of Last
Inspection
Standards
Checked
Outcome of
Inspection
Improvement
Actions Identified
Progress
Nottinghamshire***
28/02/2012
1
Compliant
N/A
N/A
2
Compliant
N/A
N/A
4
Moderate concerns
7
Major concerns
An alleged safeguarding
incident had not been
reported to the CQC.
All safeguarding allegations
are now reviewed daily by
the senior management
team and reported to
safeguarding and CQC in
line with policy.
13
Major concerns
Excessive use of
agency staff.
Increased local recruitment
activity and a significant
number of vacant posts
have been filled.
One service user did not
Improved process for
have an up to date copy of updating care plans in ward
care plans in their paper file. rounds and ensuring all care
Some care plans did not
plans are updated in paper
always pick up on all the
files following ward rounds
information from the
have been introduced.
assessments.
A work plan to establish a
local staff bank system has
been brought forward.
Developed an approved list
of agency staff that have
worked regularly for the unit
and had full induction.
Daily checking of staff
rosters to ensure best
deployment of available
resources across the
location.
In the interim we deployed
additional resources from
our main site in
Northampton.
14
Moderate concerns Insufficient staff supervision
Increased number of ward
team meetings.
Introduced one to one
monthly management
supervision sessions for all
staff in addition to
established clinical
supervision meetings.
Strengthened ward
management.
16
Major concerns
Management oversight
of safeguarding allegations.
Actions as per outcome 7.
Inadequate staff supervision. Outcomes as per outcome 14.
Some gaps in seclusion
registers.
10
St Andrew’s Heathcare | Quality accounts for 2011/12
Daily review of seclusion
registers by ward managers
/nurse in charge.
Regulatory information
Registered
Location
Date of Last
Inspection
Neuropsychiatry
Standards
Checked
Outcome of
Inspection
02
Improvement
Actions Identified
Progress
Has not been inspected since registration
Registered
Location
Date of Last
Inspection
Standards
Checked
Outcome of
Inspection
Improvement
Actions Identified
Progress
William Wake House
14/02/2012
4
Minor concerns
Care plans were not
always written in a
personalised way.
Care plans are regularly
reviewed in ward rounds
to ensure personalisation.
Additional staff training has
been provided.
7
Minor concerns
Service users did not
always have access to
appropriately sized safe
clothing when put in
seclusion.
Additional stocks and range
of sizes of safe clothing have
been ordered and are now
available.
Registered
Location
Date of Last
Inspection
Standards
Checked
Outcome of
Inspection
Improvement
Actions Identified
Progress
Women’s Service
13/02/2012
4
Minor concerns
Service users did not
always understand why
restrictions were placed
upon what they were
allowed to do.
Developing improved easy
to read materials on how
service users are given
increased levels of personal
responsibility in line with
reduced levels of risk
behaviour.
Some staff were not
Increasing Healthcare
adequately trained to support
Assistant training in
service users in understanding communicating with people
why they were not allowed
with learning disabilities.
to do certain things.
7
Moderate concerns Records for a service user in Staff training and supervision
seclusion did not adequately
to ensure they record all
describe what had happened antecedents to restraint and
prior to the events that led
seclusion events.
to seclusion.
All incident reports of
restraint or seclusion to
include antecedent events.
*At the time of writing the CQC had issued a draft report following a visit to the Adolescent Service on 08/03/12.
The Service was found to be compliant in all areas.
**At the time of writing the CQC had issued a draft report following a visit which took place on 05/04/12 and 10/04/12.
The Service was found to be compliant in all areas inspected.
*** Nottinghamshire has had two visits in this year. The first visit was on 15/09/11 and the second visit was on 28/02/12. A follow up visit
took place at St Andrew’s Nottinghamshire on 12/04/12 and the Service was re-assessed and found to be compliant in outcome 16.
Quality accounts for 2011/12 | St Andrew’s Heathcare
11
Regulatory information
St Andrew’s Healthcare will
be developing a revised
Data Quality Strategy for
2012/13 including an
improvement plan focusing
on areas where an
improvement in data quality
is required or where there
is a requirement for already
excellent data quality to
be maintained.
Data quality
Good quality data underpins the effective
delivery of service user care at St Andrew’s
Healthcare. The Charity strives to be able
to produce accurate and timely information
which can be used to influence management
decisions and the effective care of our
service users.
St Andrew’s Healthcare continues to ensure
that the information we record, hold and
use in the treatment and care of our
service users:
• is updated and validated in a timely manner
• is monitored for accuracy and completeness
• complies with the NHS national clinical
coding ensuring consistency in reporting
information that can be comparable with
other organisations.
St Andrew’s Healthcare will be developing
a revised Data Quality Strategy for 2012/13.
The new strategy will focus both on areas
where it is recognised that an improvement
in data quality is required, alongside
maintaining those areas with existing
excellence in data.
Throughout the coming year we will be
introducing an audit schedule which will
monitor and track scheduled Information
Governance audits. We will also be looking
to support data quality across the Charity
through exciting new developments such
as the introduction of a Data Warehouse
and the Information Asset Owner projects.
12
St Andrew’s Heathcare | Quality accounts for 2011/12
02
NHS Number and General Medical
Practice Code Validity
St Andrew’s Healthcare did not submit
records during the reporting period 1 April
2011 to 31 March 2012 to the Secondary
Uses service for inclusion in the Hospital
Episode Statistics which are included in the
latest published data.
Information Governance Toolkit
attainment levels
Our Information Governance Assessment
Report score for the reporting period
1 April 2011 to 31 March 2012 was 48%
of the toolkit requirements and was graded
Red*. To achieve a “satisfactory” rating,
we need to comply with all requirements to
a standard of level 2 or above. A significant
Information Governance project has been
initiated within the Charity that will ensure
we achieve a better assessment in the
2012/13 reporting period. The project
involves the completion of a full records
inventory throughout the Charity, which
will enable us to identify areas that
require better standards of data quality
to be applied
* Our percentage is not calculated from 100% as
there are a number of elements which we are not
required to comply with. This figure therefore
represents 78% as an overall score.
Clinical coding error rate
St Andrew’s Healthcare was not subject
to the Payment by Results clinical coding
audit during the reporting period by the
Audit Commission.
Section
03
Review of quality performance
In preparing last year’s Quality Accounts, we discussed
our priorities with service users, staff and trustees.
The results of these conversations led us to agree the
following improvement priorities for 2011/12.
Quality accounts for 2011/12 | St Andrew’s Heathcare
13
Patient safety
03
On track with patient safety
Making Services Safer
Keeping people safe is a top priority for
the Charity. We do everything we can to
provide a safe and secure environment for
service users, staff and visitors, but we
also recognise that unplanned events can
and do happen when providing healthcare.
We know that having systems in place to
identify, respond appropriately and learn
from these events is crucial to achieving
our goal of clinical excellence.
The Charity has made many improvements
during the year which has helped to make
services safer. These include:
• Strengthening our processes for
assessing the safety of new and
existing equipment and furniture.
This has significantly improved the
safety of our care environments.
Serious Untoward Incidents (SUI’s)
The Charity has worked hard to improve
incident reporting and to make services
safer by learning from incidents. This year
we have seen incident reports increase
overall and the number of incidents which
are graded as ‘serious’ reduce. This
suggests an overall improvement in the
safety of our services and indicates a
positive cultural shift with regards to
clinical quality. This was achieved alongside
a marked increase in occupancy.
• Ensuring clients with identified physical
health problems get earlier proactive
physical health reviews thus helping to
reduce medical emergencies.
• Improved and appropriate management
of Serious Untoward Incidents (SUI’s)
includes learning lessons and
re-designing services based on safety
and risk. Where recommendations from
governing bodies have been made,
implementation of improved processes
and practices has been carried out,
resulting in a safer environment with
enhanced governance.
Safety Management Systems
• Developing the role of our pharmacy
technicians on the wards, this is improving
the safety of our medicines management.
• Introducing a ‘Falls team’ to ensure
prevention and care planning for falls is
in place for our ‘at risk’ service users.
The Charity has retained its British Safety
Council (BSC) 5 Star Award for Health
and Safely Management Systems in
Northampton and Birmingham. We have
also gained BSC recognition for our site
in Nottinghamshire.
• Roll out of a standardised risk assessment
tool linked to service users’ care plans.
This allows clearer communication about
risk issues and ensures that care plans
are aligned to improve safety.
Year total SUI’s
2011
2010
0
20
40
60
80
100
120
140
160
180
200
220
240
260
280
300
320
Monthly % SUI’s (All incidents)
2011
2010
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
This achievement has been supported by improving the processes we use for reviewing our most serious incidents,
and ensuring the plans we agree for improvements are completed.
14
St Andrew’s Heathcare | Quality accounts for 2011/12
340
360
Patient safety
Essen Climate Evaluation Scale
(EssenCES)
EssenCES remained an important priority
for the last year. This indicator is part of the
Commissioning for Quality and Innovation
(CQUIN) payment framework and a Care
Quality Commission requirement.
This scale explores how much service
users feel safe and supported, by both their
peers and care staff. Evidence suggests
that service users respond better, engage
more and recover faster where they feel
safe and comfortable.
In 2011/12, the Charity focussed on service
user perceptions of the ‘risk status’ system.
We implemented a number of initiatives
that relate to the areas of Therapeutic Hold,
Patient Cohesion and Experienced Safety
for all services, with the exception of
Neuropsychiatry. Over the last year these
were regularly tracked and a range of
outcome measures have been recorded
including rates of attendance at therapeutic
sessions, service user and staff
satisfaction, positive behaviour changes
and staff education.
Examples
‘Therapeutic Hold’ has improved via the
proactive engagement of service users in
one to one sessions and ward based
activities. In Birmingham this included the
involvement of the Geese Theatre
Company. Therapeutic drama based
sessions were held for service users to
explore changing behaviour and rehearse
03
new skills and strategies for dealing with
the issues that they come across everyday
on the wards. The service users that took
part were asked to complete self-reports
about the project topic, before and after
the sessions. They were also interviewed
to help evaluate their views of what they
have gained from the project.
“I learned more confidence, how to listen
to others more efficiently, how to ‘think on
my feet’ and how to deal with potentially
difficult situations.”
Service User
St Andrew’s Birmingham
“I learned more confidence,
how to listen to others
more efficiently, how to
‘think on my feet’ and how
to deal with potentially
difficult situations.”
Service User
St Andrew’s Birmingham
‘Patient Cohesion’ initiatives have included
the ‘Living Together’ group, a social
gathering and the community meeting.
On Robinson ward, in William Wake House,
engagement has been very positive with
both staff and service users welcoming the
opportunity to work collaboratively to find
solutions to issues on the ward through
role play. The meetings were well attended
with only one service user out of the 17 on
the ward declining to participate. There are
plans to further extend the meetings to a
suggestion box and monthly service
user forum.
Both of these initiatives have contributed
to an increase in ‘Experienced Safety’.
Quality accounts for 2011/12 | St Andrew’s Heathcare
15
Patient safety
Design manual
We are committed to providing well
designed healthcare environments.
We want to create safe, homely spaces
that people feel comfortable living in as
they recover.
We need to make sure that our hospitals
provide safe and secure environments for
service users and staff. Agreed quality
standards and sharing information on
product testing has meant that all of our
facilities can learn from past experience.
In 2010/11, the Charity developed a design
guide which sets standards for the quality
of our hospital environments. The guide
builds on the national regulatory standards,
and includes information to make sure that
any development or refurbishment meets
and (where appropriate) exceeds those
requirements. It also helps colleagues to
learn from the Charity’s experience and
share information about environments and
products for particular service user groups.
The design guides are a framework for our
clinical environments. There has been a
collaborative approach across the Charity
with staff and service users assisting in
the development of the manuals.
During 2011/12 we worked with service
users to develop the guide further, and
16
St Andrew’s Heathcare | Quality accounts for 2011/12
03
include specifications for specific room
types. Design guides for Medium Secure,
Low Secure and Psychiatric Intensive Care
Units were launched in October 2011 for
inclusion in all projects including
refurbishments. The guide prevents
unnecessary risks and identifies areas that
may be susceptible to problems. This
includes information on products tested,
to minimise risk and encourage shared
learning without stopping creativity.
The Charity has looked at seclusion rooms
and the necessary requirements to ensure
staff and service user safety. This was
done through using a range of methods
including 2D plans, 3D modelling and visits
to secure sites such as Rampton high
secure hospital.
The next stage of the project is to design
and build a prototype to allow thorough
testing of all design elements to ensure we
have a robust and cost effective solution.
A total of 36 environmental incidents have
been reported over the two year period.
There has been an increase of 25% from
2010/11 to 2011/12. This increase can be
attributed to two new services opening,
Nottinghamshire in September 2010 and
William Wake in December 2010. All other
services show a decrease of 38% in
reported incidents.
38%
decrease in reported
incidents
Patient safety
Safe access to technology
Many secure mental healthcare providers
routinely prevent service users from
accessing technology; however we make
every effort to help people access
technology for work, leisure, education
and communication and so we focus on
managing access and risk assessing
individuals to ensure they access
technology safely.
In 2011/12, we dedicated more resources
and support to service users. This included
risk management training sessions and
providing regional testing equipment.
The Charity’s ‘Patient Access to
Technology Group’ organised training on
managing risks safely which was run
through a full day workshop with over 70
members of staff attending from across all
four sites. The session aimed to highlight
to staff the technology that is available
to service users and how to manage
risks safely.
We have increased resources for forensic
screening by the recruitment of an IT
Security and Digital Analyst. We have also
supported our security teams across all
sites by offering them digital forensic triage
training which has reduced the time it
takes for devices to be returned to service
users. We are the only independent mental
healthcare provider to have a digital
forensic lab that inspects technology in
accordance with the Association of Chief
Police (ACPO) guidelines. In addition to the
03
forensic lab in Northampton, we are looking
to establish secure areas in Birmingham,
Essex and Nottinghamshire.
Investigation into the potential for a
music library is still underway including
supervised access to sites such as iTunes
where service users are able to download
music. The service user intranet project is
currently being reviewed and resources,
both clinical and IT, are being evaluated
to make further progress.
We have explored various ways of helping
service users connect with relatives. We
have now introduced secure PC based
video conferencing which ward staff can
access via a ward laptop or education PC.
The system allows service users to stay in
touch with family and friends where
contact would otherwise have been
problematic. It has also been used to allow
service users to virtually attend remote
tribunals or court appearances with the
minimum of disruption to their routine.
Ben Meade, Head of IT Support Services
at St Andrew’s, says: “Because of the
security built in to the system, we can
use it for virtual meetings between staff.
We can also provide a confidential and
convenient environment at any of our sites
for our service users to keep in touch with
their friends, family and care team.
travelling costs. We have also been able to
provide a truly international service to our
customers, linking up a service user in
Northampton with a member of their care
team who was away in India and family
members in Abu Dhabi in the UAE. We
realised that it also offered real benefits to
people using our services for deaf people,
because they can still benefit from seeing
a British Sign Language interpreter.”
Many secure mental
healthcare providers
routinely prevent service
users from accessing
technology; however we
make every effort to help
people access technology
for work, leisure, education
and communication use.
“It was easy to set up a trial of the system
and we soon realised that it would be
valuable to improve collaboration between
our multi-disciplinary teams, and save
Quality accounts for 2011/12 | St Andrew’s Heathcare
17
Patient safety
03
“Because of the security built in to the system, we can use it for virtual meetings
between staff. We can also provide a confidential and convenient environment at any
of our sites for our service users to keep in touch with their friends, family and care team.
It was easy to set up a trial of the system and we soon realised that it would be
valuable to improve collaboration between our multi-disciplinary teams, and
save travelling costs. We have also been able to provide a truly international service to
our customers, linking up a service user in Northampton with a member of their care
team who was away in India and family members in Abu Dhabi in the UAE.
We realised that it also offered real benefits to people using our services for deaf people,
because they can still benefit from seeing a British Sign Language interpreter.”
Ben Meade
Head of IT Support Services at St Andrew’s
18
St Andrew’s Heathcare | Quality accounts for 2011/12
Clinical effectiveness
Recovery planning
Recovery is a key focus for the Charity. We
aim to put service users at the centre of
their care; to help them to explore what is
right for them and live the best life they
can, in the context of their mental illness.
By working in partnership, a person’s life
experiences and understanding of their
own illness is recognised and valued.
As a pilot site for Implementing Recovery:
Organisational Change (known as ImROC),
we have reviewed and challenged our
existing services to find ways to build
on existing good practice.
All service users, with the exception of
those within our Neuropsychiatry service,
are offered the opportunity to complete a
recovery plan appropriate to their needs.
This is typically Recovery Star or Teen
Stars for adolescents. Service users are
encouraged to review the plans at least
every six months and develop and review
actions as part of this process
We monitor the uptake and report quarterly
on performance of the ImROC project
through CQUIN reports.
ImROC progress and achievements
so far include:
03
• The introduction of a core group with
indentified leads for the six work streams
• Establishing a Recovery Forum
with representation from all of our
registered hospitals
• Roll out of workshops across the Charity
to increase awareness of recovery for
staff and service users
• An increase in service user involvement
in training, including at staff induction and
participating in focus groups to be used
in future training.
A group of female service users participated
in the recently introduced Research
Training Programme, in collaboration with
the University of Northampton, which has
had an extremely positive impact on both
service users and staff. The group has
been a role model to not only their peers
but also to staff on what can be achieved.
We aim to involve service users in all
aspects of the Charity, including research
and with this project the service users
were leading the group in the direction that
they chose. Having successfully completed
phase one of the project they are now very
excited about moving on to phase two and
looking at how their findings can influence
improvements and developments in services.
Quality accounts for 2011/12 | St Andrew’s Heathcare
19
Clinical effectiveness
“Mental healthcare which
focuses on an individual’s
needs and hopes for
recovery is increasingly
acknowledged as a key
element in achieving
positive and lasting change.”
Dr Geoff Dickens
Mental health nurse and academic
at St Andrew’s
20
St Andrew’s Heathcare | Quality accounts for 2011/12
Recovery planning
Rachel West, Head of Clinical Services,
Women’s Service said:
“The project was an opportunity to enable
service users to participate in research in a
meaningful way. The growth of the individuals
in the group in terms of confidence, willingness
to share ideas, getting to know new people,
listening and respecting was well worth the
challenge of setting up the group.”
The Recovery Star is another key tool that
the Charity has been using to help mental
health staff and service users discuss
recovery, and to provide a measurement of
progress across a range of issues strongly
believed to be key in the recovery journey.
Importantly, the tool emphasises the
uniqueness of each individual’s recovery
from mental illness, and is particularly
focused on human issues like identity, hope
and self-esteem rather than on symptoms.
03
Lead author Dr Geoff Dickens, a mental
health nurse and academic at St Andrew’s,
said: “Mental healthcare which focuses on an
individual’s needs and hopes for recovery is
increasingly acknowledged as a key element
in achieving positive and lasting change.”
“It is important that tools are available to help
professionals to provide this recoveryorientated care. The work we have
undertaken shows promising early signs that
the Recovery Star has the potential to do this,
and points a clear way forward for further
development of the tool.”
Our service users have also been working
with the Mental Health Providers Forum in
conjunction with Triangle Consulting in
developing the Secure Star, an adaptation of
the Recovery Star for secure environments
Clinical effectiveness
Care Programme Approach (CPA)
The Charity follows the Care Programme
Approach (CPA), a national clinical
framework for supporting people with
complex mental health needs. Every
service user has an individual care plan,
and an appointed care co-ordinator, who
meet individual service users at least
weekly to discuss their care plan and
how things are going.
Through CPA, we support service users to
help them achieve optimal mental health
and recovery. The focus is on working in
partnership with service users to plan and
manage their treatment programmes. This
helps them to move out of secure care and
back into the community.
In 2011/12 we reviewed our CPA
processes, to bring together clinical
practice and the contractual requirements
of our Commissioners. This work will
continue through 2012/13 including,
refreshing our policy and agreeing key
roles and responsibilities.
From the review all administration has now
been standardised and training for key
workers and clinical secretaries will be
rolled out this year. The role of our
CPA measures as part of the Charity’s
performance management framework
is still under review.
Service users’ views have been an
important part of the process too, with
their contribution at workshops and forums
to discuss both the design of the CPA and
the service user experience. In February
and March 2012 service users attended a
number of workshops and forums to look
at the service user ‘Twenty Defined
Standards’ from the Yorkshire & Humber
region. Service users have currently added
another twelve that they would like to be
adopted by the Charity in its commitment
to service users, their families and
Commissioners.
03
In quarter three of the reporting period we
conducted an audit with 421 service users
across the Charity. The results of the audit
provide us with a measure to compare
against as we embed My Shared Pathway
and the revised standards into our practice.
This change will be reflected in a further
review of CPA process to demonstrate
a more recovery focussed process.
A summary of the results is shown below.
In quarter 3 of the reporting period we
conducted an audit with 421 service
users across the Charity.
89%
82%
7%
Feedback from service users and from
staff is being collected throughout this pilot
phase by the co-ordinators, as well as more
formal individual feedback provided by both
groups through the evaluation team from
York University, led by Dr Liz Hughes.
The information gathered from the pilot
study will allow My Shared Pathway to be
rolled out across all secure services with
the aim of 100% compliance by 31 March
2013. The progress will be reported
quarterly through CQUIN reporting.
were able to identify their
key worker
had been given an
explanation of CPA
did not know if they had
been given an explanation
Respondents rated their current level of
involvement in their CPA using the scale
of 1 (not at all involved) to 5 (fully involved).
26%
25%
rated their level of
involvement 1 or 2
rated their level of
involvement 4 or 5
The My Shared Pathway project will
allow service users to actively shape
CPAs further.
We are using My Shared Pathway
workbooks to further engage service
users, and then provide feedback on
their experiences. Two of our hospitals,
St Andrew’s Birmingham and St Andrew’s
Essex, are participating in the national pilot
scheme of the My Shared Pathway
workbooks, with each hospital identifying
ten service users from the male mental
health pathway, who were willing to take
part in the pilot study.
Quality accounts for 2011/12 | St Andrew’s Heathcare
21
Clinical effectiveness
03
You are working with a difficult patient group, who often
have very poor diabetic control. The service users who
are controlled have fantastic control, many of whom have
an HbA1c of less than 6%. This is very rare in general
practice and again is down to your professional care.
I also wanted to mention the high quality of record keeping
I witnessed and the obvious dedication by your team.”
Jo Perez
Diabetes Specialist Nurse Advisor, National Service for Health Improvement
10%
of service users
are diabetic
Enhancing physical healthcare
Like everyone else, people with mental
health difficulties need access to good
physical healthcare. Regular health checks,
screening programmes and vaccinations
mean we can identify possible problems
and ensure service users get any treatment
they need.
Physical health was a continued priority for
us last year. A high proportion of people
referred to us have diabetes - around 10%
of service users are diabetic, compared to
a national average of 4% (source: Diabetes
UK, 2009). In 2010, we piloted a structured
six-week programme to help diabetic
service users to manage it themselves
with support from staff.
22
St Andrew’s Heathcare | Quality accounts for 2011/12
Both primary care and physical healthcare
nurses have been working collaboratively
with key clinicians, including dieticians, to
ensure that the National Institute for Health
and Clinical Excellence quality standards
for diabetes in adults are being worked
towards. In addition to this an external
audit of diabetes control (HbA1c) was
conducted by a Diabetes Specialist Nurse
from the National Service for Health
Improvement. The team identified diabetic
service users with an increased HbA1c for
a baseline and then an intense programme
was introduced for those individuals with
poor control, as this leads to an increased
risk of complications.
Clinical effectiveness
“You are working with a difficult patient
group, who often have very poor diabetic
control. The service users who are
controlled have fantastic control, many of
whom have an HbA1c of less than 6%.
This is very rare in general practice and
again is down to your professional care.
I also wanted to mention the high quality
of record keeping I witnessed and the
obvious dedication by your team.”
Jo Perez
Diabetes Specialist Nurse Advisor
National Service for Health Improvement
We have undertaken a number of other
physical healthcare initiatives during the
reporting period. All new service users
arriving at our Northampton site are
assessed by our practice nurses who are
able to identify any primary healthcare
needs and put care plans in place for
issues such as nutrition, physical activity,
glycaemic control and diabetes.
During the reporting period we reviewed
the objective around cleanliness and
developed a ‘Cleanliness’ electronic KPI
tool. The tool was completed Charity-wide
by Facilities Managers on a quarterly basis
and recorded on the electronic Matrix
system for quality assurance.
We have successfully exceeded the World
Health Organisation influenza vaccination
target of 75% for over-65s, with 80% of
our service users aged over 65 receiving
the vaccination during 2011/12. We
achieved 56% in 2011/12 for the number
of under-65s and we aim to increase this
to 75% in 2012/13.
25 hours therapeutic activity
Since 2007, medium secure healthcare
providers have been required to provide
25 hours of therapeutic activity to each
service user weekly. Activity and
engagement are often closely linked,
so we aim to fully engage service users in
focusing on their recovery. That way, they
understand what is happening and can sign
up to the benefits of getting involved.
The Charity follows the 2007 Offender
Partnerships Best Practice Guidance for
Mental Health Services.
Evidence suggests that boredom and
reduced motivation results in poorer clinical
outcomes for service users in secure care.
This work promotes a balanced and
structured day of meaningful activity, linked
to agreed care plans that promote recovery.
03
An audit of services using a benchmarking
tool in September 2011 demonstrated that
we were 96% compliant with action plans
in place for each service to improve.
The service action plans are reviewed
quarterly to further improve quality.
We have been working on developing a
new performance framework tool which
involves adapting the ‘community diary’
on our patient records system to develop
timetabling modules linking to progress
notes, and help us to record and report
activity hours.
We will shortly be trialling the new system
and should be ready to launch in 2012/13.
To align the Charity’s systems and
treatment programmes with the agreed
national definition of ‘meaningful activity’
we have implemented a standard template
known as a Pre Admission Assessments
Form (PAAF). This tool allows clinicians to
link an individual’s identified needs to a
care plan and their treatment. To ensure it
is meaningful activity, each of our services
has a directory of therapeutic activity which
is monitored by the Effective Therapeutic
Practice Group (ETPG).
The Charity’s aim is to achieve the targets
set nationally and in the reporting period
we have achieved all targets relating to
25 hours of therapeutic activity.
We now vaccinate
80%
of over 65s
against influenza.
This successfully
exceeds the WHO
target of 75%
Quality accounts for 2011/12 | St Andrew’s Heathcare
23
Patient experience
03
His Royal Highness,
The Prince of Wales,
praised the quality of food
we provide to service users
He made the comments
during a reception hosted
at Clarence House.
Dining
Food quality and menu choices are very
important to the daily life of most service
users. By giving people freshly-cooked,
tasty produce we can help improve their
quality of life as well as their physical and
mental health. We aim to maintain the high
level of service user satisfaction that we
had last year.
Our priorities for 2011/12 were to complete
the analysis of all recipes and publish the
‘healthiest options’ on the intranet. This will
include an online ‘menu builder’ where
chefs can pick items from a list. The
intranet hosts a resource of over 300
recipes, all with a complete nutritional
analysis including a traffic light guide to
help with menu planning. Recipes are listed
under headings such as lighter meal
options, vegetarian, vegan and further
resources to give information to chefs on
catering for conditions such as diabetes
and dysphagia.
We have now planted several herb gardens
to support the Charity’s kitchens. Plans are
underway in our longer term project to
support service users to grow fruit and
24
St Andrew’s Heathcare | Quality accounts for 2011/12
vegetables with the provision of allotments
on our Northampton site, allowing them
to grow salad crops for the summer and
vegetables for Christmas lunch and build
the service users understanding of
food production.
At our Workbridge facility, staff and service
users have historically grown soft fruit for
use in the canteen and coffee shop onsite.
Workbridge is a vocational extension to the
care pathway allowing service users to
learn new skills and gain confidence
working in their garden centre, coffee
shop and ceramics workshop.
Just over half of all food ingredients are
sourced locally or from sustainable
schemes such as Red Tractor and/or
are ethically produced such as Organic
and Fairtrade.
Our nutrition and wellbeing training
programme has been integrated at various
levels. All new staff now complete an
awareness session and workbook activity
on nutrition and health and further training
is provided at ward level for the nutritional
care for the specialist needs of different
service user groups.
Throughout the year a number of health
and wellbeing events have been held to
raise awareness for both staff and service
users of good nutrition with dieticians and
catering staff working together to present
on a range of subjects which have been
consistently received positively.
Customer satisfaction levels with the
dining experience continue to be high
with the renewal of the Hospitality
Assured accreditation from the Institute
of Hospitality for the third year running
in December.
His Royal Highness, The Prince of Wales,
praised the quality of food we provide to
service users. He made the comments
during a reception hosted at Clarence
House to congratulate fourteen hospitals
for their work to provide excellent food.
The Soil Association selected the hospitals
for this celebration of the best of British
hospital food.
Patient experience
03
“We know that food plays an important role in the lives of the people who use
our services and it makes a real difference. Satisfaction levels of 80% and
above speak for themselves and our catering teams can be rightly proud of
what they have achieved. They have received six national awards
in the last two years, recognising the amazing things they have done.
This really adds to our service users feeling that their fresh-cooked food
is truly wholesome, helping them regain their health and wellbeing.”
Professor Philip Sugarman
Chief Executive Officer
Quality accounts for 2011/12 | St Andrew’s Heathcare
25
Patient experience
03
Research extract
Nutritional management of individuals with Huntington’s disease:
nutritional guidelines
Ailsa Brotherton , Lillian Campos , Arleen Rowell , Vanessa Zoia ,
Sheila A Simpson , Daniela Rae
Neurodegenerative Disease Management, February 2012, Vol. 2, No. 1, Pages 33-43.
Identification of nutritional risk by nursing staff in secure psychiatric settings:
reliability and validity of St Andrew’s Nutrition Screening Instrument
A. Rowell BSc Hons1,
C. Long PhD 4,*,
L. Chance BSc2,
O. Dolley BSc 3
Article first published online: 10 JAN 2012. DOI: 10.1111/j.1365-2850.2011.01848.x
Dignity
Helping vulnerable service users to retain
their dignity whilst in secure care is hugely
important to us. Supporting people to give
them the best quality of life throughout
their stay is likely to achieve better service
user experiences of care.
We reviewed our dignity, choice and care
policy and identified a number of actions
and key milestones required to ensure our
approach to dignity still meets the very
latest industry practice.
These included protected meal times
especially on wards where we care for
people that require assistance during
mealtimes such as our Huntington’s
Disease unit.
There have been two significant events to
recognise the importance of dignity held
in the last year. The first one was a joint
presentation for staff and service users
with Age UK. Staff presentation posters
were subsequently displayed illustrating
the research and outcomes for older
people across the Charity. There was also
a poster raising awareness of dignity in
care and highlighting the importance of
dignity - “Dignity is a human right, not an
optional extra”. During this event a dignity
diary was handed out to members of staff
26
St Andrew’s Heathcare | Quality accounts for 2011/12
where they were encouraged to make one
entry over five working days as to how you
promoted a person’s dignity.
Age UK also highlighted the services that
they provide for older people in the local
community and during this time we also
collected clothing, books, and bric-a-brac
for Age UK to sell in their Charity shops.
“Dignity is a human right,
not an optional extra.”
In February 2012 we held a Dignity Action
Day. It aims to ensure that people in care
are treated as individuals and are given
choice, control and a sense of purpose in
their daily lives and provide stimulating
activities.
The day gave everyone the opportunity to
contribute to upholding people’s rights to
dignity and provide a truly memorable day
for people receiving care.
Involvement and personalisation
strategy
Where service users and care staff work in
partnership, service users are likely to
move through a shared pathway more
quickly. This can mean shorter stays and
better service user experiences of care.
This indicator is part of the Commissioning
for Quality and Innovation (CQUIN)
payment framework.
We are dedicated to providing a wide range
of opportunities for service users to get
involved in to help shape the Charity.
People can contribute formally through
work-related tasks, informally through
activities and feedback, and of course
influence the recovery process.
We encourage service user input to
develop Charity practice and enhance
recovery. As part of the Charity’s
involvement in ImROC, a strategy for
involvement and personalisation has
been implemented.
The main objective within the strategy is
to increase the involvement of service
users in training and research.
As part of our corporate and local
inductions, service users share their
recovery story with new staff joining the
Charity. This has given staff a clear
understanding, from their first day in their
new job, of the types of people we care
for, what it is like to be at St Andrew’s
Healthcare and how each and every
member of staff can help on a service
user’s recovery journey.
Patient experience
We held 18 central induction sessions in
2011/12, with over 1000 individuals
attending in Northampton. Attendees
included new staff, volunteers and
students. Service users have delivered a
30 minute session at 16 of these central
induction events.
This work has had a huge impact on the
patient experience at St Andrew’s and staff
have benefitted too. 96% of those
attending induction each month rate the
service user sessions as good or excellent.
The ‘below average’ and ‘poor’ scores
occurred mainly from two occasions when
the service user could not attend.
This experience and involvement extends
beyond the first few days of joining the
Charity. We ensure that service users are
involved in many training topics such as
awareness of seclusion and risk. Our
service users have produced two DVDs for
staff which share their views on restraint
and seclusion, including what it feels like
and how people wish to be treated, as well
as risk and safety and how to involve
service users in managing this themselves.
Research is a large part of the Charity, with
81 research papers published in 2011.
We have involved service users in some
of our research projects over the last year.
One of these was to develop a service user
involvement charter which included service
users from across the Charity taking part in
training at the University of Northampton
and gaining key research skills and
experience.
We continue to make good progress on
the development of Care Pathway Star and
have received positive feedback from the
Mental Health Providers Forum who
commented that the Charity has made the
largest contribution to the development
out of the four hospitals involved.
This continued work allows us to positively
involve and enhance the patient experience.
At the beginning of the last reporting
period, we set an objective to produce a
joint service user and staff report, to show
how the Charity can achieve the choices
made by service users. Whilst this
reporting continues to be developed, there
have been many occasions where staff and
service users have collaborated to plan and
implement their choices and make
decisions affecting them. This work
includes adding a further 20 national
standards to the CPA policy around which
work continues, making decisions on
facilities that will be developed on our
parkland areas at our Northampton site
and influencing developments in our
food provision and the development of
conferences and events.
03
Service Users and their
involvement (May-Oct 2011 extract) Excellent
66%
Good
30%
Below average
2%
Poor
1%
No response
1%
96%
of those attending
induction each month
rate the service user
sessions as good
or excellent
Quality accounts for 2011/12 | St Andrew’s Heathcare
27
Involvement
03
Who have we involved?
In producing this document we have listened to a range of partners who have
an interest in our work.
The people formally consulted on these accounts are:
• Lead Commissioner
• Local Involvement Network LINk
• PCT
• Colleagues
• Overview and Scrutiny Committee
• Service users
Partnership working is very important to St Andrew’s Healthcare. we work with
hundreds of people and organisations to support service users, develop and
manage services and share best practice.
The diagram below outlines some of the key partners we work with, and what
we achieve together.
Networks
Share best practice and
influencing opportunities
Communities
Carers
Share knowledge
and understanding
to support people
ndrew’s
St A
Help us to prepare
people for life
Governors
Provide an independent
view of our work
Service users
Researchers
Discover and share
information to improve
quality of care
Regulators
St
A n d re w ’s
Education specialists
Partner us to provide
learning opportunities
28
St Andrew’s Heathcare | Quality accounts for 2011/12
Check we’re upholding the
law and meet national
standards
Commissioners
Work with us to provide
safe and suitable
placements
Feedback
03
“...The improvement priorities for 2012/13 identified in the Quality Accounts appear
logical and reasonable and to support the delivery of the three key objectives set
out in the Charity’s strategy. The emphasis given to making improvements in the
following areas is particularly welcomed:
Involving service users and carers in decisions about their specific care and treatment
and in working to improve the overall patient experience.
Developing and delivering quality improvements that are objective and relevant
to local needs.”
Councillor Judy Shephard
Chair, Health & Social Care Scrutiny Committee (Northamptonshire)
“In general it looks very good and represents a
true account of your performance...”
Phil Brian
Commissioning Manager, Birmingham and Solihull Mental Health NHS Foundation Trust
Following discussions with Northamptonshire LINk, it was noted that currently there were not sufficient
organisational relationships to enable informed commentary on the St Andrew’s Healthcare Quality
Accounts this year. It was agreed that David Ward (LINk) and David Thomas (Director of Quality &
Governance, St Andrew’s Healthcare) would work together to resolve this during the coming year.
Quality accounts for 2011/12 | St Andrew’s Heathcare
29
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