Quality
Account
2012/13
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
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CONTENTS
1
PART 1: CHIEF EXECUTIVE’S STATEMENT ........................................................................................................ 3
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
1.11
1.12
2
PRIORITIES FOR IMPROVEMENT............................................................................................................................. 5
OUR PRIORITIES FOR 2013/14 ............................................................................................................................ 5
STATEMENTS OF ASSURANCE.............................................................................................................................. 10
REVIEWING THE QUALITY OF TRUST SERVICES........................................................................................................ 10
CLINICAL AUDIT ............................................................................................................................................... 11
CLINICAL RESEARCH.......................................................................................................................................... 13
GOALS AGREED WITH COMMISSIONERS (CONTRACTUAL KEY PERFORMANCE INDICATORS) ............................................. 14
WHAT OTHERS SAY ABOUT THE TRUST ................................................................................................................ 16
DATA QUALITY ................................................................................................................................................ 17
NHS NUMBER AND GENERAL PRACTICE CODE VALIDITY .......................................................................................... 18
INFORMATION GOVERNANCE TOOLKIT ATTAINMENT LEVELS .................................................................................... 19
CLINICAL CODING ERROR RATE ........................................................................................................................... 20
PART 3: REVIEW OF QUALITY PERFORMANCE .............................................................................................. 21
2.1
2.2
2.3
2.4
PART 3A: DEPARTMENT OF HEALTH MANDATORY INDICATORS ................................................................................ 21
PART 3B: PERFORMANCE AGAINST QUALITY IMPROVEMENT PRIORITIES 2012/13....................................................... 28
PART 3C TRUST PERFORMANCE AGAINST ADDITIONAL QUALITY PERFORMANCE INDICATORS .......................................... 33
PART 3D - STATEMENT FROM THE TRUST’S KEY STAKEHOLDERS. ............................................................................... 42
3
CONCLUSION................................................................................................................................................ 42
4
HOW TO PROVIDE FEEDBACK ....................................................................................................................... 42
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
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1 Part 1: Chief Executive’s Statement
2012/13 has been a challenging year for the whole healthcare system, with the implementation
of NHS reforms and the publication of reports into failings of care at Winterbourne and MidStaffordshire NHS Trust.
With this in context, Dudley and Walsall Mental Health Partnership NHS Trust (the Trust) has
had another productive year with a continuing high focus on quality, led by the Executive
Director of Operations and Nursing and the Joint Medical Directors, supported by rigorous and
regular reporting to provide assurance to the Board.
For example the Board‟s Governance and Quality Sub–Committee meets monthly to review and
maintain effective systems for integrated governance, risk management and internal control
across all of the Trust‟s activities, both clinical and non-clinical. More broadly the Trust also
uses the Monitor Board Governance and Quality Framework, on a quarterly basis, as a live
mechanism to self-monitor and assure the Board of the robustness of its Quality Governance
systems and processes.
We therefore welcome the opportunity to present the annual Quality Account to demonstrate our
continued commitment to delivering high quality care and ensuring quality is at the heart of the
organisation. It is particularly pleasing to be able to confirm that the Trust has continued to
achieve all targets set nationally for Mental Health Trusts in 2012/13, delivered the
Commissioning for Quality and Innovation (CQUIN) schemes, and retained „registration without
conditions‟ with the care Quality Commission. More detail is provided in the key quality
improvements delivered by the Trust in 2012/13 and the quality challenges we have set for
ourselves for 2013/14.
On a practical level, the Trust firmly believes that the delivery of high quality services is an
integral part of everyday practice and is “everyone‟s business”. In support of this, during the last
year the Trust has:
Completed the delivery of Quality and Governance Road Shows to every individual team
and department including the setting of team “quality challenges”
Continued to invest in leadership development for senior staff and clinicians
Implemented an integrated performance dashboard, including quality indicators to ensure
that the monitoring of quality is embedded
Reviewed the Trust‟s embedding lessons framework to ensure that there is an
accountable process whereby recommendations result in actions to improve quality
Become a member of the Triangle of Care network in January 2013 to provide a best
practice model of partnership working between the service user, their carer and the
professionals involved
Introduced „Hear and Now‟ reviews – an internal peer review process for monitoring and
improving the quality of clinical services
Introduced the Friends and Family (“Net Promoter”) test. We are pleased to report 75%
of the 1696 people asked responded with „likely‟ or extremely likely‟ when asked „how
likely would you recommend this service‟
Implemented the safety thermometer and used the data to inform quality improvement, in
particular the falls prevention programme
Maintained Royal College of Psychiatrists Centre for Quality Improvement (CCQI)
Accreditations
Increased research capability and capacity across the Trust
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
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Launched in August 2012 a new tool „Bright Ideas‟ for staff to put forward innovative
ideas for improving quality and developing services.
As Chief Executive of the Trust, I can confirm that, to the best of my knowledge, the information
contained in this Quality Account is accurate. The Statement of Directors responsibilities
summarises the steps taken to develop this Quality Account and external assurance is provided
in the form of statements from our commissioners. The report of an external audit undertaken by
Grant Thornton UK LLP is included in the quality account which gives assurance on the content
of this Quality Account
Gary Graham Chief Executive
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
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Part 2: Priorities for improvement & statements of assurance from the
Board
1.1 Priorities for Improvement
This is the forward-looking section of the Quality Account. It details of the improvements
planned for the next year and explains why the priorities have been chosen.
During 2012/13, the Trust embraced an ambitious agenda for quality improvement which has
been delivered through the Quality Improvement Strategy. The Trust will continue this journey
during 2013/14, and has identified 9 quality improvement priorities through a process of
reviewing services and working with stakeholders, and by looking at the Trust‟s performance
against national and local quality indicators.
These quality priorities are especially pertinent as barometers for service quality as they:
reflect the current priorities for the organisation
are distributed across three domains of quality
represent both local and national agendas
include priorities important to stakeholders and partners
are a mixture of new areas and those which build on key priorities from 2012/13and are
applicable to services being developed as part of the Trust‟s Service Transformation work.
For each of the quality priorities a delivery strategy has been developed to track the performance
against improvement trajectories at all levels from Ward to Board. Monitoring will take place
through quarterly integrated „Quality Reports‟ to the Governance and Quality Committee.
1.2
Our Priorities for 2013/14
Delivering high quality safe services
Quality Goal 1: Caring for people in a safe environment and protecting them from
avoidable harm relating to falls
Rationale for Inclusion
The Trust has identified through the National Safety Thermometer and local incident reporting
that there is a need to continue to embed a targeted falls prevention programme within the
organisation. During 2012/13 the Trust undertook a deep dive looking at falls incidents and has
subsequently renewed the falls prevention programme. The Trust is keen to ensure that this
programme is embedded and high quality standards are maintained.
Local Indicator
Patient safety incident reporting
Severity of harm
Safety Thermometer benchmarking
Improvement Initiatives
Implementation of Trust-wide falls prevention plan led by inpatient matrons and clinical
leads
Measurement
Incidence of inpatient falls
Incidence of falls causing moderate/severe harm
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
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Quality Goal 2: Protecting people from avoidable harm from the use of medicines
Rationale for Inclusion
Following feedback from the National Community Patient Survey, Psychiatric Observatory for
Mental Health (POMh) Clinical audits, local clinical audits and lessons learned from incident
reporting, the Trust has identified medicines management as a priority for 2013/14. The aim is to
deliver the Trust‟s Medicine Management Strategy to further improve the safe and cost effective
use of medicines.
Local Indicators
Patient safety incident reporting
Severity of harm
Patient survey
POM‟s audit
Local Clinical audit
Compliance with competency framework (CQUIN)
Improvement Initiatives
Patient information and explanation of medicines
Monitoring of side effects of drugs used in Schizophrenia including Lithium
Competency framework for medics
Measurement
Incidence of medication errors
Patient reported satisfaction with information provided about medication and side effects
Performance against national and local clinical audits
Achievement of CQUIN
Quality Goal 3: Protecting people from avoidable harm through comprehensive clinical
risk assessment
Rationale for Inclusion
The Department of Health (2007) document „Best Practice in Managing Risk‟ provides a clear
framework of principles that should underpin best practice across all mental health settings.
The Trust recognises that an effectively planned, organised and controlled approach to clinical
risk assessment and mitigation is the cornerstone of sound practice. Recommendations arising
out of Serious Incident investigations, together with staff feedback on the current risk
assessment methods, have led to the identification of a new clinical risk assessment tool with
associated training.
Local Indicators
Patient safety incident reporting
Serious incident recommendations
Staff satisfaction feedback
Number of staff trained in risk assessment and mitigation
Number of service users with completed risk assessment and mitigation plans
Improvement initiative
Introduction of Functional Analysis of Care Environments (FACE)
Suicide response and mitigation training
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
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Measurement
Number of recommendations from Serious Incident investigations relating to risk
assessments
Access to clinical risk and mitigation training
Access to suicide response and mitigation training
Clinical audit results
Delivering Services that are Clinically Effective and Outcome Focused
Quality Goal 4: Ensuring effective communication with primary care following discharge
from services
Rationale for Inclusion
During 2012/13 the Trust has focussed on improving pathways for service users through the
transformation of its services. As part of the evaluation, the Trust has received feedback from
General Practitioners (GP‟s) and Commissioners, regarding the need to improve communication
with Primary Care following discharge from services. This has also been identified as an area for
improvement through the Trust‟s “Hear and Now Quality Reviews”, which are peer reviews for
internal quality monitoring.
Local Indicators
Patient safety incident reporting
Complaints
Compliments
Commissioner feedback
Clinical audit
Improvement Initiatives
Roll-out of discharge letter template and standards
GP literature packs
Introduction of joint clinical audit
Measurement
GP satisfaction with discharge letters
Consistency of content of discharge letter based on agreed best practice standards
Quality Goal 5: Ensuring the effectiveness of physical healthcare pathways and interfaces
between the Trust and primary care
Rationale for Inclusion
The Trust identified physical healthcare monitoring as a quality improvement priority for 2012/13
and significant work was undertaken to ensure physical healthcare is embedded within clinical
processes. This will be a continued priority for the Trust during 2013/14 to ensure the
effectiveness of the improvements and to develop improved physical healthcare pathways and
interfaces between the Trust and Primary Care. This work will be aligned with the National
Outcomes Framework and incorporate learning from the National Schizophrenia Audit.
Local Indicators
Patient safety incident reporting
Clinical Audit
Commissioner feedback
Annual health checks
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
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Improvement Initiatives
Continued roll out of physical healthcare improvement plan
Development of pathways and information sharing protocols with primary care
Well being clinics Physical Health Competency Framework
Measurement
Clinical audit results
Service user experience
Defined physical healthcare pathways
Staff competency
Quality Goal 6: Ensuring care plans are underpinned by personalisation and reenablement
Rationale for Inclusion
The Trust is working in partnership with Dudley and Walsall Local Authority to ensure that
personalisation and re-enablement are embedded in the Trust‟s clinical processes and ethos of
care. Whilst some key initiatives, including personal budgets, underpin personalisation, fitting
services around people‟s needs will lie at the heart of empowerment and recovery support.
Local Indicators
Health of the Nation Outcome Scales (HONOS)
Care Programme Approach (CPA) audit
Uptake individual budgets
Improvement Initiatives
Roll-out of personalisation implementation plan
Personalisation training
Development of local quality personalisation metrics (qualitative and quantitative)
Measurement
Number of individual budgets
Service user satisfaction
Listening to, involving and empowering service users and continuous improvement of
the quality of services
Quality Goal 7: Ensuring service users are active participants in the formulation and
implementation of their care plans and are provided with a copy of their care plan
Rationale for Inclusion
The Trust endorses the Care Quality Commission report „no decision about me, without me‟ and
that:
care plans become the driving force, or action plan, behind a person‟s recovery
care plans need to be collaboratively developed to co-create understanding and coproduce knowledge between the service user and their care co-ordinator.
Whilst the Community Patient Survey results published June 2012 show the Trust has improved
overall in relation to care planning, further work is needed in relation to copies of care plans,
where it still falls slightly below the national average (41% said they had had a copy of their care
plan within a year, compared to 29% last year and a national average of 42%).
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
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Local Indicators
National community survey – copies of care plans
CPA/Non-CPA audit
Service user feedback/satisfaction
Key Performance Indicator for the giving of care plans to service users
Improvement initiative
Revision of the CPA/Non-CPA training on outcome focussed and service user lead care
planning
Revision of the Trust wide clinical standards for care planning
Measurement
Community Survey results
CPA audit results
Service user satisfaction
Quality Goal 8: Ensuring and enabling effective engagement with family and carer
involvement
Rationale for Inclusion
The National Strategy for Mental Health – No Health without Mental Health (Department of
Health 2011) – describes the importance of involving families and carers in care and treatment.
Hence one of the Trust‟s 2012/13 Quality Improvement Priorities was to improve engagement
with families and carers with care and treatment. As a consequence the Trust signed up as a
member of the Triangle of Care Network in January 2013; this is a nationally recognised model
of partnership working between the service user, his or her carer and the professionals involved.
Over the next year, the Trust will be focussing on rolling the model out within our Adult Services
and has determined that this area will remain a quality improvement priority for 2013/14 to
ensure the Triangle of Care is implemented effectively within the Trust.
Local Indicators
Triangle of carer accreditation
Local family/carer satisfaction
Triangle of care self-assessment
Improvement Initiatives
Implementation of Triangle of Care Model across Adult Services through four work
streams:
o Policies, protocols and procedures
o Carers support/information
o Training
o Documentation and record keeping
Measurement
Accreditation by Triangle of Care
Family and carer satisfaction
Number of staff trained in carer awareness
Compliance with carers pathway standards
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
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Quality Goal 9: Ensuring service users and carers have a positive experience of services
underpinned by the principles of excellent customer care and compassion
Rationale for Inclusion
The Trust is committed to ensuring service users and carers have a positive experience of
services which is underpinned by the principles of excellent customer care and compassion, as
set out within the Trust‟s vision and values.
To ensure this remains high on the agenda during 2013/14, the Trust will delivering to staff a full
programme of customer care training, embedded in leadership development. This initiative will
incorporate lessons leant from the Francis report and also local lessons learned from
complaints.
In particular the Trust will be relaunching its Professional Respect Innovation Dignity
Effectiveness (PRIDE) initiative valuing the nursing workforce, originally launched in 2011.
PRIDE puts nurses at the centre of the delivery of high quality services.
Local Indicators
Complaints
Compliments
Service user and carer satisfaction
Staff survey
Improvement Initiatives
Customer care training
Leadership events
PRIDE re launch
Measurement
Complaints related to customer care and staff attitude
Compliments regarding customer care and staff attitude
Service user and carer satisfaction
1.2.1
How will we review and monitor these priorities?
Each quality improvement priority identified for 2013/14 will be delivered through the framework
identified in the Trust Quality Improvement Strategy. Progress will be monitored through the
Trust performance framework and overseen by the Governance and Quality Committee.
1.3 Statements of Assurance
The aim of the following sections (2.4 - 2.10) is to provide information to the public which will be
common across all Quality Accounts, thereby enabling people to gain a more informed and
transparent view about what different healthcare organisations have reported.
The statements in this section offer assurance from the Trust Board to the public that the Trust
is:
Performing to essential standards
Measuring our clinical processes and performance
Involved in national projects and initiatives aimed at improving quality
1.4
Reviewing the Quality of Trust Services
During 2012/13, the Trust provided NHS services through five service lines:
Acute Services
Older Adults Services
Recovery Services
Early Intervention Services
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Community Services
The Trust has reviewed the data available to them on the quality of care in all five of these
services.
The income generated by the NHS services reviewed in 2012/13 represents 100% of the total
income generated from the provision of NHS services by the Trust for the reporting period
2012/13.
1.5 Clinical Audit
As part of the Clinical Governance Agenda, the Trust has a comprehensive clinical audit
programme that is delivered as part of the annual audit programme. This is monitored by the
Clinical Governance and Quality Committee on behalf of the Trust Board. The Audit Committee
may also requests specific clinical audit reports as appropriate.
1.5.1
National Clinical Audits and Confidential Enquiries
During April 2012 to March 2013, five national clinical audits and one national confidential
enquiries covered NHS services that Dudley & Walsall Mental Health Partnership Trust provides.
During that period Dudley & Walsall Mental Health Partnership NHS Trust participated in 100%
of national clinical audits and 100% of national confidential enquiries of the national clinical
audits and national confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Dudley & Walsall Mental
Health Partnership Trust was eligible to participate in during April 2012 to March 2013 are as
follows:
1. National audit of Psychological Therapies for Anxiety & Depression
2. Prescribing Observatory for Mental Health (POMH): Prescribing for people with
Personality Disorder
3. POMH : Screening for metabolic side effects of antipsychotics
4. POMH : Prescribing antipsychotic medication for people with dementia
5. POMH : Prescribing for Attention Deficit Hyperactivity Disorder (ADHD) in children,
adolescents and adults
6. National Confidential Enquiry into Homicide and Suicide
The national clinical audits and national confidential enquiries that Dudley & Walsall Mental
Health Partnership Trust participated in during April 2012 to March 2013 are as follows:
1.
2.
3.
4.
5.
6.
National audit of Psychological Therapies for Anxiety & Depression
POMH : Prescribing for people with Personality Disorder
POMH : Screening for metabolic side effects of antipsychotics
POMH : Prescribing antipsychotic medication for people with dementia
POMH : Prescribing for ADHD in children, adolescents and adults
National Confidential Enquiry into Homicide and Suicide
The national clinical audits and national confidential enquiries that Dudley & Walsall Mental
Health Partnership Trust participated in, and for which data collection was completed during
April 2012 to March 2013, are listed below 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.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
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Figure 1 National clinical audits
Audit Title
National Audit of Psychological Therapies for
Anxiety & Depression
POMH : Prescribing for people with Personality
Disorder
POMH : Screening for metabolic side effects of
antipsychotics
POMH : Prescribing antipsychotic medication
for people with dementia
POMH : Prescribing for ADHD in children,
adolescents and adults
National Confidential Enquiry into Homicide
and Suicide
Participation
Yes
Yes
Yes
Yes
Yes
Yes
% cases submitted
3600 were submitted (no
minimum was stated)
64 were submitted (no
minimum was stated)
93 were submitted (no
minimum was stated)
60 were submitted ( no
minimum was stated)
130 were submitted (no
minimum was stated)
Ongoing participation
The reports of three national clinical audits were reviewed by the provider in April 2012 to March
2013 and Dudley & Walsall Mental Health Partnership Trust intends to take the following actions
to improve the quality of healthcare provided:
Medications should be recorded in the patient‟s crisis plan. The crisis plans have been
altered to allow medication recording to be documented.
Weight checks for patients must be done within 48hrs of admission. Weighing scales are
to be provided to each inpatient area and the weighing of patients will form part of the
standard physical healthcare protocol.
Weight checks and blood pressure checks for community patients are to be undertaken
every 6 months and patients should not be prescribed medications until their blood
pressure has been checked appropriately, due to issues that some medications can have
with low blood pressure.
A checklist for patients with dementia who are in receipt of antipsychotics will be included
in each patient file so that doctors can ensure that they have carried out and recorded all
appropriate physical healthcare checks.
1.5.2
Local clinical audits
Each year the Trust develops a clinical audit forward plan which aims to complement the Trust‟s
objectives to improve quality. During 2012/13, the Trust has completed and reviewed 4 clinical
audits during the reporting period.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
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Figure 2 Local clinical audits
Title of audit
Summary of actions/recommendations
Safeguarding
(Children and Adults)
To provide training to all Clinical Managers and leads relating
to Adult West Midlands pan procedures.
To introduce database through the use of the Safeguard
system to collate data for Safeguard vulnerable adults and
children.
To agree and develop a dashboard for quality and performance
related to safeguarding.
Service User
Experience in Mental
Health
Pharmacists are to commence visibility sessions on all inpatient
areas. This will be conducted on a four weekly rolling cycle to
conduct an open forum with patients.
Every patient ready for discharge from an inpatient area will
have a one to one meeting with their mental health pharmacist.
Community Recovery Service (CRS) teams will build into their
care plans a standardized set of information for the service
user on where to access support once discharged from our
Mental Health services.
Medical Record
Keeping
A common checklist will be put in place for all inpatient areas to
be used in ward round to aid compliance with best practice.
International Classification of Diseases (ICD10) laminated
sheets will be provided to all outpatient clinics.
Medical record keeping standards will feature as part of all
induction processes for all levels of medical staff, not just
trainees.
Self harm – Long
Term Management
Audit
To review clinical risk assessment tool this includes best
practice standards for deliberate self harm.
To review care plans to ensure they capture risk factors
contributing to self harm.
1.6 Clinical Research
During 2012/13, the Trust has participated in 13 portfolio based research projects of which 4 are
complete and 9 are still in progress.
The number of patients receiving NHS services provided or sub-contracted by Dudley and
Walsall Mental Health Partnership Trust in the period 1st April 2012 to 31st March 2013 that
were recruited during that period to participate in research approved by a research ethics
committee was 67.
The Trust has been successful in securing funding from the Birmingham and Black Country
Comprehensive Local Research Network. This is to secure the Clinical Studies Officer for a
further year and also provides the capacity to build the Trust research capability.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
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Figure 3
Research Study Title
Molecular Genetic Investigation
CEQUEL (Comparable evaluation of Quetiapine and Lamotrigine combination
versus Quetiapine monotherapy)
Status
Open
Completed
NCISH (National Confidential Inquiry into Suicide and Homicide)
Open
Sudden death in psychiatric inpatients and the relationship with psychotropic drugs
Open
Mental illness among victims of homicide
Open
HOMASH 2 (Hospital Management of Self Harm)
Completed
OASIS (Observational Assessment of Safety in Seroquel)
Completed
Community mental health teams for older people: a study of the outcomes from
different ways of working
Completed
The impact of CQUIN (Commissioning for Quality and Innovation Payment
Framework)
Completed
Explaining Health Managers Information Behaviour and Use
Completed
Parades Study On Bipolar Disorder (Project on mental capacity and Bipolar
Disorder)
Completed
ECHO (Expert Carers Helping Others)
Completed
DPIM – Schizophrenia (DNA Polymorphism in Mental Health illness –
Schizophrenia)
Open
Molecular Genetic Investigation
Open
GREAT – Goal Orientated Cognitive Rehabilitation in early Stage Dementia:
Multicentre sling-blind randomised controlled trial
Open
*PATTERN – A non intervention prospective cohort study of patients with persistent
symptoms of Schizophrenia to describe the course and burden of illness
Open
PRAISE - Cluster randomised controlled trial of two contingency management
schedule targeting a) treatment attendance b) abstinence from street heroin use in
people treated for heroin dependence
Open
Translation of Strengths and Difficulties Questionnaire into British Sign Language
Open
*Commercial project
1.7 Goals Agreed with Commissioners (Contractual Key Performance
Indicators)
A proportion of Dudley and Walsall Mental Health Partnership NHS Trust‟s income in 2012/13
was conditional on achieving quality improvement and innovation goals agreed between the
Dudley and Walsall Mental Health Partnership NHS Trust and the commissioners through the
Commissioning for Quality and Innovation (CQUIN) framework. CQUIN is a national initiative
which aims to embed demonstrable quality improvements within the commissioning cycle for
NHS healthcare.
For further details for the agreed goals for 2012/13 and for the following 12 month period are
available electronically at www.dwmh.nhs.uk.
The CQUIN scheme indicators, financial values and performance for the past 3 years are
summarised below. Note the Forecast Achievement Financial value for 2012/13 is based on
Month 11.
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Figure 4 Historical CQUIN Performance 2010–2013
2010/11
CQUIN
Schemes
2011/12
8 schemes:
1. Productivity
Improvement &
Pathways
2. Managed Leave
3. Patient experience
4. Duration of Untreated
5.
6.
7.
8.
7 schemes:
1. Patient Experience
2. Medicines Management
3. Planned and Effective
Discharge
4. Crisis Resolution/Home
Treatment Teams
Psychosis
Facilitating Discharge
Medicines
5. Length of Stay, Rehab
Management
Ward
Accommodation &
6. Psychiatric Liaison
Employment
7. Improved Response to
Smoking
Emergency Mental
Reducing Did Not
Health Assessment
Attend in Outpatients
Referrals
2012/13
7 schemes:
1. Patient Experience
2. Medicines
Management
3. Safety Thermometer
4. Making Every Contact
Count
5. Effective Care
Planning in CAMHS
6. Reduce Average
Length of Stay
7. Reduction in referral
to treatment to
Community Recovery
Service
Outcome
92% Achieved
90% Achieved
99.5% Achieved
Financial
value
Value £881,000
Achieved £813,010
Value £807,738
Achieved £730,195
Value £1,410,249
Forecast Achievement:
£1,403,197
CQUIN Schemes 2013/14
For 2013/14, the Trust has agreed six CQUIN schemes (see below) with a total value of
£1,368,634. The schemes cover a range of services including the four quality domains of Patient
Experience, Safety, Effectiveness and Innovation
Figure 5 Agreed CQUIN Schemes for 2013/2014
2013/14
CQUIN
Quality
Domain
CQUIN Details
Value
1
Safety
NHS Safety Thermometer
Collection of patient harm data
15%
2
Patient
Experience
NET Promoter
Surveying discharged patients by asking the „Family
and friends test‟ question
10%
Effectiveness
Making Every Contact Count
Public Health Training in 2 Teams on providing
advice on modifying lifestyle behaviours
25%
Medicines Management
Development for formulary/prescribing guidance and
audit to demonstrate compliance
15%
Reducing Falls in Older Peoples Mental Health
Develop Falls Prevention checklist in order to reduce
falls in our Older People‟s wards
25%
Undertake Agency for Healthcare Research and
Quality's (AHRQ) Patient Safety Culture Survey
Conduct AHQR survey assessing patient safety
10%
3
4
5
6
Effectiveness
Safety
Safety
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
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Further details or the agreed goals for the reporting period and the following twelve months can
be obtained from communications@dwmh.nhs.uk
1.8 What Others Say About the Trust
As a provider of NHS services, the Trust is monitored and regulated by a variety of external
bodies and arrangements. This regulatory framework helps to ensure that the Trust provides
services which are of the highest quality, well-managed and make appropriate use of resources.
Statements from the Care Quality Commission (CQC)
Dudley and Walsall Mental Health Partnership NHS Trust is required to register with the Care
Quality Commission and the Trust has no conditions on registration. Through the Trust‟s quality
governance processes the Trust identifies guidance issued by the Secretary of State which
relates to chapter 2 „ Registration in Respect of Provision of Health and Social Care „of the
Health Act 2009, and act and acting upon it appropriately.
Dudley and Walsall Mental Health Partnership Trust has the following conditions on registration:
None.
The Care Quality Commission has not taken enforcement action against Dudley and Walsall
Mental Health Partnership Trust during the period 1st April 2012 to 31st March 2013
Dudley and Walsall Mental Health Partnership NHS Trust has not participated in any special
reviews or investigations by the CQC during the reporting period.
The Trust has participated in two thematic inspections during 2012/13
CQC Themed Dignity and Nutrition (DANI) The review took place at Bloxwich Hospital
In August 2012. The inspection focussed on Outcome 1, respecting and involving people
who use services, Outcome 5, meeting Nutritional needs, Outcome 7 Safeguarding and
Safety, Outcome 13, Staffing and Outcome 21, Records. The inspector‟s comments
were positive and highlighted that the required standards were being met.
Joint working between Adult and Children Services when parents and carers have mental
ill health and/or drug and alcohol problems
The Trust participated in September 2012 in a Thematic Inspection by OFSTED and
the CQC which explored how well mental health services and drug and alcohol services
considered the impact on children when their parents or carers had mental ill health
and/or drug and alcohol problems. The Trust participated as a partnership organisation to
Dudley Local Authority. Findings from the thematic inspection have contributed to a
national report and the Trust has looked as lessons learned which it is embedding into
practice and also contributing to improvements across Health Economies.
The Trust participated in the OFSTED and CQC Inspection of Safeguarding and
Looked After Children in Walsall in June 2012. The Trust is currently working in
partnership to deliver the Walsall Children‟s Improvement Plan.
Royal College of Psychiatrists Centre for Quality Improvement (CCQI) Accreditations
During 2012/13 the Trust has continued to participate in CCQI National Quality Improvement
projects managed by the Royal College of Psychiatrists. This is a voluntary national
improvement and development programme which aims to raise standards of care in mental
health services. CCQI accreditation is a nationally recognised indicator of high quality services
which support continuous quality improvement.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
Page 16 of 47
The Trust has achieved CCQI accreditation for
all of its working age adult inpatient wards via the Accreditation for Inpatient Mental
Health Services programme
both of its Electro-Convulsive Treatment (ECT) Services via the Electro-Convulsive
Therapy Accreditation Scheme
three of the four older peoples‟ inpatient wards via the Accreditation for Inpatient Mental
Health Services – Older People and its memory service via the Memory Services
National Accreditation Programme
The figure below shows the number of CCQI accredited services in the Trust.
Figure 6 Number of CCQI accredited services in the Trust.
CCQI Programme
Participation by the Trust
ECT Clinics
2 ECT clinics (100%)
Working Age Adult Wards
5 wards (100%)
Older People‟s Mental Health Wards
3 wards (75%)
Memory Services
1 service (100%)
The Vocational Employment Team ‘Centre of Excellence’
The vocational employment team was awarded „centre of excellence‟ status from the centre for
Mental Health for its development of the Individual Placement and Support Model of Supported
Employment. This is an internationally recognised quality standard.
1.9 Data Quality
Good quality information underpins the effective delivery of care and is essential for measuring
and monitoring improvements in quality and performance. The Trust has made significant
improvements to its performance management and reporting framework over the past two years,
and has taken a number of actions to improve data quality.
In 2010/11 the Trust developed the Contract Activity Review Meeting (CARM). This meeting is
held at the start of each month to discuss and review the previous month‟s data, before it is
presented to the Finance and Performance Committee, to Commissioners at the Contract
Review, Clinical Quality Meetings and then at Board. CARM has continued to take place
throughout 2011-13 and will continue to be held during 2013/14.
The function of CARM has been further developed during 2012/13 to help raise the profile of
information in the Trust and to drive data quality improvements. In particular, this forum is now
also used to:
Standardise data definitions
Explore emerging performance challenges
Commission work covering more detailed analysis and forecasting
Help managers understand the financial impact and implications of changes in the
level of activity.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
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Also in 2011/12 the Trust refreshed its Data Quality Policy and agreed a Data Quality
Improvement Plan (DQIP) aimed at ensuring that all strategic, operational and clinical decisions
are made on the basis of good information drawn from robust base data. The Policy will be
reviewed in Q1 of 2013/14 and continue to focus on three main areas:
Theme 1
Assuring the accuracy of basic caseload and activity data
Theme 2
„Deep data quality dives‟ to test the accuracy of performance reporting in high risk
and high profile areas of service, and where performance needs to improve
Theme 3
The development of a data dictionary to improve the consistency of recording and
reporting
The DQIP was endorsed by Management Executive Team and the Finance and Performance
Committee, and implementation has continued throughout 2012/13. This has included the
establishing of weekly operational data quality and exception reports, together with progress
monitoring reports, within the data warehouse desktop dashboards.
The Trust has developed a data quality dashboard providing performance information on a wide
range of indicators including:
National Metrics
Local Contractual Targets
Internal Service Transformation indicators
New processes have been put in place to track and monitor all data quality checks and
exercises. The scope and purpose of each data quality process is agreed centrally and the
results are documented to ensure that a clear audit trail of checks and changes is maintained.
The Performance Department monitor other Data Quality Reports. These include Blank Team
Referrals, Floating Referrals, Duplicate Referrals, Appointments with no Outcomes, Daily
Demographic checks, Monthly Batch Trace files cross referencing GP Practices and Deceased
Records.
Care Programme Approach (CPA) Exception Report
During 2012/13, the Trust has a developed a CPA exception report.
The purpose of the CPA Exception Report is to look at the Trust‟s CPA Caseload and ensure it
is accurate and meets all the relevant targets for KPIs. It includes a Summary for the Trust,
Team Member Summary and the Patient Level Data for each Team. Fortnightly the Information
and Performance Team extract and analyse the data, then send to clinicians in order for them to
update the relevant records.
1.10 NHS Number and General Practice Code Validity
The Trust submitted records during 2012/13 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 patient‟s valid NHS number was:
99.3% for Admitted Patient Care (national 99.1%)
99.9% for Outpatient Care (national 99.3%)
The percentage of records in the published data which included the patient‟s valid General
Practice medical code:
100% for Admitted Patient Care (national 99.9%)
100% for Outpatient Care (national 99.9%)
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
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1.11 Information Governance Toolkit Attainment Levels
Information Governance (IG) refers to the systems and processes which the Trust has in place
to safely and effectively manage all types of information. „Connecting for Health‟ has developed
a toolkit for measuring compliance with best practice for information governance and Trusts are
required to assess themselves annually against the standards in the toolkit.
The Trust improved IG compliance in 2012/13 with a significant focus across the organisation
and an ambitious plan was put in place to drive improvement in this area.
In 2012/13, the stringency of the requirements of the IG toolkit increased significantly reflecting
the importance placed upon this agenda by the Department of Health. By March 2013 the Trust
attained 78% compliance against the toolkit.
As a result of these actions, the Trust IG Assessment Report overall score for 2012/13 was:
78% and was graded Green (Satisfactory) from IGT grading scheme, and the Trust
exceeded minimum attainment levels in various areas
95% of all staff have received IG training in the past year.
„Significant Assurance‟ was given by the Internal Audit of IG.
Figure 7 IG Toolkit compliance in 2012/13
Trust Overall compliance with IG toolkit
Monitoring
March 2012 compliance
April 2012
May 2012
Actual compliance
level
Aim
74%
72%
Version 10 not released until the end of May 2012
and so the 74% compliance from 11/12 remains in
place for month 1 & 2
June 2012
38%
30%
July 2012
42%
32%
August 2012
42%
32%
September 2012
48%
40%
October 2012
54%
46%
November 2012
55%
47%
December 2012
55%
50%
January 2013
67%
65%
February 2013
78%
68%
March 2013
78%
77%
Aim
77%
1
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
Page 19 of 47
1.12 Clinical Coding Error Rate
Clinical Coding compliance applies to inpatient records to ensure that diagnosis and procedures
are coded correctly and consistently across the Trust. Clinical Coding is part of the Information
Governance (IG) Toolkit requirements where the accuracy of coding must be maintained at a
given level to achieve level 2 or 3 within the Toolkit.
The Trust was not subject to Payment by Result clinical coding by the Audit Commission during
2012/13 and as the Trust had never conducted a clinical coding audit before, there was no
baseline for improvements to be developed.
The Trust completed the external clinical coding audit for 2011/12 in January 2012; the outcome
of the audit was that the Trust did not meet the required levels as set by the IG Toolkit. The
figures highlighted in the red boxes below for the 2011/12 Audit Results show where we fell
below the Level 2 Target in relation to the audit conducted in 2011/12.
To meet the requirements of the IG Toolkit the Trust put a full action plan in place with a view to
attaining level 2 before the end of 2012. The work was reviewed by our internal auditors who
confirmed that it was completed to a level to satisfy the IG Toolkit requirements.
The Trust was re-audited in December 2012 and exceeded the aims of achieving level 2
compliance within the IG Toolkit.
Figure 8
Minimum
accuracy Target
set by IG Toolkit
(%)
2011/12 Audit
Results
(%)
2012/13 results
(%)
IG Toolkit level
met for 2012/13
Primary
Diagnosis
Coding
Level 2: >=85
Level 3: >=90
84.0
92.0
LEVEL 3
Secondary
Diagnosis
Coding
Level 2: >=75
Level 3: >=80
54.6
85.85
LEVEL 3
Primary
Procedure
Coding
Level 2: >=85
Level 3: >=90
0.0
100
LEVEL 3
Secondary
Procedure
Coding
Level 2: >=75
Level 3: >=80
100
100
LEVEL 3
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
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2 Part 3: Review of Quality Performance
This section provides information related to the quality performance of the Trust‟s services. The
data relates to all services and the three domains of quality: clinical effectiveness, safety, and
patient experience. External sources of data have been used to provide the public with as much
benchmarking information as possible.
This part of the Quality Account is presented in four sections
1. Part 3A – Performance against Department of Health (DOH) Mandatory Indicators, which
Trusts are required to report against in their Quality Accounts for 2012/13
2. Part 3B – Performance against 2012/13 Quality Improvement Priorities
3. Part 3C - Performance against additional Quality Performance Indicators chosen by the
Trust including National and Contractual KPIs
4. Part 3D - Statement from the Trust‟s key stakeholders.
2.1 Part 3A: Department of Health Mandatory Indicators
The NHS (Quality Account) Amendments regulations 2012 set out a set of core quality
indicators, which Trusts are required to report against for their Quality Accounts from 2012/13
onwards. The Trust has reviewed these indicators and is pleased to provide the Trust‟s position
against ALL indicators relevant to our services for the last two reporting periods (years)
2.1.1
Preventing People from Dying Prematurely – 7 Day Follow-up
The data made available with regard to the Percentage of Service Users Discharged from
Inpatient Care Followed Up Within 7 Days
The Trust has utilised the information available from the Information Centre and the Trust
considers that the data is as described for the following reasons:
Staff are aware of their responsibilities regarding data quality through regular
communications and team meetings. In addition, all national, local and internal quality
indicators are reviewed and data validated at the Contracted Activity Reporting meeting
with representation from all Trust areas.
Robust data quality monitoring and validation processes and procedures are in place and
embedded along with clear guidance on the requirements to record data accurately.
The Trust has taken the following actions to improve this percentage, and so the quality of its
services, by:
Taking rapid action through a series of awareness sessions, daily exception reports and
monitoring.
Strong leadership provided by senior operational staff to ensure that the clinical
importance of this indicator was understood. This continued to be an important area for
the Trust in 2012/13.
The information provided by the Information Centre showed numerators, denominators and
percentages for 7 Day Follow-up, by Trust, as at Q3 2012/13.
The actions were successful with the Trust performing strongly throughout 2012/13 and
managed to achieve an overall target of 98%.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
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The table below provides the percentage achievement for the last two reporting periods in
addition to a comparison to the national position (latest published figures for seven day follow-up
relate to Quarter 3 (Q3) 2012/13).
Figure 9
Indicator
Target
Full Year
2011/12
7 Day Follow Up
95%
95%
Full Year
2012/13
98%
Q3 2012/13
Q3 2012/13 Q3 2012/13
National
Lowest Trust Highest Trust
Average
97.6%
92.5%
100%
The graph below provides the monthly percentage achievement in 2012/13.
Figure 10 Seven Day Follow Up in 2012/13
2.1.2
Enhancing the Quality of Life for People with Long Term Conditions - Gate keeping
All Admissions to Acute Inpatient Services will have had Access to Crisis Resolution/Home
Treatment (CRHT) Team
The Trust has utilised the information available from the Information centre and the Trust
considers that the data is as described for the following reasons:
Staff are aware of their responsibilities regarding data quality through regular
communications and team meetings. In addition, all national, local and internal quality
indicators are reviewed and data validated at the Contracted Activity Reporting meeting
with representation from all Trust areas.
Robust data quality monitoring and validation processes and procedures are in place and
embedded along with clear guidance on the requirements to record data accurately.
The Trust has taken the following actions to improve this percentage, and so the quality of its
services, by:
Taking rapid action through a series of daily exception reports and monitoring.
Strong leadership provided by senior operational staff to ensure that the clinical
importance of this indicator was understood. This continued to be an important area for
the Trust in 2012/13.
The information provided by the Information Centre showed numerators, denominators and
percentages for all admissions to acute inpatient services and how many were gate-kept by
CRHT Team, by Trust, as at Q3 2012/13.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
Page 22 of 47
This has been an area of consistent strong performance throughout 2012/13 with all Inpatient
Admissions being gate-kept in 2012/13.
The table below provides the percentage achievement for the last two reporting periods in
addition to a comparison to the national position (latest published figures for Crisis Gate Keeping
relate to Q3 2012/13).
Figure 11
Indicator
Target
2011/12
2012/13
Gate keeping of
Inpatient
Admissions by
CRHT
95%
99%
100%
Q3 2012/13 Q3 2012/13
Q3 2012/13
National
Lowest
Highest Trust
Average
Trust
98.4%
90.7%
100%
The graph below provides the monthly percentage achievement 2012/13.
Figure 12 Admissions Gate Kept by CRHT for 2012/13
2.1.3
Ensuring that People have a positive Experience of Care – Staff Survey
The percentage of staff employed by, or under contract to, the Trust during the reporting period
who would recommend the Trust as a provider of care to their family and friends
The Trust has utilised the information made available by the Information Centre with regard to
the results based on a sample of the workforce surveyed as part of the 2011 and 2012 staff
survey, who would recommend the Trust as a provider of care to their family and friends. The
Trust‟s performance against this question is as follows.
Figure 13
The Trust
MH/LD Trust Average
2012 Survey – Q12d „If a friend or relative needed
treatment, I would be happy with the standard of care
provided by this organisation‟
60%
60%
2011 Survey – Q22b „If a friend or relative needed
treatment I would be happy with the standard of care
provided by this Trust‟
55%
59%
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
Page 23 of 47
The Trust considers that these percentages are as described for the following reason:
As recommended the Trust used an independent approved contractor to run the staff
survey on behalf of the Trust in 2011 and 2012. Approved contractors provide external
assurance of the process.
The Trust has taken the following actions to improve this percentage, and so the quality of the
services provided:
The Trust undertook focus groups and staff engagement sessions involving variety of
staff from various locations and services to obtain more insight on issues raised from the
staff survey.
An action plan was devised and agreed by the Trust Board. This action plan outlined a
requirement for senior management to be more visible to staff on the ground and
communicate on the future delivery of services through service transformation. This
allowed views of delivering better standard of care being outlined to senior managers for
consideration.
2.1.4
Helping people to recover from episodes of ill health during injury – readmissions within
28 days of being discharged from hospital
The percentage of patients readmitted to hospital which forms part of the Trust within 28 days of
being discharged from a hospital which forms part of the Trust during the reporting period.
Readmission Rates
The Trust has utilised information made available from the Trust‟s information system OASIS as
the information was not accessible from the Information Centre to enable meaningful
comparison. The information presented relates to adults only.
The Trust considers that the data is as described for the following reasons:
Staff are aware of their responsibilities regarding data quality through regular
communications and team meetings. In addition, all national, local and internal quality
indicators are reviewed and data validated at the Contracted Activity Reporting meeting
with representation from all Trust areas.
Robust data quality monitoring and validation processes and procedures are in place and
embedded along with clear guidance on the requirements to record data accurately.
The Trust has taken the following actions to improve this percentage, and so the quality of its
services, by:
Developing processes and procedures, to agreed parameters, with clinical staff to ensure
validated readmissions figures were reported internally and externally.
Establishing robust reporting through the trusts data warehouse dashboard to enable
services to view the level of readmissions.
Strong leadership provided by senior operational staff to ensure that the clinical
importance of this indicator was understood.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
Page 24 of 47
The Trust has closely monitored this Contractual Key Performance Indicator (KPI) and year end
results shows a compliance rate at 7.2% against a Contractual target of 10%.
There was a significant increase in the readmission rate in August 2013 against the 10%
contractual threshold. A review of the information reported was completed and clinical services
ensured additional checks and balances were put in place for readmissions to inpatient services.
A data quality exercise concluded that the information reported for August was accurate and had
exceeded the 10% by 4%. For the rest of the year, the Trust‟s performance did not exceed the
target of 10%, which ensured contractual compliance.
The table below provides the percentage achievement for the last two reporting periods: (note,
no national benchmarking data available at time of writing this document).
Figure 14
Indicator
Target
2011/12
2012/13
Readmission Rate
<10%
5%
7.2%
Direction of travel
(12/13 compared
to 11/12)
The graph below provides the monthly percentage achievement 2012/13.
Figure 15 Trust Readmission Rate in 2012/13
2.1.5
Ensuring People have a positive Experience of Care – Patient Survey
The Trust‟s patient experience of community mental health services indicator with regards to a
patient‟s experience of contact with a health or social care worker
The Trust has utilised the information available from the Information Centre in relation to the
2011 and 2012 Community Patient Survey. To determine the Trust‟s performance against this
indicator, the mean score achieved against the following five questions has been calculated from
both the 2011 and 2012 Survey of people who use community mental health services:
Extract from Survey – Section Health and Social Care Workers:
1. Did this person listen carefully to you?
2. Did this person take your views into account?
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
Page 25 of 47
3. Did you have trust and confidence in this person?
4. Did this person treat you with dignity and respect?
5. Were you given enough time to discuss your condition and treatment?
Figure 16
Experience of Care*
Performance
2011 Survey
2012 Survey
DWMH
8.5
8.8
Lowest Trust
8.6
8.0
Highest trust
8.9
9.1
*The overall score is the average of the domain scores, which is taken as the experience of care
score.
The experience of care score for the Trust has significantly improved from 8.5 in 2011 to 8.8 in
2012. The Trust not only showed an improvement but scored higher than the lowest scoring trust
and almost as high as the highest scoring trust.
We consider the percentages are as described for the following reasons:
The Trust used an independent approved contractor to run the Community Patient
Survey on behalf of the Trust in 2011 and 2012
2012 figures for the lowest and highest scoring Trust are provided by the CQC
We have taken the following actions to improve this score further, and the quality of the services:
Designed a bespoke service experience training module for all staff
Improved the visibility of our Service Experience Desk (PALS and Complaints) to better
support service uses, carers and staff
Launched the Triangle of Care to improve the carer experience of services
The Department of Health have recently issued a new toolkit that allows Trusts‟ to measure
patient experience consistently. This is described in more detail along with the Trust‟s results in
section 3.3.5.
2.1.6
Treating and Caring for People in a Safe Environment and protecting them from
Avoidable Harm – Patient Safety Incidents.
NRLS – Patient Safety Related incidents
The number and, where available, rate of patient safety incidents reported within the trust during
the reporting period, and the number and percentage of such patient safety incidents that
resulted in severe harm or death.
The Trust has obtained data from the Information Centre which utilises data from the National
Reporting and Learning System (NRLS) from which national benchmarking data is scrutinised by
the Trust to monitor performance.
The figures below are taken from the last 3 half yearly feedback reports from the NRLS who
collect information regarding all Patient safety related incidents within the Trust and offer a
comparison against similar organisations, As a Mental Health Provider we are placed into a
cluster group alongside 56 other Mental Health Organisations
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
Page 26 of 47
Figure 17
1st April 2011 – 30th September 2011
st
st
1 October 2011 – 31 March 2012
st
th
1 April 2012 – 30 September 2012
Number of
Incidents per
1000 bed days
Median –
per 1000
bed days
Percentile of 56 other
reporters within mental
health cluster
18.3
21.1
Middle 50%
13.0
19.9
Lowest 25%
19.6
23.8
Middle 50%
Fig 18 shows the level of Patient Safety Related incidents Submitted to the NRLS, for the last 3
reporting periods.
Figure 18
1st April 2011 – 30th September 2011
1st October 2011 – 31st March 2012
1st April 2012 – 30th September 2012
None
Low
Moderate
Severe
Death
270
286
14
0
7
46.8%
49.6%
2.4%
0.0%
1.2%
195
175
27
2
10
47.7%
42.8%
6.6%
0.5%
2.4%
247
237
47
6
10
45.2%
43.3%
8.6%
1.1%
1.8%
Total
577
409
547
The Trust considers that this data is as described for the following reasons.
Incident reporting is a central component to risk management within Dudley and Walsall
Mental Health Partnership NHS Trust and all incidents have been managed according to
the Trusts „Incident, Near Miss and Serious Incident Reporting Policy
All incidents are recorded on „Safeguard‟ which is the Trust‟s Integrated Risk
Management System, for which staff receive training and ongoing support
The Trust is considered to have a good reporting culture and that all incidents are
reported in a timely manner, with regular training provided to all staff and managers.
The organisation also recognises the importance of having robust process for the investigation
of Incidents, Complaints and Claims. This is done through the use of Root Cause Analysis
Techniques that can be used to identify any key areas of learning for the organisation and
identifies any systems failures, key events, human errors and areas for improvement.
The Trust submits its Governance Exception report to the Commissioner Quality Review
meeting on a monthly basis for external scrutiny. This process acts as an independent scrutiny
check and would highlight any issues such as underreporting or trends in respect to the quality
of services provided.
The Trust has taken the following actions to improve this:
Embedding lessons – The Trust has a comprehensive embedding lessons system which
is led by the Trust Governance Team and the Heads of Service. It has been reviewed by
the CQC and NHSLA who complimented the processes and systems employed. In
addition the Trust is participating in a commissioner sponsored SI/Embedding Lessons
Research and Development project which aims to compare local Trusts‟ SI and
embedding lessons procedures and make recommendations for improved practice and
shared learning.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
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Incident Categories – During 2012/13 The Trust worked in partnership with the National
Reporting Learning System (formerly the National Patient Safety Agency) to ensure that
the categories of incidents used by the Trust Incident Reporting System (Safeguard) are
appropriately matched to the NRLS dataset 2 categories. All patient safety related
incidents are therefore captured appropriately by the Trust for uploading to the NRLS.
Clinical Governance and Quality Road shows – The Trust has commissioned a series of
road shows to visit each team or department with particular emphasis on staff
responsibilities for incident reporting, promoting an understanding how the incident data
is used, and how this can improve patient safety and the quality of care provided.
2.2
Part 3B: Performance against Quality Improvement Priorities 2012/13
This section of the Quality Account demonstrates the significant improvements made against the
five Quality Improvement Priorities for 2012/13.
The progress against the priorities and the associated action plans were monitored by the
Governance and Quality Committee and the Trust Board, and the need and opportunity for
further improvements in two areas (physical healthcare and involving families and carers) were
identified during the development of priorities for the coming year. They will roll over to 2013/14
and the other priorities will continue to be monitored as part of the Trust‟s quality agenda.
2.2.1
Progress against 2012/13 Priorities
Priority 1: Patient Safety
Quality Goal: To maintain and improve the cleanliness of the Trust hospitals and community
facilities
Rationale for Inclusion:
As the Trust moves through Service Transformation, which includes a series of estates moves,
the Trust is keen to ensure high quality cleanliness standards are maintained and wherever
possible improved.
Also during 2012/13 the Trust‟s Facilities Services were retendered. With significant changes in
the service and the contracting arrangements the Trust decided to operate an internal overmonitoring programme based on PEAT standards in addition to the new contractor‟s selfmonitoring programme. An internal target of 95% compliance was set.
Figure 19 Progress against Priority 1
Progress 2012/13
The Trust has remained compliant with the CQC Hygiene Code throughout 2012/13.
The Trust has introduced a process of over monitoring cleanliness of services to assure
maintenance and improvement throughout service transformation and changes in contracts.
This process of monitoring services included input from Experts by Experience to ensure the
user voice was embedded in the process.
Monitoring against the standards has demonstrated Q1: 97%, Q2: 97%, Q3: 97% Q4: 98% for
2012/13 demonstrating compliance of cleanliness standards through a period of transition. The
Trust exceeded the locally set target of 95% throughout the reporting period.
Improvements Achieved
Introduction of Trust over-monitoring of cleanliness of services based on PEAT
standards
Exceeded locally set target throughout the reporting period
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
Page 28 of 47
Areas for Further improvement
Continue over-monitoring as an integral part of Trust‟s quality monitoring processes
Priority 2: Clinical Effectiveness
Quality Goal: To embed physical healthcare monitoring consistently into clinical processes
Rational for Inclusion
National evidence suggests that people with complex mental health needs are at greater risk of
developing long term health conditions and that their access to physical health services is
relatively poor.
As the Trust moves through Service Transformation, there is an opportunity to ensure that
physical healthcare monitoring is embedded into clinical processes.
Figure 20 Progress against Priority 2
Progress 2012/13
Whilst significant improvements were made during the year, there continues to be a need to
further embed ideas into practice and also define interfaces and pathways with primary care.
This will continue to be a priority for the Trust during 2013/14.
The Trust has successfully implemented the safety thermometer as required by the CQUIN
and is using the information gathered to inform quality improvement, for example in informing
the Quality Improvement Priorities for 2013/14 in relation to falls prevention. This has
complemented the work being undertaken by the Trust in relation to physical healthcare and
patient safety.
The Trust has undertaken local audits in relation to physical healthcare, in particular in
relation to inpatient care. The Trust has also participated in national audits. In February the
Trust led a Clinical Audit conference with a focus on improving physical healthcare pathways
for service users.
Lessons learned from clinical audits are being used to inform changes to the Trust Physical
Healthcare Protocols and ensure consistent standards for physical health care and wellbeing
across the organization are based on best practice.
Improvements Achieved
Established physical healthcare steering group
Improved compliance with inpatient physical healthcare protocol in acute inpatient
services following local clinical audit
Harmonised physical healthcare equipment across the Trust and refreshed training
programme
Areas for Further Improvement
Development and implementation of competency framework
Further development of interfaces with primary care and the development of physical
healthcare pathways (identified as 2013/14 priority)
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
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Priority 3: Clinical Effectiveness
Quality Goal: Improve treatment and outcomes for service users who deliberately self harm
Rationale for Inclusion
The Trust‟s focus in the 2011/12 Quality Account was to improve care for service users who
displayed consistent levels of self harmed within inpatient acute services. This priority was
extended to 2012/13 as the work needed to also span across the community services.
Figure 21 Progress against Priority 3
Progress 2012/13
The Trust has undertaken a considerable amount of work in relation to improving care for
service users who deliberately self harm. This year the Trust has focused on up-skilling
clinical teams through targeted training which commenced in June 2012. The training is led
by local experts and aims to challenge attitudes towards personality disorders and deliberate
self harm and present current research on effective interventions.
The Trust is continuing to redefine clinical pathways based on best evidence.
Targeted work has also been undertaken to improve outcomes for people who display high
levels of self harm and are admitted to inpatient services. This has included mapping service
user journeys to improve patient pathways.
Improvements Achieved
Up-skilling clinical teams through targeting training led by Nottingham University
Mapping „patient journeys‟ for people who frequently self-harm and are admitted to
hospital
Board and senior management team development sessions in deliberate self-harm and
borderline personality disorder
Challenged attitudes within clinical teams towards personality disorder through
awareness raising and training
Areas for further development
Completion of care pathways including interfaces with inpatient and community
services.
On-going training and development of clinical teams.
Priority 4: Clinical Effectiveness
Quality Goal: Increase the number of care plans that have clear outcomes and are recovery
focused
Rational for Inclusion
The Trust‟s vision is one of a recovery orientated service. In the 2011/12 Quality Account, the
Trust said it would improve outcomes based care planning for service users. This included the
remodelling of clinical processes to support the delivery of outcomes based care planning and
the recovery model. The Trust decided that there was further work required to embed outcomes
based care planning and recovery, and therefore this remained a priority during 2012/13.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
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Figure 22 Progress against Priority 4
Progress 2012/13
Training delivered to community teams demonstrably increased the staff‟s understanding and
skills needed to produce outcomes based care plans supporting recovery.
Further work is being undertaken to align outcomes based care planning, the Care
Programme Approach and Payment By Results (PBR) to support service user recovery. This
work links into regional and national initiatives.
Improvements Achieved
Outcomes based care planning training was delivered to community staff
An evaluation of the training indicated an improvement in staff understanding and skills
to produce outcomes based care plans
Care plan format altered on OASIS clinical record system to support outcomes based
care planning
Areas for further improvement
Integration of outcomes based care planning into the development of clinical processes
for PBR
Expansion of training to inpatient staff as part of implementation of electronic clinical
records
Completion of CPA audit in 2013/14
Priority 5: Patient Experience
Quality Goal: Improve engagement with families and carers in care and treatment
Rational for inclusion
The national strategy for mental health – “No Health Without Mental Health” (DoH 2011) –
describes the importance of involving families and carers in care and treatment.
In 2011/12, the Trust identified from incident and complaints investigations a number of
recommendations for improving engagement with families and carers which should help to
embed lessons learned into service delivery.
Alongside this, the Trust has a Service User and Engagement Strategy with an objective of
developing a range of mechanisms to record and report service user and carer experience.
The Trust gave priority to undertaking a focused quality improvement initiative to effectively
engage with families and carers in care and treatment. This initiative is an integral part of the
Trust‟s Service Transformation journey.
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Figure 23 Progress against Priority 5
Progress
During the year, the Trust has undertaken improvement work to ensure family and carer
engagement is embedded within care and treatment. This has included
Identification of clinical carer leads and champions
Development of information sharing protocol
Review of clinical processes to ensure care involvement if embedded
Appointment of project lead.
Carer involvement
To ensure consistent standards across the service the Trust became a member of the
Triangle of Care Network in February 2013 which provides a national best practice model
and is supported by the Carers Trust.
In March 2013 the clinical teams completed an assessment against the Triangle of Care selfassessment tool which has set a baseline for the Trust measure itself against post
implementation. The Trust is also completing a carer‟s survey.
Significant progress has been made in developing the clinical processes and infrastructure to
support the roll out of Triangle of Care. This will remain a Quality Priority for 2013/14 to
ensure it is firmly embedded into practice and there is an evaluation of the effectiveness of
the model.
Improvements achieved
Membership of Triangle of Care network
Implementation of information sharing protocol
Appointment of clinical carer leads and champions
Baseline assessment
Realignment of clinical processes and development of carers checklist
Areas for further improvement
To successfully implement and embed principles of triangle of care across clinical
services. This has been identified as a priority for 2013/14 for inclusion in the Quality
Account
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2.3 Part 3C Trust Performance against additional Quality performance
Indicators
This section of the Quality Account aims to provide a selection of indicators chosen by the Trust
to demonstrate a holistic view of quality across the services provided. The Trust has included
contractual and national key quality indicators and a selection of quality indicators the trust uses
to monitor the quality of the services provided.
2.3.1
Contractual Quality Requirement Goals agreed with Commissioners
For 2012/13 the Trust agreed 16 Contractual Quality Requirements with its commissioners,
which were reported on a Monthly basis as KPI‟s. 8 of these Quality Requirements are also
existing National Measures from the Operating Framework & Monitor Governance Risk Rating.
All 16 KPI‟s were met at Trust level which demonstrates that the Trust has sustained significant
high performance for the past 2 years.
Figure 24 Contractual KPIs in 2011/12 and 2012/13
2011/12
17 of 17 contractual KPIs met (100%)
2012/13
16 of 16 contractual KPIs met (100%)
Figure 25 Contractual KPI’s Performance in 2012/13
Contractual KPIs
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Number of new cases accepted to Early
Intervention
7 day follow up on Inpatient Admissions
Mixed Sex Accommodation Breaches
Annual Health checks for long term
Inpatients
Average Length of Stay
Readmissions within 28 days
Copies of Care Plans (CPA caseload)
MRSA
Clostridium Difficile
Inappropriate under 18 Admissions
Admissions gate kept by CRHT
Referral to Treatment Time – Complete
Referral to Treatment Time – Incomplete
Number of Home Treatment episodes by
Crisis Teams
Improved Access to Psychological Therapies
– People completed Treatment & attended
last 2 sessions
Target
Achieved
89
95
95%
0
100%
97%
0
100%
<64 days
10%
95%
0
0
0
95%
95%
92%
1187
45 days
7.2%
96%
0
0
0
100%
98%
95%
1440
Dudley: 53.8%
Walsall: 50.5%
Dudley:
55%
Walsall:
51%
1.02%
Delayed Transfers of Care (DTCs - NHS
Only)
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
<7.5%
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The Trust‟s overall performance against the commissioners‟ KPIs is very positive and has
improved throughout the year.
Significant improvements have been made in data quality and the Trust meets regularly with
commissioners to discuss performance and quality.
The Trust is fully aware of areas it needs to improve and is working closely with commissioners
to achieve this.
Figure 26 Contractual KPI Performance in 2012/13 – Locality
Contractual KPI
Trust Achievement
Dudley
Walsall
Number of new cases accepted to
Early Intervention
7 day follow up on Inpatient
Admissions
Copies of Care Plans (CPA
Caseload)
95
(Target 89)
97%
(Target 95%)
96%
(Target 95%)
48
(Target 43)
97%
47
(Target 46)
98%
96%
95%
Number of Home Treatment episodes
by Crisis Teams
1440
(Target 1187)
728
(Target 579)
686
(Target 608)
2.3.2
National Key Performance Indicators/Monitor Governance Risk Rating (GRR)
The Trust routinely reports performance against the national outcome framework and Monitor‟s
GRR (a single integrated measure of service quality and performance) to the Management
Executive Committee, Finance and Performance Committee and Trust Board each month. The
report summarises previous, current and target GRR ratings and highlights any risk areas.
The Trust has improved or maintained performance in most areas against the National metrics in
2012/13 (as shown below).
Figure 27 National Indicators 2010 – 2013
National Indicators
2010/11
2011/12
2012/13
7 Days Follow Up
98%
95%
Target = 95%
Achieved = 98%
8%
4%
Target < 7.5%
Achieved = 5.4%
99%
99%
Target = 95%
Achieved = 100%
84%
107%
Target = 95%
Achieved = 101%
0
0
0
0
Target Percentile= 18.3
(weeks)
Completed=12.3
Target Percentile= 28
(weeks)
Completed=18.3
Minimising Delayed Transfers
of Care
(NHS reasons)
Gate keeping of Inpatient
Admissions by CRHT
Number of new cases
accepted to Early Intervention
(against contract)
MRSA
Clostridium Difficile
Referral to Treatment –
Complete
N/A
Referral to Treatment Incomplete
N/A
Data Completeness Identifiers
97%
99%
Data Completeness
Outcomes*
51%
75%
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
0
0
Target = 95%
Completed = 98%
Target = 92%
Completed = 95%
Target = 97%
Achieved = 99%
Target = 50%
Achieved = 57%
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*We will monitor levels of Data Completeness Outcomes through looking at the CPA Exception
Reports with a view to improve our overall completeness score. We will look at refining our
Internal Data Quality reports to ensure we take a more proactive approach in looking at this
data.
Referral to Treatment
In the contract for 2010/11 we did not report referral to treatment. During 2011/12 we submitted
the figures in weeks and only started to report on this KPI from August 2011. During 2012/13
good performance was maintained for this KPI due to close monitoring by the Performance
Team including sending out alerts to the service teams where referrals are reaching the 18 week
threshold.
Examples of the dashboard reports used to report on the Governance Risk Rating (GRR) to the
Trust Board are shown below. The position at the end of the year is a GRR of 0 (the best score
achievable) and this has been sustained for the whole of the last quarter of the year.
The figures below are based on year end position Quarter 4 cumulative of 2012/13 and show
that all national indicators have been achieved.
Figure 28 Monitor Governance Risk Rating Dashboards
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
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2.3.3
Patient Environment
There is a strong evidence to suggest that the environment within which mental health care is
delivered has a significant impact on both safety and patient experience. This link becomes even
more important for inpatient services and the Trust is committed to improving the quality of
inpatient areas.
Every year, all healthcare facilities in England with more than 10 inpatient beds are inspected
and rated using Patient Environment Assessment Team (PEAT) assessments. Each hospital is
given an annual rating of excellent, good, acceptable, poor or unacceptable, based on levels of
cleanliness, aspects of infection control, quality of environment (such as decoration,
maintenance and lighting), standard of food offered to patients and privacy and dignity.
Figure 29 below show the most up to date scores for PEAT assessments completed on the
Trusts hospital sites and how they have either made progress or maintained their high standards
in the vast majority of areas. In particular the food has improved and dignity has maintained an
excellent rating across all 3 hospital sites.
Figure 29 PEAT Scores
Site Name
Bushey Fields
Dorothy Pattison
Bloxwich
Hospital
2.3.4
Year
2009
2010
2011
2012
2009
2010
2011
2012
2009
2010
2011
2012
Environment
Food
Privacy and
Dignity
Excellent
Excellent
Good
Excellent
Acceptable
Good
Excellent
Good
Good
Excellent
Excellent
Excellent
Excellent
Acceptable
Good
Excellent
Good
Good
Excellent
Excellent
Excellent
Good
Excellent
Excellent
Excellent
Excellent
Excellent
Excellent
Good
Excellent
Excellent
Excellent
Good
Excellent
Excellent
Excellent
National Health Service Litigation Authority (NHSLA) Compliance
The Trust is currently accredited at level 1 against the NHSLA‟s risk management standards for
Trusts providing Acute, Community, Mental Health and Learning Disability services. Compliance
against these standards continues to show a commitment to the proactive management of risk
and the continued effort to provide quality and safe services.
The Trust has identified any issues raised by its February 2012 assessment and is continuing to
take a proactive approach to moving towards NHSLA level 2. Owing to the suspension of
assessments by the NHSLA during the 2013-14 period the Trust will not be undergoing an
assessment during the forthcoming financial year whilst the NHSLA reviews their assessment
processes.
The suitability of policies pertaining to NHSLA standards, will continue to be overseen by both
the Trust‟s Policies and Procedures Focus Group and the Trust‟s Governance and Quality
Committee and the further roll out of the Risk Module of the Trust‟s Risk Management System
will continue to act as a driver for ensuring that the management of risk remains a priority for the
organisation in order to safeguard the safety of our services users and maintain the high quality
of the services provided by the Trust.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
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2.3.5
Patient Experience
The Trust continues to have a strong commitment to the safe delivery of care, which is fostered
and embraced by all those involved in providing care. Protecting service users from avoidable
harm is a fundamental feature of the way services are delivered. The following are a selection of
indicators chosen by the Trust as important barometers of patient experience
Friends and family test – net promoter
From April 2013, every NHS hospital is required to ask patients in accident and emergency and
on the wards whether they would want a friend or relative to be treated there in their hour of
need. The Prime Minister says the results will be made public so „everyone will have a really
clear idea of where to get the best care‟ which will „drive other hospitals to raise their game‟.
The Trust implemented this test in 2012 as part of its CQUIN schemes. People being discharged
from community services were asked “How likely is it that you would recommend this service?”
We are pleased to report that 75% of the 1696 people asked, responded with “likely” or
“extremely likely”. The full results are shown below.
Figure 30 Net Promoter (Friends and Family Test) Scores
Patient Satisfaction Score Benchmarking
The Department of Health has developed a tool that provides NHS Trusts with an indication of
Patient Experience. They extract the responses to a selection of questions from the latest
relevant CQC survey to generate an overall Patient Experience Score.
The results from the last two scores are shown below.
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Figure 31
Patients Experience Overall
Score
Dudley and Walsall Mental Health Partnership NHS
Trust
East of England SHA Average
West of England SHA Average
England Average
2012/13
2011/12
76.5
75.9
74.1
74.4
74.2
n/a
n/a
74.0
The overall patient experience score for the Trust is greater than the England for the past two
years.
Community Survey 2012 overall satisfaction score
The Annual Community Mental Health Survey 2012 was conducted independently for the Trust
by Quality Health and sent out to around 800 service users to gain their feedback on a wide
range of topics. Around 330 of the surveys were returned to Quality Health – one of the best
response rates in the country – so the information within the results is a really powerful indicator
of the satisfaction levels of our service users.
One of the areas covered asked service users how they would rate services. Results for the
Trust showed that 81% described the service they received as being “Excellent, Very Good or
Good”
Excellent 37% compared to 31% in 2010/11
Very Good 25% compared to 26% in 2010/11
Good 19% compared to 22% in 2010/11
The Trust not only showed an overall improvement on the previous year, but scored higher than
the national average and the average of Trusts in its SHA region.
Compliments and Complaints 2012/13
Despite our focus on quality, we recognise that sometimes people‟s experience of our services
is not always as positive as we would hope. In October 2007, the Health Service Ombudsman
published „Principles for Remedy‟ as an overall good practice guide for public bodies in dealing
with complaints. Our complaints policy is based around these principles which are:
1.
2.
3.
4.
5.
6.
Getting it right
Being customer focused
Being open and accountable
Acting fairly and proportionately
Putting things right
Seeking continuous improvement
During the period April 2012 to March 2013, we received a total of 74 formal complaints. Of
these, we responded to 49 within the target; 8 more are still open cases and remain within this
target at the time of writing.
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Figure 32 Compliments and Complaints 2012/13
The number of complaints received is relatively small
compared to the number of patients we see and treat
each year. Over the last twelve months we are pleased
to say we have also received 262 written compliments
from people who have accessed our services,
highlighting cases where the quality of our services has
been recognised and appreciated. The Service
Experience Desk (SED) feature “On a Happy Note”
highlights the positive comments made by service users
about their care by posting a selection of experiences
from service users on the Trust Intranet every month.
Some examples of what people have said about our services are demonstrated below:
“Thank you so much for all your help. I couldn‟t have come this far without you. I really
appreciate all your patience and understanding.”
“I appreciate everything you did to help me successfully find a job which has really helped my life
be happier.”
“You have been a great help to me in my time of need and you have helped me turn my life
around and begin to see life in a more positive light after many, many years of negativity and
increasing worries and anxiety.”
“It's been a very difficult journey for my wife and I over the past several months - but in part to
the well running of the ward and the interested and caring attitude of staff both on Clent and
Wrekin I'm finally where I want to be.”
“The world's a BETTER place because of people just like you. You are caring and giving. I want
to say thanks for your time and effort helping me when I needed it. You have been there for
me.”
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“Thank you so much for all that you have done, we now have our „old son‟ back thanks to your
services”
Feedback from Service Users and Carers
Over the past twelve months our eight Experts by Experience (EBEs) have been significantly
involved in raising awareness of Trust activities and gaining valuable feedback from service
users and carers. We have also gained essential and valuable feedback via informal concerns
and comments from the Service Experience Desk, patient surveys and the electronic patient
experience trackers.
Here are just a few of the selected actions that have been carried out as a result of feedback
from those who use our services, their relatives and carers:
Figure 33 Comments and Actions Taken
We Did
You Said
You wanted clearer signs for the
Outpatients Department at Dorothy
Pattison Hospital.
We provided additional signage for the
Outpatients Department to clearly signpost it
from the main reception area in the hospital.
You felt that awareness and access
to a „Quiet Garden‟ at Dorothy
Pattison Hospital was limited.
We put up posters informing of access to the
garden which is facilitated by staff, with
support from Occupational Therapy
Assistants. It is also part of the ward activity
schedules.
You were not sure you had seen a
copy of your Care Plan.
We put posters in Outpatients departments
across Dudley & Walsall to ensure that
patients were aware/had seen a copy of
their care plan. We introduced „orange
front sheets‟ to clearly indicate to Patients
their Care Plan.
As a result the National NHS Community
Mental Health Service User Survey found
that this year we have seen an increase in
the number of people who have been given
(or offered) a written or printed copy of their
Care Plan, showed significant increase.
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2.3.6
Feedback from Staff
The Trust values the opinions of its staff and as such encourages the completion of the Staff
Survey each year. The response rate for this year was above the national average for Mental
Health Trusts of 57% of a sample of 695 staff. In addition to this quantitative information the
Trust has agreed a joint initiative between staff side and management known as the Staff
Engagement Project where all teams receive a visit across all hospital and community sites to
enable them to express their views about working within the trust in an open and honest way.
This will result in a report to management team and a series of recommendations for
consideration improvement by the management team. This will form the basis of a Staff
Engagement Strategy to embed this within Trust culture and practice.
The initiative is further building on the areas for improvement in the 2011 staff survey where 48%
of staff reported that they were consulted in change which affect their work, and 55% of staff felt
satisfied with the recognition they receive for doing a good job
The 2012 Staff survey showed an improvement in many areas from the previous year as shown
below.
Figure 34
Areas showing improvement from the previous year:
72% staff have received Equality and Diversity training
81% received training on Infection Control
81% of staff are able to do their job to the standard they are pleased with
71% of staff said their manager gave clear feedback on their work
However, the results also highlighted some areas where improvement could be made as shown
in the table below.
Figure 35
Key areas for improvement within the 2012 staff survey:
Senior Managers action staff feedback
Percentage of staff receiving an appraisal
Percentage of staff experiencing workplace stress
These results will form an action plan that will be addressed throughout 2013/14.
Staff Health and Wellbeing
The wellbeing of our staff is of paramount importance to us as we recognise that this has a direct
impact on clinical outcomes and the experience of patients. It is therefore important that our staff
are energised, motivated and healthy and with this in mind a dedicated Health and Wellbeing
Strategy was launched in last year.
This year one of the key areas of focus from the 2012/13 staff well being action plan has been
assisting staff and managers to get staff back into the workplace, particularly in the instance of
long term sickness, by providing extra help and support of a Health and Well Being co-ordinator.
In addition to this, a Stress Resilience training course has been piloted within the Trust, led by
two of our clinical psychologists. This aims to enable staff to develop a personal toolkit to deal
with stress both in the workplace and in life in general.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2012/13
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Regular Health and Well Being Events have continued to be delivered and staff have had the
opportunity to receive a health MOT, experience some alternative therapies and receive advice
from a series of professionals about improvement to their lifestyle. This is going to be further
developed during 2013/14 into monthly sessions which will range from financial advice to healthy
lifestyle advice and be facilitated across the Trust.
2.4 Part 3D - Statement from the Trust’s key stakeholders.
We approached the following stakeholders to comment on the Quality Account:
Lead Commissioner for the Trust – Care Commissioning Group
Walsall Health Overview and Scrutiny Committee
Dudley Health Overview and Scrutiny Committee
Dudley Health Watch
Walsall Health Watch
The following responses were received;
Lead Commissioner for the Trust – CCG
The Commissioning body for Dudley and Walsall Mental Health Partnership NHS Trust has
provided the following comments…”The Quality Account was presented and reviewed by the
Integrated Governance Team, it was felt that the Account provided a fair reflection of the
services the Trust provides and the information included in the report was accurate”
3 Conclusion
This is the Trust‟s third full Quality Account and is designed to present an open and transparent
view of the quality of services provided by the Trust. It describes the quality improvement
progress we have made during 2012/13 and sets out the local quality improvement priorities for
the coming year.
During 2012/13, the Trust has made significant progress on its journey to transform services and
become a Foundation Trust. This has involved a strong emphasis on quality governance and
quality improvement.
The Trust is extremely grateful for the input and the continued support of key stakeholders and
partners in developing this document. We are fully committed to maintaining and strengthening
this dialogue through the coming year.
4 How to provide feedback
Thank you for taking the time to read the Trust‟s Quality Account for 2012/13. If you have any
comments or would like to provide feedback about the contents of this document, please contact
the Trust in any of the following ways:
Phone:
0300 555 0262
Email:
communications@dwmh.nhs.uk
Post:
Trust Headquarters
Trafalgar House
47-49 King Street
Dudley
West Midlands
DY2 8PS
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